We are the Association for Child and Adolescent Mental Health, or ACAMH for short, and this is ACAMH learn. Welcome to the Mind the Kids podcast. Imagine you're a parent watching your child struggle to focus in the classroom, missing key learning moments because attention slips away unnoticed amid more disruptive behaviours. Could early genetic predispositions to neurodevelopmental traits be quietly shaping their path to academic success or struggle. This episode is called genetic clues to classroom struggles. I'm Mark Tebbs. I'm your host for today. I spent my whole career working in mental health, from frontline service delivery to director of mental health commissioning, and currently chief executive of a charity. I'm also a trustee for mental health organisation, and I'm a career coach. And I'm really delighted to be hosting these podcasts, as we get to speak to clinicians and academics at the forefront of child and adolescents mental health research. Today, I am thrilled to be welcoming Marie-Pier Larose from the Turku Institute of Advanced Studies at the University of Turku in Finland, with a PhD in Public Health from the University of Montreal. This episode, we unpack her JCPP paper, showing how genetic risks for attention and conduct problems mediate academic outcomes over and above cognitive abilities and educational attainment in polygenic scores. Marie-Pier, shares her attention issues demand that priority awareness, practical implications, like limiting early screen time with high-quality childcare, and the need for comprehensive, community-based strategies to keep children engaged in school without being excluded. So let's get started. Hello, Marie-Pier. Really nice to be speaking to you. Thank you. Speaking with you, the same. Great stuff. So let's start with some introductions. So it'd be great if you could introduce yourself and maybe say a little bit about the people that you work with on the paper. Yes, absolutely. My name is Marie-Pier Larose. I'm a senior researcher at the Inequalities, Interventions and New Welfare State Research Flagship Centre, or INVEST for short. And I'm also a fellow at the Turku Institute for Advanced Studies at the University of Turku in Finland. I have a PhD in public health from University of Montreal in Canada, and my research focuses on the early developmental mechanism for school readiness and academic achievement, with a focus on children genetic predisposition and the early learning environment such as childcare. For this paper, I had a very international team with Dr. Isabelle Schuurmans and Dr. Charlotte Cecil at the Erasmus Medical Centre in the Netherlands, Dr. Barker and Garcia Mondragon at the King's College London, and Dr. Timmer and Walman joining us to complement our team from Harvard and Emory University in the United States. Wow, an international collaboration, very impressive. Very international. Good stuff. Let's start with an overview. So it'd be really interesting if you could just give us a bit of an overview of the study and maybe what the underlying motivations were behind what you were studying. Yes. So briefly, this study examined the developmental mechanism between two higher order genetic predisposition for psychopathology, more specifically the ones for externalising and neurodevelopmental traits and their link to academic achievement. So we perform the analysis in two population-based cohort, Avon Longitudinal Study of Parents and Children, or ALSPAC and the Generation R Study. We focus on three types of mental health symptoms in childhood, that is to say, aggression, attention, and emotionally reactive problems, and for mental health symptoms and traits from childhood to adolescence. More specifically, for the adolescent sample, we examined oppositional defiant disorder, attention deficit hyperactivity disorder, conduct problem, and social communication problem. We were interesting in having two developmental periods, so we can examine the replication pattern and potentially highlight developmental differences. Finally, we were looking at young children and teens. And we focus on academic achievement at the end of primary as well as mandatory school, because these are two developmental milestones that are pivotal for choosing their next academic and professional pathways. Regarding the motivation for this study, the article stemmed from the finding from a study from Daniel Belsky on the genetics of success, where they look at the mediating factor between the polygenic score for educational attainment and later life outcome. And they identify self-control and interpersonal skill as important mediating factors. The study was very meaningful for me because it was tying together a biopsychosocial approach, which was the theoretical framework of my previous work, but also incorporating behavioural, genetic, and identifying potential key actionable targets of intervention. However, the study of genetic success focused on the polygenic score for educational attainment, which was normal, considering that their outcome of interest was later life development and later life outcome. And the fact that the polygenic score for educational attainment, especially at that time, was the one that explained the greater variance in academic and non-academic phenotypes or outcome more