[COOL MUSIC] We are the Association for Child and Adolescent Mental Health or ACAMH for short. Hello. Welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I'm Jo Carlow, 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. To tie in with eating Disorders Awareness Week, I have with me Dr. Naomi Warne, a research fellow within Bristol Medical School population Health Sciences at the University of Bristol. And Dr. Helen Bould, consultant senior lecturer in child and adolescent psychiatry at the same institution. Naomi and Helen would talk us through their paper, Emotional Dysregulation in Childhood and Disordered Eating and Self-harm in Adolescents, Respective Associations and Mediating Pathways. Recently published in the JCPP. If you're a fan of our Papers Podcast series, be subscribing in your preferred streaming platform. Let us know how we did with the rating or review. And do share with friends and colleagues. Naomi and Helen, welcome. Thank you for joining me. Can you start with introductions about who you are and what you do. Thanks so much for having us. So I am Naomi Warne. I'm a Research Fellow based at the University of Bristol in Bristol Medical School. My research focuses on investigating potential risk factors for mental health problems, such as disordered eating, anxiety, depression, and self-harm in young people. And how we can target these factors to prevent mental health problems from occurring. And hi, Jo. Nice to meet you. I'm Dr. Helen Bould. And I'm a Senior Lecturer in child and adolescent psychiatry also here in Bristol Medical School. And I work clinically as a consultant in Gloucestershire. Thank you. Let's turn to the paper. This is Emotional Dysregulation in Childhood and Disordered Eating and Self-harm in Adolescents, Respective Associations and Mediating Pathways. Recently published in the JCPP. Maybe start by telling us about the co-morbidity between disordered eating and self-harm, and also emotional dysregulation. What is known about these associations? Yes. So we know that both disordered eating behaviors, by which we mean things such as fasting, purging, binge eating, excessive exercise, and self-harm, are both common in adolescents. And we know from studies and patient samples that the co-occurrence of eating disorders and self-harm, including suicide attempts, are really quite high. So around 14% to 64% of patients with eating disorders report self-harm. And we know from our own earlier work that there are also high rates of occurrence in these behaviours in the community. So in some of our work in ALSPAC sample that Helen will go on to talk about in a moment, at age 16, that amongst those with disordered eating, around 1/3 of females and 1/4 of males also report self-harm. And in those who have self-harm, 2/3 of females and 1/3 of males also report some form of disordered eating. So this co-occurrence is really, really high. Maybe it reflects some common etiological pathways and some shared risk factors. So emotional dysregulation has been suggested as one shared risk factor for both disordered eating and self-harm. Helen, do you say a little about that? Yeah. So in our paper, we define emotion dysregulation as the inability to be aware of, accept, regulate, and modify emotional reactions and subsequent behaviors. So that's something that I see quite a lot in young people in clinic, especially alongside disordered eating and self-harm. And some interventions that we might use in a clinic setting aim to try and help people to learn ways to regulate their emotions. It's particularly a focus of dialectical behavioral therapy, or DVT. But what we don't know for certain is whether it's something that happens before self-harm or disordered eating develop. And whether it might be something that might make someone go on to be more likely to develop those difficulties. And that's why we're interested in studying it. I was going to ask you to set the scene a bit. So you already started. Can you turn into the research, can you say a little more about what you looked at and also why. As Helen said, we're interested in emotional dysregulation, whether it occurs before, and maybe a risk factor for disordered eating and self-harm. And there have been some previous studies that have looked at the prospective association between this earlier emotional dysregulation and later eating disorders or self-harm in adolescents. But the majority of these, although they found evidence of associations, they tended to have shorter follow ups of around a year or less, or focus on specific maladaptive strategies such as rumination rather than broader or global emotional dysregulation deficits. And when we were looking on this, we also weren't aware of any studies that considered both disordered eating and self-harm together, which is really important bearing in mind the co-occurrence that we've just been talking about. So the first thing of our study was to assess the association between global measure of emotional dysregulation in childhood and both disordered eating and self-harm in adolescents. And we're also interested in other things that might lie along that pathway, from emotional dysregulation to self-harm and disordered eating. And having this longer follow up has enabled us to be able to examine some specific mediators that might lie along this pathway. Yeah. So as Naomi says, we kind of wanted to see whether there were some other things that might be important in that relationship, particularly things where there might be a