We are the Association for Child and Adolescent Mental Health or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids, a podcast series dedicated to exploring the latest advancements in child and adolescent mental health research and practise. I'm Clara, an academic clinical fellow in child psychiatry. And I'm passionate about understanding and addressing the diverse mental health challenges faced by young people globally. In this series, I will be joined by renowned researchers and clinicians from around the world to discuss their cutting edge research, innovative interventions, and best practises in child and adolescent mental health. Today, I have the pleasure of receiving Dr. Tessa Reardon, a research fellow in the Department of experimental psychology and psychiatry at the University of Oxford. And we're going to be discussing her paper, parent-led CBT for young children identified as at risk for anxiety disorders, a cluster randomised control trial, which was just published at the JCPP. It's an honour to have you here, Dr. Reardon. Thank you so much for accepting to do this podcast with us. And if you could start by telling us a bit about yourself and your research journey so far. Yes, of course. And thanks so much for having me. I'm really, really delighted to have the opportunity to come and talk about this research. So I grew up in the UK and were benefited from having access to state funded, really good quality schooling that I think really gave me, helped me to develop curiosity about the world and really valuing and wanting to I guess, make a positive contribution to society. And then I went on to study psychology as my undergraduate degree in Swansea in Wales. And following my first degree, my introduction into the world of research was actually educational research. So I worked for a charity doing educational research. And alongside that, I trained to be an English language teacher. And I went to live in a few different places in the world. I think mostly because I wanted to experience living and working in different parts of the world and in different cultures. And I returned to psychology, actually in Australia. So I lived in Australia for a couple of years and worked as a research assistant and a couple of different institutions, working with teams really focused on child and adolescent mental health research. And that's really what inspired me to then go on to do a PhD within this field. So I came back to the UK and I did a PhD working with Kathy Creswell at the University of Reading. And my PhD really focused on families experiences of seeking help for anxiety problems, specifically among primary school aged children. And really in that work, we were trying to understand the challenges that families face accessing support. And I've been really fortunate, I think since then to be able to really to be conducting research that builds on that work that I did within my PhD to develop and evaluate and implement really approaches that are designed to try to minimise and reduce some of those really common barriers and challenges that families face seeking and accessing support, including this study that we're talking about today. You know that's amazing. And I think in this study, clearly focused on anxiety and children experience at high risk for anxiety disorder in schools. And I think this is just such an important topic right now, because we know that the prevalence of mental health conditions among children and young people is increasing. But I think there's also some really interesting data from the mental health of children and young people national survey showing that actually the prevalence of subthreshold symptoms is also increasing. So clearly, even if people don't meet a diagnostic set criteria for a full-blown diagnosis, they're still experiencing a lot of distressing symptoms, and anxiety and depression are among the most common ones. And your paper, you did a trial trying to evaluate outcomes from therapist-supported online CBT supporting parents to deliver CBT to young children from, as you said, primary schools that were identified as at risk for an anxiety disorder. So can you tell us a bit more about the rationale. And you said you were building up on your PhD work and the specific gaps you were trying to cover. Yeah, of course. I mean, so exactly as you say, really, this was very much in the context of this growing understanding and awareness of this gap between need for mental health support and intervention and really receipt of evidence-based care with children and young people, often not accessing support or having to wait really long periods to do so, and for difficulties really to be quite severe before they're able to access services. And it was really my PhD research that really pointed to I guess, the potential role for schools here to try to bring support to families and try to minimise some of those barriers associated with accessing external support. And really, I think just the extent of the challenges that families can face before even being confronted with those oversubscribed services. So specifically in the context of anxiety problems and early signs of anxiety problems in children. Parents often talk about really difficulties making decisions or judgments about whether early signs of difficulties with fears and worries are really something to be concerned about or not. Parents often report worries about and/or experience really of being blamed or being made to feel they're to blame for their child's difficulties, which really can make it hard to seek support, as well as just a lot of uncertainty about how best to go about doing that. And really in parallel to planning this study, we were doing some research focused on slightly older primary school