generally. Now, what we know from the many recent study, and from the statistical logic behind genome-wide association studies, or GWAS, is that polygenic score for educational attainment contained cognitive, but also socio-emotional or more broadly defined as non-cognitive associated variants that help children to thrive in the educational system. Therefore, in the present project, we wanted to adjust for the cognitive component on a phenotypic, but also genetic level, but also explore all other polygenic scores related to psychopathology could be related to academic achievement over and above the polygenic score for educational attainment. OK, amazing. So there's a lot there. So let's unpack it a little bit at a time. So let's start really broadly. So the link between educational attainment and later life outcomes, could you tell us a little bit about what that association is, and how strong it is? We see from sociological and epidemiological study, that it is quite a strong association with the fact of graduating or not graduating from high school, for example, and your mental health and physical health later in life, but also on the next academic opportunity that you will get. So more and more, there are prerequisite for later training that having or not your high school diploma will be quite important determinant so that's why we were focusing on academic achievement for later life outcome. So a really important indicator about what happens in the rest of someone's life. And then you mentioned that you were focused on neurodevelopmental traits. And I think you said externalising behaviours. So why were you particularly focused on those two areas, and maybe not internalising behaviours, for example. So we focus on neurodevelopmental and externalising problem and their genetic predisposition because we found it clearer to link it with challenges that children experience in the school system. For internalising problem, the directionality between experiencing anxious or depressive symptom and academic performance is not as clear as the one that if you are exhibiting attention problem, hyperactivity, aggression. So you're taking out of the school environment or the classroom. Then the link with academic achievement is a little bit clearer. So that's why we decided to focus on these two umbrella terms or umbrella psychopathology. So could you maybe explain that with an example of a child, just like to bring it home to listeners. Yeah, so we can take the example of a child that is arriving at school and has a little bit more difficulties to focus on what is happening in the classroom environment. So this child will lose some learning opportunities and may fall behind on grasping fundamental concepts in mathematics, arithmetics, language reading. And then this takes a toll over the course of time. That makes this child a little bit less likely to succeed in school. For the externalising problem, this is about the same. If a child is having tantrums in the school environment, and we're really focusing more on the childhood period here, then it may be taken out. And then, again, they're losing learning opportunities. Brilliant. And your study was looking at the link between a genetic predisposition, these mediating factors, and then later childhood academic outcomes. Cool. Brilliant. So it'd be really interesting if you could just explain before your study what was known and what were you trying-- what was the gaps you were trying to fill through this kind of research? I think there are two points that make our study unique and wanted to address these gaps. First, we were a bit bored with the idea that we could still explain academic achievement after accounting for the genetic predisposition for educational attainment. Cognitive ability is measured with IQ tests and set a set of sociodemographic covariates. But the idea was to really focus on mental health dimension and their genetic predisposition for them, and to link them with academic achievement to find additional pathways pathway that might not be that directly related to polygenic score for educational attainment. The other element that our study was interested in filling the gap was to use two cohorts to study developmental pathways in two developmental period. Here, I think, there was a methodological, as well as theoretical benefit. Because we were able to look at different questionnaire that has been used in the literature and see the strength and the robustness of the association. But we were also able to talk about the importance of these non-cognitive skills or pathways at two different time points. Right, yeah. So let's just take one-- let's take them one at a time then. So you mentioned polygenic scores. So could you just say a little bit what they are and how they relate to this topic. Yeah. So if we go with broad definition of polygenic score, a polygenic score is at the beginning a tool researchers use to estimate a person's genetic propensity or predisposition towards a particular trait. Here, we're talking about attention difficulties, depression, or even academic performance. It is calculated by combining the effect of many small genetic differences across a person's DNA, each of which has a tiny individual association with a specific trait. At the end, what you get is a