possibility of intervening, again, to try and prevent later self-harm or disordered eating. And we looked at three possible things in this paper. Firstly, social cognition. So that's kind of how people make sense of social situations. Secondly, emotion recognition, which is about how accurately people can recognize and identify facial emotions. And, again, we meet a lot of young people in clinic where those are things that they find challenging. And that can make going through adolescence really difficult. And the third thing that we looked at was experiences of being bullied. And we know that being bullied is associated with a range of later mental health problems. And it's also something where we already know that it is possible to intervene to prevent it. I would like to come to looking at some of the interventions a bit later. But before we go there, can you say anything more about the methodology used for the study? Sure. So we used a cohort study called the Avon Longitudinal Study of Parents and Children, asthmatic children too. But it's also known as the Children of the 90s Study. And the study recruited 14,000 pregnant women in the early '90s. And it followed them and their children up every year since then. So now those children are in their early 30s, which makes me feel quite old. But we used data from when the children were between seven and 16. And we took a measure of emotion regulation which was reported by their parents when they were seven. And it's a measure that's been used by other groups of researchers. And which probably quite a lot of clinicians will be familiar with because it takes some subscales from the strengths and difficulties questionnaire which we quite often use in CAMHS as a kind of screening questionnaire. And it pulls out the emotional hyperactivity and conduct subscales from the SDQ. And then we use measures of self-harm and disordered eating that were reported by the young people when they were 16. So the self-harm measure asks about whether the young person has hurt themselves on purpose in the last year. And the disordered eating measure asks about any of the disordered eating behaviors ALSPAC measured at that age. So fasting, which we define in ALSPAC as not eating for at least a day in order to lose weight or to avoid gaining weight. Purging, so that's vomiting or taking laxatives or other medications to lose weight or avoid gaining weight. Binge eating, so eating a large amount of food in a short period of time with a sense of loss of control. And excessive exercise, which is exercise in order to lose weight or avoid gaining weight that routinely interferes with your daily routine or your work. And, again, those measures were in the past year. So we worked with Jon Heron, who's an expert statistician at Bristol, to analyze this data from just under 7,000 children. And, firstly, we looked at the associations between emotion dysregulation at age seven, both disordered eating and self-harming at age 16 using something called bivariate probit regression models. And what these are, these essentially take into account the pair of binary correlated outcomes. And then we use road test to see if there are any differences in the associations according to outcome. So any differences between disordered eating and self-harm by sex, so for males or females. And in this model, we accounted for some key confounders that we thought could influence both our exposures and our outcomes. They include things such as sex, socioeconomic disadvantage, maternal mental health, and child gender cognitive ability. And for our second aim, we extended the model to incorporate three hypothesized mediators. So that's the social cognition, emotion recognition, and being believed, that Helen's already mentioned. And we examined the indirect effects of each of these mediators by calculating the proportion of the total effect explained by the pathway. And this tells us the amount of the associations between emotional dysregulation and the outcomes that the mediator or the pathway can explain. Let's look at some of the findings and what-- we're going to the detail. But can you give an overview what were the key findings that you would like to highlight. Yes. So our main results of findings are that the emotional dysregulation in childhood was prospectively associated with both disordered eating and self-harm in adolescence. What was really particularly interesting was that these associations didn't vary by sex and they didn't vary by outcome. So higher emotional dysregulation scores were associated with greater probability of both disordered eating and self-harm, with a similar magnitude of effect, and for both males and both females as well. And I think that the most important finding is that it does really strongly suggest that difficulties with emotion dysregulation happen before self-harm and disordered eating. So that suggests that it's really worthwhile to try and develop interventions to support children to learn to regulate their emotions because it looks like, from this evidence, that that would be a good way to try and prevent them from going on to develop problems with disordered eating and self-harm. So just to understand it, is the thought here that this is a kind of not a particularly functional way of trying to quell the emotional dysregulation through self-harm or through disordered eating? So I guess that they're both really, really complex things that people present with. So it's difficult to be, sort of, catch all and answer