age children. And we've been working with families and school staff to develop an approach, really to try to address some of these key barriers around seeking support by identifying children with anxiety problems through schools and actively offering those families interventions through a school setting. And it was really that work that I think started to make us think about the potential benefit of I guess, trying to really intervene that bit earlier as well. So trying to reach children at a younger age and perhaps children who aren't yet necessarily experiencing significant difficulties with anxiety but are kind of heightened risk. So maybe more likely than their peers to go on to do so. And as you said, really in the UK, there hadn't been any trials that had evaluated providing a CBT intervention for children, young children, under 8 to a heightened risk for going on to develop anxiety disorders. So that was the key gap that we were really trying to set out to address here in this study. That's really interesting. And I think, as you said, particularly thinking about this younger children group like 4 to 7, which was the group you focused on. Well, the threshold for CAMH services is so high and lots of parents are in a limbo, just even before they think about going to a GP to look for help. Yeah, exactly. It's just so tricky. It's like hurdle after hurdle after hurdle. Oh, it is. And I suppose in the beginning of the podcast, when you're talking about your background, you mentioned that one of the things you really liked about the UK, which I suppose is one of the things I really like about the UK as well, is your access to state-funded education. And I think here, we do have access to state-funded health system, which is a wonderful thing. I think the principles of the NHS are amazing. I think at the moment we're facing-- I mean, not just at the moment, but it's been building up. Services are so overstretched and we definitely need something to bridge the gap because as you said, the threshold for CAMHS is just so high. And actually, this is something I talk to the consultants I work with. Lots of them they're like they see their families are struggling, but they're like, oh, I know this child is not going to meet the threshold for CAMHS referral. And it's just like there's just this huge gap in provision and research as well. Yeah, exactly. But what I wanted to talk to you about-- so as you said, you focused on really young children, so age 4 to 7. And I think in terms of developing anxiety symptoms, this is a really important developmental window. Both in terms of the literature but also your PhD work, what do we know about this age group in terms of developing interventions? And how did you approach this problem, considering it's such-- I think one of the big novelties of your study is precisely using such a young age group. Yeah, it's a great question. And I mean, I guess we think mental health problems more broadly often do start early in life. But anxiety disorders particularly are characterised by often really starting at a young age. And there's a meta analysis from a couple of years ago where they've combined findings from across studies that it's really striking that the most frequent age of onset, so when a disorder is first diagnosable for some types of anxiety disorders, there's just 5 and 1/2 years of age. So it is a really frequent age of onset, this early young childhood period. And where we are thinking about intervening and providing support before difficulties do really become more ingrained and ongoing. When we're thinking about that in the context of anxiety problems, we do need to be including and thinking about providing support for really quite young children. I think there was another consideration specifically for this project where right from the beginning and throughout the delivery, and I guess now as well, we were always thinking about how could this work in practise, partly because of that gap that you've referred to I think about how can we help fill this gap going forward? So we were very much thinking about how the kind of school system works, and particularly schools in England. And so part of the rationale for the specific age range that we're focused on was tying into the school years in the English schooling system. So we were focused on the first three formal years of education. That makes total sense. And actually links really well to my next question, because I'm still speaking about the methods and the design of the study. I was going to ask why you chose to focus on schools as your main recruitment. Just thinking with my clinician hat on and you've mentioned that as well. Some families they go to GPs, but sometimes they also go to counsellors. But you chose schools as your recruiting unit. And yeah, if you could talk a bit about that. Yes, absolutely. And I think that was-- that definitely was-- I think we would say is a key feature of the design of this study was choosing to focus on schools. I mean, perhaps the first thing to say is this isn't focusing on schools, doesn't mean that this is the only route in the place to be offering and providing support, that of course, there are different routes, and different routes are going to suit different families. But it was very much both, I guess, findings from my PhD research and then also the wider context and including policy context that did inform this decision. So certainly in my PhD research, those common challenges that families talked about, identifying anxiety problems and then going on to seek help for those anxiety problems by identifying children through schools and delivering and offering support through schools. It is very much you have this opportunity to really bring support to where