We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH learn. Please be aware that this podcast covers the topic of non-suicidal self-injury and suicidality in adolescents. Some listeners may find these topics upsetting. 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, their innovative interventions and best practises in child and adolescent mental health. And today, I have the pleasure of receiving Nita De Neve-Enthoven and Susan Ravensbergen. They are both researchers and PhD candidates from the Department of Psychiatry at the Erasmus University Medical Centre in Rotterdam. And we're going to be discussing their paper, debt and experienced financial scarcity associations with non-suicidal, self-injury and suicidality in adolescents at risk for psychopathology, published at the Camp Journal recently. And there will be a link for the paper which you can access. And it's an honour to have you both here, Nita and Susan. Thank you so much for agreeing to do the podcast with us. And to start, I wondered if you could just share with us a bit about your research trajectories so far. Yeah, well, thank you for having us, first of all. So Susan and I have been working at the iBerry Study in Rotterdam for quite some time now. It's a large longitudinal cohort study, and we've been following over 1,000 adolescents for over 10 years now. And these adolescents, they are all at increased risk for developing mental-health problems. And I think one of our unique strengths is that it allows us to follow young people over time, and that helps us to better understand not only what conservatives do this, health difficulties but also, what helps them, protect against them. And within this study, we have quite a large research team, and we all have our own topics. So my topic is on self-harm. Susan will introduce her topic, as well. But we also have researchers that are looking at substance use, psychosis, or other topics. I have a background as a psychologist, and as I said, I'm focusing on self-harming behaviours in adolescents. And usually it's just one or the other. I say-- under self-harm, we say, OK, it's not only about suicidal self-harm, but it's also about non-suicidal self-harm. And I think that's where our research makes a difference. We have such a large group, and we are able to measure both these constructs that can be related but are not always related. And I'm just curious about how are these behaviours developing over time, what will increase the risk of developing this? And how can we identify a young persons that are already engaging in certain behaviours? And how can we support them earlier on? And a couple years ago, I got the opportunity that alongside my research, I was also able to start as a scientific teacher at the medical school here at Erasmus University. And there I supervised master's and bachelor's students, and I teach them about well-being in bigger classes on communication skills. But I also see them individually, and that's where I see that I have a connection with my research versus practise. So I'm very happy that gives me the chance to see what's actually happening with adolescents instead of just looking at data. So I have a bridge over there. So that's about me. And I am Susan Ravensbergen. I also work with Nita and our whole research team at the iBerry Study, and my topic focuses on the relationship between financial problems and mental health in young people. And I'm interested in how experiences such as debt or financial stress, or economic disadvantage can affect young people's well-being and especially their mental health. And alongside my academic work, I also work as a psychologist with adult population in an outpatient clinic, and this also gives me the opportunity to see the impact of financial difficulties on daily life. And I see they are connected with stress, depressive symptoms, anxiety, but also a relationship problems. So all this link I observe here as well that really motivates me also to better understand the connection between mental health and financial hardship, and how they may influence each other. Yeah, it's really amazing to see how your research interests are complementary and also how you brought them together in the paper, because in your paper you look at dissociation of debt and financial scarcity. So your interest isn't with non-suicidal self-injury, but also suicidality. And I wanted to ask you both, so we know a lot about the impact of debt and self-perceived financial scarcity in adults. And we know that it can affect outcomes such as mental health. But what do we know about adolescents and what was the gap your paper was trying to address? Yeah, indeed, we know that financial difficulties, debt and financial stress as well, they've been linked to depression, suicidality and even suicide by death in adults indeed. And we know that for quite some time already. When we started this research, we realised that we knew surprisingly little about whether the same applies to adolescents or young people as well. When we looked at the literature, we saw that most of the existing studies they had focused on adults or University students or young adults, but mainly in their 20s. And well, yet adolescence is such an important period because that's often the period when mental health problems start to emerge, but also when financial responsibilities start to grow. And we were surprised that very little research was done on this topic in adolescence, about their own financial