Dr. Umar Toseeb Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Umar Toseeb, a Professor at the University of York. 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 talking to Bushra Farooq, PhD student at the Centre for Academic Mental Health, Population Health Sciences, at the University of Bristol. Bushra is the Lead Author of a paper in JCPP, called “The Relationship Between Type, Timing and Duration of Exposure to Adverse Childhood Experiences and Adolescent Self-Harm and Depression Findings from Three UK Prospective Population-Based Cohorts.” 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 your friends and colleagues. Bushra, thank you so much for joining me. Can you start with an introduction about who you are and what you do? Bushra Farooq I am a PhD student at the University of Bristol and my work focuses on the association between adverse childhood experiences and self-harm and depression. And I’m particularly interested in the developmental timing of adverse childhood experiences and patterns of co-occurrence. Dr. Umar Toseeb Thank you. Let’s now turn to your paper. Can you give us a brief overview of what you did and what you found? Bushra Farooq So, adverse childhood experiences are well-established risk factors forself-harm and depression, but less is known about the impacts of developmental timing and duration of exposure to adverse childhood experiences on self-harm and depression. So, we address this gap in the literature by examining the association between different types of adverse childhood experiences, including types of abuse and neglect and indicators of household dysfunction, such as substance abuse, domestic violence, parental mental health problems. And we consider their developmental timing of occurrence, as well as duration to exposure to each type using data from three UK cohorts. So, we use data from the Avon Longitudinal Study of Parents and Children, ALSPAC, which is also known as Children of the 90s. Then next, the Millennium Cohort Study, MCS, and the Environmental Risk Longitudinal Twin Study, E-Risk. Our study included data from over 22,000 children and adolescents and they had been followed up for at least 14 years. We used regression models to examine the association between 11 different types of adverse childhood experiences and self-harm and depression and we used a structured life-course modelling approach to examine whether the accumulation of exposure to each type of ACE, adverse childhood experience, or a critical period had the strongest effects on self-harm and depression in adolescents. And in the paper we plot results for each cohort separately to see whether findings could be replicated across these different cohorts. So, what we found was that most of the adverse childhood experiences were associated with an increased risk of co-occurring self-harm and depression and these findings were consistent across the three cohorts. Next, we examined the impacts of developmental timing and duration of exposure in two cohorts, and we found the importance of timing and duration differed between these two cohorts. So, for parental mental health problems, we found that longer duration of exposure was associated with a higher likelihood of co-occurring self-harm and depression, regardless of the developmental timing of the occurrence, and this was consistent across both cohorts. And for other adverse childhood experiences, in ALSPAC we found exposure in middle childhood, so between ages six to ten years, were the most strongly associated with co-occurring self-harm and depression. Whereas in the Millennium Cohort Study, we found exposure to certain adversities in early childhood, so between birth and age five, or early adolescence, at age 11, was more important than others. Dr. Umar Toseeb Excellent, thank you, and we’ll just unpack that, ‘cause it was a greathigh-level summary of what you did and what you found, and we’ll unpack that a bit more as we go through. We’ll start with the data. So, you used, as you said, a number of population-based cohorts. So, you used three in total, you said. Can you tell us a bit more about these three cohorts and why you needed to look at three? Bushra Farooq So, ALSPAC is a big cohort study based in the Avon region in the south-west of England. Approximately 14,000 pregnant women with expected delivery dates between April 1991 and December 1992 were recruited into the study, and these women, their partners and children have been followed up at multiple timepoints over time. So, these families are still being followed up and the cohort children are all now over 30-years-old. The MCS is also a longitudinal study and includes around 18,000 families. Children in this cohort have been followed up from around nine-months-of-age. So, they were born between 2000 and 2002 in England, Scotland, Wales and Northern Ireland. So, this is a UK-wide cohort and they’ve been followed up over several intervals over time. And finally, the E-Risk study is a longitudinal twin study. It follows up around 2,000 same-sex twins born between 1994 and 1995 in England and Wales and these families have also been followed up at several intervals. Now, whilst ALSPAC contains very detailed information on childhood adversity and mental health outcomes measured over time, the sample is based in a more affluent area in England. So, the majority of sample is of white ethnicity, and to ensure that our findings could be generalisable to the wider population, we used the Millennium Cohort and the E-Risk studies. And the Millennium Cohort Study includes families from across the UK, so those from