to say yes. This is always a problem for people. But sometimes it's a part of the difficulty for people, is that they struggle to regulate emotions. And they might use things which are less healthy in an attempt to try and manage the way that they're feeling. You mentioned earlier the three potential mediators. I wonder if you could describe these and the relevance of them. So you describe three potential mediators of the association between emotional dysregulation and subsequent disordered eating and self-harm. Perhaps you can talk us through these. Yeah. So as I described earlier, we looked at three things that might be important along that journey from struggling to regulate emotions to later self-harm and disordered eating. We've looked at emotion recognition, which in ALSPAC was measured by getting people to look at faces with different facial expressions, and try to quickly identify what the facial expressions were. It didn't seem to be at all important in the models that we felt. It didn't seem like that was a major player in this pathway. However, social cognition, which is about how people make sense of the social world, did seem to be important in that pathway, and so did experiences of being bullied. But it all gets a little bit complicated in terms of our two different outcomes, so the self-harm outcome and the disordered eating outcome, and also in terms of sex. So I think that Naomi is going to talk a little bit more about how those differ between the two outcomes in the two genders. But it seems to me that the social cognition and the bullying are, again, areas where working to support young people could be really useful in preventing later health problems. You said the paper found that mediating pathways appear to differ by sex and outcome. So can you say a little bit more about that? In our mediation analysis, we didn't find much evidence for difference by sex and outcome or emotion recognition. As Helen said, there wasn't really any evidence of mediation there. But for social cognition and for bullying, we tended to see that the proportion of the total effect mediated was often greater in females than it was in males, and greater for disordered eating than it was for self-harm. So whilst we found that social cognition was an important mediator for both sexes and outcomes, it accounted for a much larger proportion of the total effect of females compared to males, and for disordered eating compared to self-harm. And we also saw this pattern for bullying. So for our disordered eating outcome, we saw that bullying accounted for 17% of the total effect of females compared to 10% the total effect for males. But for self-harm, being bullied mediated 16% of the total effect to self-harm females, but only 4% in males. And that's quite a difference there. What we kind of tell from this is that in females, they tended to have two dominant indirect pathways. So one via social cognition and one via bullying. So both disordered eating and self-harm. But in males, it was a bit different. So males have these two dominant pathways for disordered eating, but only one dominant pathway via social cognition for self-harm. So there might be some differences going on there that might be interesting to look at further. Any hunches as to why? I guess is what gets us into the realm of speculating. Do you want to do some speculating? Yeah, I could do. One of the things we was thinking was that, actually, it may be that other things are on line on that pathway for males. So it could be that actually there are all sorts of different mediators in play. And there is not the social cognition and emotion recognition and bullying are important in these pathways, but it's something different for males. And, similarly, it could be different outcomes for males. So emotion dysregulation may be related to completely different outcomes rather than disorder eating, self-harm for males. So lots more to still look at. Is there anything else in the paper that you'd like to highlight before we look at things like interventions? Yes. I think we just wanted to say a little bit about limitations, actually, because we've made this theoretical model about how emotion dysregulation and disordered eating and self-harm relate to each other, and then we've looked at these particular mediators that we've picked out. And so I guess we just want to put a little bit of caution in there, really. I think all models are probably wrong, but some models tell us something useful along the way. And when we were thinking about this, and particularly when we were responding to reviewers around their comments about the paper, it's possible-- as Naomi said-- that things that we haven't studied here that might be really important along that pathway. And it's also possible that we've used things as though they happen separately from each other and at different times and aren't really related to each other at all. We looked at social cognition and presented it as though it's totally unrelated to emotion regulation. And, yes, it's measured by a different scale at a different time. But that doesn't necessarily mean that it's not a kind of different facet of a similar kind of concept that we just happen to have presented in this way because of the model that we've used here. So, I guess, that we just wanted to have a little note of caution. As you've already mentioned, the results suggest that emotional dysregulation, social cognition, and potentially bullying may be useful targets for the prevention and