situation. Because we saw some research was done on for example, family financial stress, but not the situation and the experience of the adolescent themselves. So that was the gap we tried to address in our study. That's brilliant. And I think one thing you've mentioned at the beginning of the podcast thing, that I don't think I had realised about your research group is how interdisciplinary it is, and you all have different expertises. And I think one of the things that's really nice about the paper is that you've had with a financial institution to be able to design questions about debt and also financial forecasting. So, yeah, I wondered if you could tell us a bit more about that and about how did you measure especially the financial scarcity, which is the more subjective concept compared to just debt? Yeah, we work closely together with the neighbours and a Dutch National Institute for family finances information, because we wanted to look at financial problems in a way that was meaningful and relevant for adolescents as well. So that's why we focus on two different aspects of the young people's financial situation. So the first was what we might call objective financial problems. So that's for example, the category of whether adolescents have debts, which might be student loans or borrowing money from someone or falling behind with payments. And the second aspect we wanted to measure, especially in adolescence, was the experienced financial scarcity, which is more the subjective one and is really about how people feel about their financial situation. Do they worry about money? Do they feel like they have enough resources, enough money to do the things they want? And whether they feel in control about their money, but also about their future, or whether they are constantly stressed about it. And I think that distinction is really important because two young people can have actually the same financial circumstances. One might feel financially insecure and the other financially secure. So we really wanted to capture both sides of the picture to get a complete insight in how they both impact mental health, maybe in a different way. Yeah, and I think one thing that's really interesting about the subjective aspect of financial scarcity is that nowadays the Gen Z, they talk a lot about this feeling of comparison all the time of their peers. That's mainly fueled by social media. And I don't think we have a lot on financial scarcity data and how adolescents perceive themselves, their financial situation in relation to their colleagues. So, yeah, I think it's really fascinating that you guys tackled this question. And speaking about your results, one result that I found really interesting was that you found an association between debt and suicidality, but you didn't find an association between debt and self-harm, if I interpreted findings correctly. And I was just wondering if you could tell us a bit more about that and yeah, how did you make sense of those findings? Yeah, there was also something that really stood out for us, because we really like to make the distinction between suicidality and non-suicidal self-harm, to see whether there's maybe different mechanisms at work. Would there be a comparable association? So we considered a range of other factors as covariates, such as the family income, the parental mental health, social support and lessons received at EKOS. But we found that adolescents with depth were almost twice as likely to report suicidality compared to their peers who did not have any debt. But interestingly, we didn't find any patterns like debt for non-suicidal self-injury. So we were wondering, OK, what's going on here? Why is there a difference here? And I think we have come up with a few possible explanations. Of course, we're open to other explanations that we haven't considered, but one of the explanations could be a really boring one. Just saying, well, we didn't have enough adolescence with debt in our study, so maybe we just had a power problem over here. So it might be harder to detect a clear relationship with NCIS than with suicidality. That could be the case. But otherwise, we were also thinking about those mechanisms. And we think that well-being in debt can create worries about the future. It can make you feel hopeless. It can make you feel stressed. It can make you feel trapped. And these are all factors that we know that have been associated with suicidality in the past, and also in adolescence. And non-suicidal suicidality, we said, OK, that can serve a lot of different functions, so it can be coping with intense emotions, but it can also be about a bunch of other factors. I've actually wrote them down. We have an instrument that measures all these components. And it can also be served as a function anti-suicide or to state some interpersonal boundaries. And I think there's so much going on there. There can be so much different reasons why somebody is performing non-suicidal self-injury that, that might be the case, that's why we didn't find an association over there. And there could be other risk factors. So we think we need some more research to see, OK, what pathways are going on here? But I think our findings do suggest that it might already be very relevant to look at debts when we are looking at suicidal thoughts and behaviours in young people. So that's something that we think we can say. Definitely. And yeah, and you found such a clear association between debts and suicidality. So