families are and try to remove that need to navigate this really complicated process. So that certainly was a key aspect of it. We were also keen to use this approach of using screening questionnaires or questionnaires to identify children through schools where they're offered universally. Again, as a way to try to minimise that demand on parents to necessarily make that decision or judgement, to say, yes, I need to go and ask for help where it's more actively being bought and offered to them, and then using the responses to those screening questionnaires to make an offer, make an offer of support. And then, yeah, I guess alongside this. I think probably internationally really, but certainly here in the UK growing recognition and importance attached to the role of schools. So again, thinking right from planning this study and for going forward. So there is very much interest and attention towards providing support through school settings. And in England now we have mental health support teams linked with and working with increasing numbers of schools. So very much from the planning stage of this study, we were thinking those teams really provide a trained potential workforce going forwards to work with schools to deliver these types of approaches. But I guess that's not to say there's not challenges with working with schools too. I mean, schools are incredibly busy places, which perhaps is inherent to schools. But certainly, as you mentioned, I mean, within this context of stripped back public services around schools, those demands on schools are ever increasing. And certainly, that was something that we were mindful of and thinking about all the way through planning and delivering this project, where we work really closely with school staff to think about how the procedures might work, and trying as much as possible to minimise additional demands on school staff. That's very sensible. And it's really interesting that you and your team tapped into the potential of mental health support teams. I was going to mention them. It's a really interesting feature in England for our listeners from other parts of the world. There's been this very landmark paper by the government called the Green Paper, which set rules about the provision of mental health support in schools precisely because schools are such an important, as you said, important place in children's lives. And I also think-- I don't know how it works in other countries, but I think it's really interesting that besides the mental health support teams in the UK, you also have the figure of the educational psychologist. And you have a whole apparatus around the school that is there to provide mental health support. Yeah, absolutely. And I mean schools we do know from the National Mental Health surveys that schools often are the first point of contact for families who do have concerns related to mental health, but also wider concerns. So they often do have a key role in signposting and linking up families with other more specialist services. And it's really interesting about the challenges you mentioned, because other people that I've also asked about working with schools all said the same thing in terms of how it's about you fitting into the routine of the school and not you expecting that the school will adapt to when you want to do things with them. Yeah, absolutely. And I mean, in this study, we had a fantastic team that worked really hard to build really good relationships with staff within schools. And so this trial was called the MY-CATS trial. And so in each school we had a nominated lead point of contact in the school who was the MY-CATS lead. And so both they were liaising with our research team. But then also the point of contact for queries or concerns from parents as well. And of course that did vary across schools, but it was really striking how it was within those schools where there were individual members of staff that had really good, strong, trusted relationships with families, that often played a really important role particularly in that initial engagement and sign up process and supporting families to complete questionnaires. And actually, in this study particularly, it was really interesting because we were working with younger children, it was often staff in support roles. So staff with perhaps pastoral support responsibilities that knew families really well in the school but were really, really critical. Yeah, that makes sense that would have been key. And speaking of the intervention in your study. So the intervention was parent-led CBT. And what I also thought was interesting is that the intervention was supported by a therapist. So parents could receive support over the phone for to deliver the intervention. So for our listeners who are not familiar with parent-led CBT, can you tell us a bit more about what the intervention looks like and about also the decision to include the therapist support remotely to deliver it. Yeah, sure, absolutely. So the intervention that we used in this study was called OSI so online support and intervention for child anxiety. So parents have access to a website. And the content includes really easy-to-read written text but then information presented in another way. So there are video testimonials from parents and animations and all the written content is available as audio recordings too. And parents often talk about being able to listen to it on the move while they're doing other things. And so parents work through online content over a series of modules, and each module-- it's designed to take about 20 minutes, and each module is then supported by a telephone call or a video call. So a short conversation within the study. It was a children's well-being practitioner who graduates trained in