ethnic minority backgrounds or those from socioeconomically disadvantaged backgrounds were oversampled. And in the E-Risk, younger mothers were oversampled and older mothers were undersampled. So, this resulted in a sample which almost perfectly represents the socioeconomic distribution of the UK population. Dr. Umar Toseeb Fantastic. That was a great overview of those three datasets. We’ll move onto the other parts of the paper. You said you were interested in ACEs as a predictor of depression and self-harm during adolescence and to investigate that, you looked at the developmental timing and occurrence of duration and exposure to adverse childhood experiences on self-harm and depression. And you used this approach called structured life-course approach. Can you tell us a bit more about that? What did that involve? Bushra Farooq So, the structured life-course modelling approach, known as SLCMA, was developedto examine how life course hypotheses for our repeat measures of exposures, or, for example, adverse childhood experiences in this study, over the life course associated with later outcomes. And it allows you to test multiple hypotheses, identifying the best fitting hypotheses supported by the data. Now, one of the limitations of, sort of, the traditional ACEs approaches, which sums up the total number of adversities experienced by each person to compare a score, this is then used as a predictor for different health outcomes, is that it fails to take into account the importance of developmental timing of an adverse childhood experiences or how long someone has been exposed to it. It could be that a specific adversity occurring during a critical period in development, such as early childhood, may be associated with poor outcomes compared to occurring during other timepoints, or it could be that a longer duration of exposure to a cer – specific adversities associated with poorer outcomes. So, this approach allows you to test these multiple hypotheses simultaneously, which addresses some of the limitations of other approaches. Dr. Umar Toseeb Excellent. So, I think what you’re saying is that an ACE score is a bluntinstrument, which just is the sum of the number of adverse childhood experiences someone might experience. And by using this other approach, what you’re doing is you’re taking into account the duration of exposure and maybe the severity, as well, or is it just the duration of exposure? Bushra Farooq No, just duration or the developmental timing. Dr. Umar Toseeb Okay, excellent, and also, you mentioned the accumulation of risk hypothesis.Do you want to tell us a bit more about that? Bushra Farooq Yes, so the accumulation of risk hypothesis suggests that longer duration of exposure, or cumulative exposure over the life course, increases the risk of a poor outcome. So, as the duration of exposure to an adverse childhood experience increases, the risk of the outcome of interest increases, regardless of the developmental timing of occurrence. Dr. Umar Toseeb And then, in reference to the developmental timing of occurrence, would you expect that adverse childhood experiences at a certain developmental stage would have a different impact on depression and self-harm? Bushra Farooq There’s two developmental timing hypotheses. First would be a critical period,which is a limited time window in which an adverse childhood experiences can have adverse effects on development and then subsequent outcomes, and these effects cannot be modified. And similar to a critical period, a sensitive period is a point in time when an exposure of an adverse childhood experience has a stronger effect on the outcome compared to it at other times. So, outside this time period, any excess risk is weaker. Dr. Umar Toseeb Thank you, and then, moving on to some of your findings. You found that the prevalence of adolescent depression and self-harm differed between the cohorts. Why might that be? Bushra Farooq There’s lots of reasons why the – we saw these differences. So, it couldbe due to differences in the cohorts that we use, so in terms of characteristics, such as ethnicity and where they live in the UK. As I said earlier, ALSPAC is based in one region in England, whereas Millennium Cohort and E-Risk include other countries. These differences could also be due to age at which the outcomes measures were taken. So, in the Millennium Cohort Study, adolescents were aged 14, they were aged 16 in ALSPAC and 18 in E-Risk. And studies have shown that the prevalence of depression increases with age. So, like other mental health disorders, depression emerges in adolescence and into – incidence increases gradually post-puberty, so, particularly during mid to late adolescence. So, we would expect the prevalence of depression to be lower in early adolescence and we see that in the Millennium Cohort Study at age 14, and it’s highest in the E-Risk cohort, when the adolescents are age 18. Now, other reasons could be differences in the measures used. And sometimes in these cohorts, the way the questions on self-harm were worded slightly differently, so differences in the prevalence could also be due to these reasons, as well. Dr. Umar Toseeb Why is it necessary to look at depression and self-harm separately, as in do they co-occur a lot of the time, in any case? Bushra Farooq Well, we wanted to look at self-harm and depression separately becauseprevious work suggests that not everyone that harms themselves do so because of mental health problems, such as depression. So, while the prevalence of self-harm with depression is high, we generally find that some young people harm themselves