yeah, there's definitely a really important point. And the other thing that your paper made me reflect a lot about was, well, we're talking about adolescence. So those are people that are reporting significant level of debt very early in their lives. And I thought it was very interesting that you not only reported if they had debt or not, but you also looked at the types of debts that they had. And so I wanted to ask you, do you think all debts are the same in terms of how they impact mental health and well-being? And I also remember from your paper that the most common type of debts reported by adolescents was educational, so student loans, which are also really common in the UK. And I wonder if you think that might have made a difference in terms of the associations you found because you could see a student loan as something that is an investment in your education, for example, versus a debt that is a credit card debt. So I'm really curious to hear your thoughts on this one. Yeah thank you for your question about that. We do think that there might be a difference, a difference in how the debt impacts a mental health in the same way. As you already said, in the UK, it's very normal for students to have these student loans. Yeah, I see that over here as well, in my work. So we think yeah, there are probably different meanings, different emotional impacts of different forms of debt. I think most students see a student loan as an investment in their future. It's also generally more socially accepted. So I have one, then for example, what you mentioned, the credit card debt or unpaid bills or borrowing money because you're struggling to cover your everyday expenses. And I think that these latter may feel very different and they come with much more stigma or social pressure. And I think that one of the interesting findings of our study is that even these debts that are considered as relatively normal, those students that may still have consequences, actually, for mental health of young people, because nearly half of the deaths in our studies were student loans. And we still found this association with suicidality. So that's very interesting. And we were also thinking about several reasons why we had these findings. We think that while student debts often come with more favourable repayment conditions in the Netherlands, I don't know if that's the case in the UK too. But I can still have an effect on your disposable income for years, sometimes even up to 35 years. Because even when you have a student loan for a positive reason, like investing in your future, nowadays, it can still cause some worry about how am I going to repay this? How am I going to start my adult life with such a big amount of debt hanging over my head? And especially in the Netherlands, that changed a couple of years ago. Is that actually your student loans can have an effect on the height of the mortgage you can get. And that's particularly relevant right now because in Netherlands the housing market is already pretty challenging for young people. This can actually make this worse. Yeah, I don't know if Susan wants to add to that. Yeah, and another way to look at it is that it's also possible for some young people student loans may serve as a gateway debt. So it will make it easier or normalise taking on more debt later on or borrowing money from someone. And if you take that over time, it starts with maybe a student loan and then borrowing money from someone because you can't cover additional expenses. So over time, that might contribute also to increasing financial pressure or increasing debt. That's something that needs to be understood better. And well. I think one important takeaway from this is that we shouldn't automatically assume that certain types of debt are less harmful or harmless, maybe simply because they're more common or socially accepted. And it might be that it's often not just the type itself that matters, but how the young people or the people feel about it and how they experience it is what matters most. Well, this is such an important point, and actually you've commented a bit on it already, but I was going to ask about, what's the current situation in the Netherlands in terms of cost of living for young people and et cetera? Because you've asked about the UK. So yeah, in the UK actually recently the student loan rules of the programmes have changed. So you still can get a student loan under more favourable repayment conditions that you would get if you were getting a loan to buy a house, for example. So the repayments changed a lot over the years. And the current programme, there is an interest obviously. Before, it used to be that it would lapse after a certain number of years. Now this number of years is like something impossibly long. I think it's 30 years, but the people listening to this podcast will definitely know the answer. I think it's 40 years, if I'm not mistaken. And then also, the other relevant thing that changed in recent years is that the interest accrues even if you're not working. So for people that spend longer in education, that has a really problematic side effect, because it basically means that while you're not earning to pay back the loan. So let's say if you want to do a PhD or if you are unemployed, the interest is still accruing. So it makes it really hard for people to be able to repay it basically, because it's the interest snowballs over time. So yeah, I definitely think it's something that young people do talk