treatment of disordered eating and self-harm. What interventions would you like to see put in place? And how do you envisage your findings being translated into practice to support this? For results about bullying, I guess, schools are an obvious place to intervene with anti-bullying measures. It's where a large amount of peer to peer bullying can occur, and it can be tackled at a school level. There's been a recent meta analysis that we cite in the paper, actually, that's found that although effect sizes are small, that anti-bullying interventions do have the potential to effectively reduce bullying and associated mental health problems in young people. So I think that'd be a really great place to start interventions. Yeah. And I think that clinically people are already doing quite a bit around trying to help young people regulate their emotions, but it tends to happen at the point where they are presenting with other challenges, like disordered eating and self-harm. So it would be good to start trying out some of those things, and trying to develop new interventions that really try and support younger children in developing strategies to help them to regulate their own emotions. And then I guess the other thing is around social cognition, which is a real challenge, I think, because clearly we're-- we live in a very social world, don't we? Look at the relationships that we have to make sense of. And when children and young people struggle with that, it does make all aspects of their life really challenging. And they can then need extra support, really, to help them to manage those challenges. I'm working at the moment in a social communication and autism survey, so I guess seeing lots of people where those are particular challenges for them and thinking about how to support them through that. And how we as the schools and wider society can be, I guess, understanding of those differences and things that people find hard. And try and help them to manage because that can-- otherwise can lead them to more problems further on down the line. Given your findings, what advice do you have for CAMHS professionals? Yeah. I work in a CAMHS team. And I see my colleagues working incredibly hard without enough resource, and doing an amazing job every day. I'm not sure that this paper is really so much for them because I think they're tending to see young people who are already struggling with self-harm and disordered eating and other mental health problems. And that really this is-- this paper really speaks more to trying to prevent those problems from developing in the first place, which is not within tertiary mental health services. It's within wider society, it's within schools. It's public health level intervention, I think. So any message to policymakers in that case? Yes. Please, can you-- please, can we be thinking about young people, really little ones, and to helping to support them in their families and in their schools. And I guess some of that I think we already know what we can be doing. We just need to do it in other areas where it would be really great to be developing some new interventions and strategies to helping children and young people. Are you planning some follow up research, or is there anything else in the pipeline that either of you would like to tell us about? Yes. So, yes, this work, this paper is part of a larger body of research that both Helen and I have been doing that's looking at the co-morbidity of disordered eating and self-harm and in their potential risk factors. But going forward, I'm also interested in investigating ways in which we can target risk factors like emotional dysregulation to prevent future mental health problems. So I'm just starting on a project where I'm co-developing a school-based intervention that aims to help young people manage their emotions through the use of creativity in art. So we hope that this intervention will help young people find creative ways to express themselves and reduce stress and improve their self esteem as ways to potentially prevent mental health problems like anxiety and depression. And I know Helen is also thinking about some schools based prevention work. I've just recently begun some work with the Age of Wonder, which is part of the Born in Bradford cohort. And we are looking at rates of disordered eating within their cohort. And we're just beginning some work, thinking with the young people themselves about what they think could be usefully put in place within their schools to help prevent those problems from developing. Naomi and Helen, finally, what is your take home message for our listeners? We would like people to understand about the strong overlap between disordered eating and self-harm. And be asking about those things when they're seeing patients in either group. We would like people to understand that emotion dysregulation does seem to be really important. And that it's really useful to target that in the prevention measures. And I think we would also like to thank both the ALSPAC participants who 30 years on are still-- more than 30 years on are still turning up to clinics and filling in questionnaires. And also the rest of the team who worked with us on this paper. Thank you both so much. For more details on Dr. Naomi Warne And Dr. Helen Bould, please visit the ACAMH website, www.acahm.org and Twitter @ACAMH. ACAMH is spelled A C A M H. And don't forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review. And do share with friends and colleagues. [COOL MUSIC]