in the absence of depression. And reasons for self-harm may be – may include to reduce distressing effect, to inflict self-punishment or signal distress to others, or to gain relief from negative emotions associated with stressful life events. And it’s important to understand these differences, differences between those that self-harm with or without depression. Dr. Umar Toseeb Thank you. We’ll just go into a bit more depth about two of your keyfindings, and the first one is the association between individual adverse childhood experiences and depression and self-harm. Do you just want to unpack that finding? Bushra Farooq So, there’s a lot of findings reported in the paper. Today, I’ll summarise thefindings for the outcome co-occurring self-harm and depression. So, what we generally found was exposure to parental mental health problems, domestic violence, substance abuse and bullying were associated with a higher risk of co-occurring self-harm and depression. And these findings were consistent across all three cohorts. For other adversities, such as separation and divorce, which was associated with a higher risk of both self-harm and depression only in the Millennium Cohort Study and ALSPAC, and physical and emotional abuse were associated with a higher risk of self-harm and depression only in ALSPAC and E-Risk. So, we found some associations only in one cohort, for example, exposure to physical neglect, sexual abuse, parental antisocial behaviour was associated with a higher risk of self-harming and depression in – only in E-Risk. Dr. Umar Toseeb And some of the findings that you observed in one cohort and not another, were they down to some of the methodological differences that you’ve described earlier, or do you think they could just be for other reasons? Bushra Farooq There could be a number of reasons. So, the first could be the measurementof the adverse childhood experiences. So, within each cohort, different measures and questionnaires were used. For example, for physical abuse, this was captured differently in the Millennium Cohort Study. So, parents were asked whether they smacked their children when they were naughty. Whereas in ALSPAC and E-Risk, they captured other aspects of physical abuse, such as hitting them so hard it left bruises, where the parents pushed, grabbed and shoved their children. Additionally, in both ALSPAC and E-Risk there were more comprehensive measures that captured harmful substance use, whereas the measures used in the Millennium Cohort Study, particularly for alcohol use, it captured high frequency of consumption, so not necessarily a con – use at harmful levels. The second reason we saw these differences could be due to the informants reporting the adverse childhood experiences and these differed across the cohorts. So, in E-Risk, it was mainly the primary caregiver, and the Researchers visited the families in their home and they reported on their observations around the home environment. And similarly, in the Millennium Cohort Study, parents completed the questionnaires, whereas in ALSPAC, we had a combination of reports from parents and children also retrospectively reported about some adversities in childhood. So, these differences could also contribute to the differences in findings we saw across the different cohorts. Dr. Umar Toseeb And the other set of findings that I just want you to unpack a bit is the findings around developmental timing and duration of adverse childhood experiences in relation to the outcomes that you’re interested in. Bushra Farooq In terms of developmental timing and duration, we were only able to examineimpacts of these in the Millennium Cohort Study and ALSPAC because sufficient data on timepoint of exposure was only available for these cohorts. So, measures of adverse childhood experience were available at all three timepoints, for early childhood and mid-childhood and adolescence, for six adverse childhood experiences in ALSPAC and five in the Millennium Cohort Study. So, exposure to parental mental health problems, domestic violence and parental separation or divorce were available in both cohorts. And ALSPAC, additionally, had exposure measures for physical and emotional abuse and parent conviction and the Millennium Cohort Study had additional measures for parental substance abuse and bullying. So, overall, we found that for parental mental health problems, the findings were consistent across both ALSPAC and the Millennium Cohort Study. So, longer duration of exposure to parental mental health problems were associated with a higher likelihood of both self-harm and depression. Now, this was irrespective of developmental timing of the occurrence. For other adverse childhood experiences, such as domestic violence or parental separation and divorce, in ALSPAC we found exposure in middle childhood was associated with a higher likelihood of co-occurring self-harm and depression. Where in the Millennium Cohort Study, we found accumulation of exposure to domestic violence was more important than developmental timing. And similarly, for separation and divorce, the exposure in early adolescence was associated with a higher likelihood of co-occurring self-harm and depression. So, overall, in ALSPAC, middle childhood was more important. Whereas in the Millennium Cohort Study, early childhood or early adolescence seemed to be more important. But for parental mental health problems, accumulation of exposure was important across both cohorts. Dr. Umar Toseeb And what were the ages that you were defining as “early childhood,middle childhood and adolescence”? Bushra Farooq Early