about and do talk about as affecting their life choices and their employment choices. So, yeah, I think it's definitely not as Susan said, yeah, it's not because it's an educational loan that it doesn't have-- and as you found, because in your study, I think in your sample, over 50% were student loans. Yeah. But how about the Netherlands? How is like the current employment situation for youth? Is it something that-- are people worried about the cost of living? Or is it something that actually it's not a super worry for young people at the moment? I think the situation in the Netherlands is comparable. The system has also changed recently about student loans. So that also makes young people talk about, well, what will happen to my student loan? What do I have to repay it if stop education? And worldwide we're dealing actually with some financial situations everywhere. So for example, the gas prices recently increased. So that makes also an impact on I think everybody's life. But also young people are now starting, their job starting, their life starting to build a life and the choices they make. And if I may add something to that. I think also for future research, it's something we want to distinguish between the different types of loans. So indeed the student loan whether it impacts mental health, maybe differently or maybe not than other types of debt. Yeah, which actually brings us nicely to what my next question. Because in the paper, you guys looked not only at the objective debt, as you explained in the beginning, but you also looked at financial scarcity. So young people's perception of their own debt and their own situation and how they were doing. And yeah, I'm really curious to know what were your findings in this area and how they correlated with suicidality and self-harm? Yeah, that was also actually something we also found very interesting indeed, because while debt was associated with suicidality, only experienced financial scarcity was associated with both a non-suicidal self-injury and suicidality. And also these associations remained after we adjusted for example, household income. And another range of factors, but especially the household income is very interesting here. So it wasn't simply a reflection of growing up in a lower income household, other the results we found. So while this suggests that as we already a little bit mentioned when talking about the instruments we use, that how young people experience their financial situation may be highly relevant for their mental health. So not only about the amount of money that's available is important, but also whether they feel financially secure and in control and are able to cope with their financial demands. So from a prevention perspective, that's also an important message, I think, because it suggests if we focus only on objective measures or indicators such as debts, we may miss young people who are vulnerable because they're experiencing significant financial stress, other than can be measured in debt depth or household income. Do you want to add anything Nita, to that or? Yeah, well, I think Susan is our financial expert. So I know when I give the floor to her and I think she-- it's nice that we found it because also in the choice of the measurements Susan uses throughout her study. Because I think you use this instrument more often. It's nice that it works out like this, that we're actually able to see these associations in this very good choice of instruments at the beginning of her study. Yeah. And it's also interesting that they do not fully overlap. So it's not only the adolescents who report having debt that also report high financial scarcity, but it's not a one on one association between the two of them. So it's actually, we see it as really a different construct. Yeah. They are. And I think it's so interesting and so important, as you said, because I'm not sure if we've made that clear. But if you guys read the paper, you'll see Susan and Nita, they also controlled for family income. So when we speak about the association between financial scarcity and worse self-harm and worse suicidality is not just that, people who are from lower incomes are struggling. It's actually that the financial stress and the financial perception of being worse off than your colleagues impacts on mental health, regardless of your family income. And I think that's so relevant for what we were talking about, about the cost of living. Because if young people are really worried about being able to afford a house or afford to pay off their loans, that will have an impact on their mental health, that has really important implications for prevention and financial literacy as well. And yeah, no, it's really important work that you guys did. Yeah, I think also because I saw such insecure times, also because of in the Netherlands, you have a lot of flexible contracts right now for young people that are kind of souls, like, OK, look, you have a lot of freedom, et cetera. But on the other hand, I think adolescents also don't have a lot of security. So it actually makes it more difficult and you're easier to laid off. And yeah, so it's something that should be positive is actually not that's positive at all. And I think it would add to the worry that they already have. Totally. And I think yeah in the UK, the youth unemployment it's a real concern. So yeah I think we've reached the highest levels of youth unemployment over of the past 10 years. And when I say youth unemployment