delivering these types of brief CBT interventions. And really those support calls really provide an opportunity for a parent to check in with their understanding around the content. And really to provide support and encouragement, help support the family with addressing any challenges, problem solving, any challenges that might crop up along the way. And it is really striking how both in this study and in other studies, where the intervention has been evaluated, that parents do really talk about those support causes feeling a really important component of the intervention, both as a motivator to keep going. And also just as an opportunity to work through challenges that might crop up and perhaps where to support parents with tailoring or adapting particular strategies for their particular child's needs or circumstances. And so the intervention originally had been designed for slightly older children and also children with anxiety disorders. And so as part of this study, at the start, we did do some work to make actually fairly minor changes to the content of the intervention, just tweaking, moving some of the more clinical language and showing examples and things were appropriate for younger children as well, and children who might not be experiencing significant difficulties with anxiety. So over the course of the intervention, parents learn strategies that are CBT-based strategies for them to use and apply in day-to-day life with their child. So some of the early content really focuses on supporting parents, I guess to gain an understanding of those anxious thoughts their child might be having. So things that bad, things that they think might happen in situations that might be scary. And so there's some strategies around having conversations or talking to children around fears and worries. And then some strategies that are designed really to support parents, to support children to test out some of those anxious thoughts and really gradual and supportive ways, as well as activities around problem solving and promoting problem solving and building confidence through gaining independence. So really cognitive behavioural strategies that you would see across and other types of CBT interventions that are delivered in different formats. And certainly this way of delivering the intervention where the support is all provided remotely, both where the content is delivered digitally, obviously brings the advantage of parents to be able to access it, fit it readily around their day-to-day life. And then similarly, the support being provided remotely by telephone or video call similarly allows parents to accommodate that within their busy lives, perhaps more readily than attending face-to-face appointment. And certainly, the amount of contact time within this intervention. So in the study, it's about 2.5 hours over the course of the intervention. So certainly, a lot less than you would see in a standard CBT intervention that's delivered directly to children, which does bring efficiencies when you're thinking about trying to maximise the number of children that could receive this type of support. But I suppose the advantage of the parent led is that you can bring scale very easily. We have such a shortage of CBT-trained therapists that-- yeah, it's-- Yeah, absolutely. And I think it is really striking as well where you talk to families that have family parents of primary school aged children that often really want to be able to support their child as the family, and have often concerns about a child going to see a therapist or someone independently. But it's having the confidence and knowing how best to do that. And so a parent-led approach does bring advantages to where there might be concerns actually about that child missing school or going to a clinic or attending face-to-face sessions with the clinician. And in terms of outcomes. So the primary outcome you and your team chose was the presence of an anxiety disorder diagnosis at 12 months post intervention. And I thought it was so interesting because you did find reduced rates of diagnoses in the group that received intervention compared to the group that didn't. However, that difference was not statistically significant. And there's an important word for our listeners who haven't read the paper. All the secondary outcomes were statistically significant. So things like parental anxiety symptoms and child self-reported symptoms, all of those things were significantly reduced in the group that received intervention. And I think my first question is, why did you choose that outcome in terms of, I think, especially considering you're using a population that wasn't necessarily looking for clinical help. It was this whole population that screened current high for anxiety. Why this outcome and how did you make sense of these findings? Yes, yeah, thank you. I mean, this is obviously something that we have thought and talked a lot about as a team. I mean, I think primarily, we chose the diagnostic outcome because we were aiming to prevent the onset of diagnosable anxiety disorders. And in order to assess that, you do need to use a full diagnostic assessment. And so I guess we set the bar high, I guess, by doing that. I mean, as you said, that at 12 months we found that there were fewer children in the intervention arm with a diagnosable anxiety disorder than in the control group. But that difference between the groups wasn't statistically significant. So I mean, we would then I think, interpret that as a null result in relation to that diagnostic outcome. So this intervention didn't reduce the frequency of diagnosable anxiety disorders over that 12-month period. But as you say, because we did find positive effects across our secondary clinical outcomes. And I think it