childhood was between birth and age five, middle childhood between six and ten years and in ALSPAC, early adolescence between 11 and 13. And in the Millennium Cohort, there was only one timepoint data was available for which was at age 11, but in ALSPAC, you see there were lots of multiple timepoints within that small period. Dr. Umar Toseeb That’s such a relief, because we’re also using these early/middle childhood and adolescence in some research that we’re doing and you’ve used the same ages that we have. So, I feel so much better. Bushra Farooq Oh, that’s great. Dr. Umar Toseeb Yeah, I was like, “Oh, howare we going to justify this?” But you’ve done the same thing. We’re alright. And okay,are there any other key findings from the paper that you would like to highlight? Bushra Farooq I just mentioned this, but I want to reiterate this, is that exposureto parental mental health problems was the most prevalent adverse childhood experiences in all cohort – all three cohorts, and it was also consistently associated with a higher risk of co-occurring self-harm and depression, and we saw these results across all three cohorts. We also found that longer duration of exposure, particularly, was associated with poorer outcomes. So, preventing parental mental illness and mitigating the impact on children is crucial. Dr. Umar Toseeb And I think that links quite nicely to the next question. Given yourfindings, what are the implications for clinical practice or other Researchers? Bushra Farooq In terms of clinical implications, our findings support the importance of primaryinterventions to prevent the accumulation of some of adverse childhood experiences and secondary interventions to mitigate the impact on self-harm and depression in adolescence. So, a lot of the support available preve – for – in terms of prevention has focused on the perinatal or early life period, but our findings suggest a sensitive middle childhood period and risk linked to cumulative exposure. These findings highlight the importance of continuing to address adverse childhood experiences throughout childhood and particularly during the middle childhood period. Additionally, parental mental health problems, again, was most frequently reported and its cumulative effect was particularly apparent. So, these findings were consistent across cohorts. So, again, preventing parental mental illness and mitigating the impact on children is particularly important. For Researchers, our findings highlight the importance of looking at adverse childhood experiences individually and also considering the duration of exposure and developmental timing, rather than summing them up to create a score and then use that as a predictor for different outcomes. Dr. Umar Toseeb And are you planning any follow-up research or is there anything else inthe pipeline that you’d like to share with us? Bushra Farooq Yes, so, I’ve recently completed a study looking at the association between parental poverty and longitudinal patterns of co-occurring adverse childhood experiences in childhood and adolescence using latent class analysis. So, this builds on this present study, where one of the limitations is I look at adverse childhood experiences individually, but we know they are more likely to co-occur because experience of one increases the likelihood of someone experiencing others. So, this next bit of research looks at this co-occurrence and specific patterns of co-occurrence and how these patterns are associated with self-harm and depression in adolescence and also early adulthood. I’m also currently working on a project looking at child maltreatment in primary and secondary healthcare records. So, this is a comparison of data from healthcare records, linked with parent and child self-reports, from a UK birth cohort. Dr. Umar Toseeb Just out of curiosity, in the healthcare records, what maltreatment datais available? Is it people who are – children who are taken to hospital, A&E for example? Bushra Farooq So, at the moment, I’m working with the GP data, but it’s things where a childmight come in and you’ve got specific – there’s specific codes that capture – it might be things like injuries in a child that are intentional. It could be things like star – the child is, sort of, physically not well, like they look malnourished or dehydrated, they could be indicators. They might be on the Child Protection Register, so there’s a flag in the GP records for that. So, we look at specific cohorts and we pack – we extract that information using previously derived algorithm. So, it’s quite interesting piece of research. Dr. Umar Toseeb That sounds very exciting, so I’m looking forward to readingthat. And finally, what’s your take home message for our listeners? Bushra Farooq So, adverse childhood experiences are common in the generalpopulation. They are associated with an increased risk of self-harm and depression in adolescents and our findings showed cumulative exposure to some adverse childhood experiences and a sensitive period in middle childhood for others are important in their risk for self-harm and depression. So, preventing efforts should focus on early intervention, with continued support throughout childhood, particularly during middle childhood, to prevent persistent exposure to adverse childhood experiences and to mitigate the impact on mental health. Dr. Umar Toseeb Excellent. Thank you so much for joining us, Bushra. Bushra Farooq Thank you. Dr. Umar Toseeb For more detailson the paper and Bushra Farooq, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. 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