is that stage of 18 to 24, so immediate post-college. And yeah, I think there are many factors behind this. But also obviously the fact that young, more young people are unemployed definitely contributes to their perception of well, financial scarcity. And as you said, Nita, the contracts are shorter and it's harder to get that long-term permanent jobs as it used to be in the past. But what I wanted to ask you as well is wrapping up this podcast. So your study was the first to look at this association between debt and perceived financial scarcity and mental health outcomes, precisely suicidality and self-harm in adolescents. And you found a significant association. What do you think, in your view, are the main implications of your findings in terms of policy, but also in terms of future research? Well, I think that the main message from our study is that financial well-being and mental well-being are much more connected than we often think. I think, but Susan can tell more about that maybe. But that's in adult populations, the patient populations in psychology, it's very normal to ask about financial difficulties because we consider them independent and it might be a problem, but I don't think we feel about adolescence like that yet. So I think, OK, you're still living with your parents. Yeah, I'd be OK. Or we only worry when the family income is not OK. So traditionally, financial problems and mental health have been treated as separate issues in adolescence. But I think that our findings suggest that they are closely related. So even during adolescence, we think for policymakers, our findings suggest that maybe financial literacy programmes or debt prevention initiatives, or accessible financial guidance for young people, that may not only improve financial outcomes but at the same time have benefits for mental health. So I once talked to a young adult saying, OK, I can have a job, I can have money, but when I don't have a house, I'm nowhere. And it makes me worry all the time. So I think it's very important that we look at the benefits for mental health. And I think we also see that it is not just the debt that counts. So the number of the debt, but it's also how young people experience and cope with the financial stress they have. And I think for clinicians our findings highlight the importance of paying attention to financial concerns as well. When talking about adolescent mental health, maybe not only their own concerns, also about the family household income, because I can imagine that also serves a lot of stress. So always take both into account. And I think that these worries about money are often overlooked, although they can be a major source of distress. And I think the same applies for families. So talking about money in your family, that's not a very easy thing to do. And I don't know if that's a Dutch thing especially, but we don't like to talk about money, but it's very important to do that. And I think that adolescents may feel embarrassed or guilty or reluctant to burden their parents with financial concerns. And I think that as a result, any financial struggles that they have can remain hidden, but also the mental health problems that can be associated with it. And I think that's a very important message. And maybe Susan would like to add some more. Yeah, I think you're right. And we don't have to make it too complicated. I think just simply asking young people, how are you doing financially? Are you worried about money? Are there things you want to buy that you cannot afford? Or do you have debts if they are of any amount of money? I think that can, that's very important to do, to also ask about how do you feel that you're coping financially? And that it helps identify well, young people are vulnerable of maybe also developing mental health problems if they haven't already. And more broadly, I think that our research results suggest that helping adolescents develop both financial skills and confidence and managing their money can be important, as part of prevention from mental health problems and especially self-harm prevention. Because financial independence is also often viewed as a practical step towards adulthood, but it's also a psychological one as we saw. And feeling capable of dealing with financial challenges and strengthening resilience in that area, I think that's very important to take as a holistic approach. So, yeah, well, I think something that we really want to communicate with our research and recognising this connection between mental and financial health could help us support young people earlier and more effectively. That's a very nice take home message. And with that, I just wanted to say a huge thank you to both of you, again, for accepting to the podcast. And I think for talking to us today about a topic that is so relevant for so many young people and their families. And No, Nita is not a Dutch thing, I think in the UK, speaking about money is a massive taboo as well. Yeah, people don't really talk about it normally. I think even with adult patients, I work in inpatient psychiatry. So lots of the time we ask and even when we ask, it's still seen as a bit of a very delicate topic. But yeah, I think it's definitely your paper sends this message very clearly in relation to adolescence that it's really important to talk about it and normalise talking about your financial situation with trusted people. Yeah, thank you so Thank you. Thank you for having us. And thank you for the listen.