was striking for us that was consistent across really a range of outcomes that we assessed. So really importantly, including those three risks that actually read assessed at the start of the study to determine inclusion. So we saw a reduction in children's anxiety symptoms, inhibitions, and an inhibited temperament parent anxiety. And also each of those child and parent behaviours that we assess that are really targeted by the intervention and CBT interventions more broadly. So those outcomes across those secondary outcomes really do provide evidence that this intervention reduced risk for future anxiety disorders. So over 12 months, we didn't find evidence of a reduction in diagnoses, but we did find a reduction in risk for the development of future anxiety diagnoses. So I mean, I guess the next step in an ideal world or if we'd had enough money within this funding period, would be to follow up these families over the years ahead to determine whether that reduction and risk does then translate to reduction in diagnosable anxiety disorders into the future and longer term. So if anyone knows anyone who would fund that, then that would be great. Yeah, absolutely. And I think also-- you mentioned about this in the beginning a bit the fact that parents felt-- I'm not sure, I'm not sure. It was not in the paper but are you guys going to do a qualitative component of the trial? Because I suppose that in terms of supporting parents feeling empowered and able to support their children throughout their primary schooling years it's such an important thing. And I think clearly your results show that your intervention is great at doing that. So, so yeah, and I think this is such a big difference. And I mean, your study didn't measure that specifically, but yeah, we know that reduction in anxiety reported symptoms is also associated with higher educational achievement in children and things that obviously, you're not going to see at 12-month follow-up, but could have ripple effects later on. Yes, yeah, absolutely. So our qualitative interview and findings aren't in the main paper. They will be published soon. So we're just finalising that manuscript just at the moment. But yeah, absolutely. So within those, we conducted interviews with parents who receive the intervention within the trial. And certainly they really do-- those interviews do point to wider potential benefits beyond things. So that was within the context of the trial. So wasn't assessing longer term, but certainly ripple effects in children and families' lives. So applying strategies and principles with other children. So with siblings and wider relationships and feeling parents often talk about having feeling that they have these things in their back pocket so that they can revisit it as and when which really points to the potential longer-term benefits. And definitely, that-- what we said there, that knock-on, ripple effect was very much a motivation for this study that we do know that anxiety problems early in life are associated with these, both in the short term but also in the longer-term negative consequences for children. So if you can change that trajectory, there's real potential for longer-term benefits for affected children, but also more broadly for society. Well, I have all my fingers crossed that you'll get the funding to do lots of follow ups and expand the trial, I suppose especially, as you said, in terms of-- we spoke about good knock-on effects. We're thinking about, I suppose, bad knock-on effects. I think just because of the threshold for accessing CAMHS being so high at the moment. Actually, by the point a young person reaches CAMHS lots of the time, so many other things have already happened to them. And then we're talking about more complex cases, which of course, can be helped. But then at that point, changing that trajectory, it's so much harder then years before. So, so yeah, I think those interventions are so important. Yes, yeah. Absolutely, absolutely. But still speaking about your trial and I suppose we talked about that a bit. That from a clinician's perspective, at the moment, we're dealing with really an overstretched services and early interventions. They just have so much potential. And this is maybe a spoiler of your future collective study. But in terms of intervention design, again, we talked about that a bit. You mentioned parents really valued that human support element of intervention. And can you tell us a bit about what the importance they placed at this support. And also, what do you think this means for digital mental health interventions going forward? Do you think that all digital mental health interventions should have that human element support option if needed or purely self-guided also works just as fine in certain settings? Yeah, thanks. So certainly in the qualitative interviews in this study and in other studies, two parents do talk about the calls as yeah, I guess providing some motivation and encouragement. I think that feels really important and also practical support with resolving difficulties throughout the course of the intervention. And it is notable, I think, in this study, the completion rates that we saw within the intervention were really-- we were really pleased with them. And when you look at them alongside other interventions that are delivered in slightly different ways, that really does I guess, provide us with confidence that this approach where parents are attending and completing sessions, that's evidence that you're doing something. Well, we had around 3/4 of the families completed the intervention, which given that this is we've recruited through schools, these are children at risk, not necessarily experiencing significant difficulties. That in and of itself, I think is encouraging. And definitely, quite similar trial that was conducted in Australia, where they used an intervention that involved parents attending face-to-face and group sessions. The attendance rate at those sessions was much lower than we saw in this study. And what's really interesting is when you look at the completion rates, I think compared to digital interventions that either don't have any support or that support is just optional. So within our intervention, the support is very much-- the parent works through a module, completes the module, and then they have the support call before they progress on. So it's integrated within the package. There was an evaluation of a digital intervention, again, by a research team in Australia, where parents work through a similar kind of website and they were able to ask for support calls, but very small numbers of families requested those calls. So it does feel like those support calls play an important role. And it does need to be really integrated and part of the intervention, rather than something that you need to ask or expect parents to ask for that as an additional add on. I think where we're thinking about whether it's better or worse or needed to have this integrated therapy support, it gets a bit more complicated. I mean, I'm always a bit nervous of saying there's just one way of doing this, and one approach is going to work for everyone. So in this approach, the support calls definitely the evidence that we have that it feels so critical component of this intervention. But that's not to say that there isn't also a place for an unguided approach in perhaps a different setting and a different population. And certainly, Sam [? Cartwright-Hatton, ?] who's based in Sussex, they've recently published findings from a trial where they evaluated a really quite light touch, unguided digital intervention for parents with elevated anxiety. And they've seen positive effects compared to no interventions. And that sort of intervention, of course, is a lot less resource involved. So it might just be there's a place for different types of interventions that are available for different groups of children and families at different stages with different needs. And almost it feels like that's really critical. That's a very sensible answer. I know also in the US and in the UK, Jessica Schleiter and Maria Lourdes do a lot in terms of self-guided digital health interventions. And their studies have been showing some really promising results. So I think it's definitely not a one-size-fits-all. Yeah, exactly, exactly. That's feels the important thing, doesn't it? To wrap up Dr. Reardon, I think we talked a bit about that already anyway. But I would be really interested in knowing moving forward in the future of school-based interventions or even CBT-led interventions, what are you looking forward to seeing next or doing next? Oh, well, yes. So thank you for having me. I've really enjoyed the conversation. I mean, I think there's lots more to do. It feels like there's always lots of questions to address and further research to do. If I may or maybe just speak about an area that I'm particularly focused on at the minute. So in this trial and in one of our other school-based trials to where a key motivation is about reaching families who are not currently reaching and accessing support and services, and reaching them at an earlier stage. And in this trial, we had schools from all different parts of the country and really with varied pupil populations. And we had families, varied backgrounds participating and benefiting from the intervention. But we did still see really marked disparities in participation across schools, where those schools with higher numbers of pupils from more socioeconomically disadvantaged backgrounds, fewer families participated. And particularly fewer families completed those initial screening questionnaires. So that really does point to a potential inequality in access, which is really a key-- feels a key focus an important area that we do need to address and keep considering going forwards. And my team at the moment are planning some qualitative work where we're going to be working specifically with families living on low incomes and school staff and other practitioners who work with and support those families to think really about what may be additional or magnified barriers or challenges that those families may face participating in this type of intervention when it's offered through a school setting. And perhaps additional targeted and tailored support, we really need to ensure is in place for those families to ensure that we don't end up inadvertently exacerbating an inequality. And so yes, so that's definitely a key focus for me, but I think would apply more broadly as well with providing support through school settings. That's so important, I think. Even if we're thinking in terms about of the effect size, the difference you can make with those groups because we know that it's very common that in lower-income settings, mental health disorders are more prevalent in parents, for example, just because of socioeconomic inequalities and struggles. So actually, we know that those children are much more likely to be struggling with anxiety symptoms. And the interventions interventions for them could make such a huge difference. Yeah, absolutely, absolutely. Well, that's such important work. And I look forward to reading that work when that's published. Maybe you can come back for another podcast. And thanks so much for being here today and for sharing with us about your paper. There will be a link to the paper in the podcast page for those of you who want to read it, but it's published in the JCPP. Thank you. Thank you for having me. [MUSIC PLAYING]