cumulative individual score, which represents the individual genetic predisposition for that specific trait. But on its own, the polygenic score doesn't determine behaviour or learning outcome. Instead, it gives us a summary measure of genetic influence that is enacted via cascade of biological pathways, which then interact with a person's environment and life experiences. So while the genes are there in the background, it's really how they play out on a more physiological and environmental background to develop behaviour and learning, that is this interplay between gene and environment. That's a great explanation. That's a really helpful explanation of how that genetic predisposition and then how it plays out in the environment and the impact that has on outcomes for individuals, so thank you for that. And then the second part of your description was about this two stages of childhood. So could you tell us a little bit more why that was so pivotal in your methodology? Well, we were interested in the continuity of symptomatology, so we really focus to the best of the data that was available on neurodevelopmental traits and externalising behaviour. But we also knew that they evolve over time, so temper tantrums and defiance, how it is expressed in early childhood is quite different than in the mid of adolescence or something, or this kind of time period. So having these two developmental period allow us to make a link between these early manifestation of opposition and later to see how their extension into more skipping school involvement in crime, bullying could have an impact on impact on academic achievement. OK, brilliant. So the last bit about methodology. So could you tell us just a little bit about the measures you use and whether there were any particular strengths in those or any kind of limitations. Absolutely. So we decided to focus on parent report questionnaire for the behavioural measure. In Generation R study, we rely on the child behavioural checklist. And in ALSPAC, we rely on Developmental and Wellbeing Assessment or the DAWBA, mainly because parents were used to complete this questionnaire, and they had it at different time point, so several times. So we can rely on one assessment or three to combine them into a latent score of psychopathology. So that was a trend that we were relying on multiple time point to assess the severity or prevalence of these mental health problems. For the more academic side of the data collection, we decided to rely on these overall measure of academic performance because in both sample, they were including arithmetics, mathematical, as well as their language skill. So we didn't have any hypothesis for how a genetic predisposition might be linked to a specific skills in the learning environment or academy. We were more interested in this overall achievement. And we were able to rely on register based data for the most part. So we don't have this social desirability bias of parents of over reporting, potentially the achievement of their children. OK, that makes perfect sense. So what did you find? What were your results? Tell us about your key findings. So we have two main key findings. The first one is highlighting the role of attention problem as a key mediating or explaining factor between genetic predisposition for neurodevelopmental trait and academic achievement. So here, what we can say is that the polygenic score for neurodevelopmental problem was associated with attention problem, which later associated with academic achievement over and above cognitive abilities, as well as the polygenic score for educational attainment. When we're looking at the adolescent sample, we found an additional pathway via conduct problem, that was associated with polygenic score for neurodevelopmental problem, but also externalising one. And these conduct problem also play an explanatory role for academic achievement at the end of mandatory school. So in the childhood sample, the attention was the key mediating factor. Was that what you expected? Was that surprised to you? We were thinking that attention problem would play a key role, but we were quite surprised that aggression was not coming up as another mediating factor. So we were having the hypothesis that both aggression and attention problem would play a meaningful role in mediating the association with academic achievement. OK, but you did find that with the adolescent sample, is that right? Yeah, exactly. So that was something we also hypothesised that conduct problem, because it involved skipping school, for example, or staying out late. Lying might be related to lower chances of obtaining your diploma at the end of mandatory school. But the differences are important in the type of behaviour and how they're handled in the school system. So I think that is one of the hypotheses why we found this developmental difference between our two samples and developmental periods. And is that consistent with other findings in the area? I would say yes. The ADHD has been found repeatedly as one of the main mental health disorder or symptoms that is linked with lower chances of graduating. I think that conduct problem, we see it. One of the strengths of our study was to take also the comorbidity into consideration. So when we're talking about the attention problem, it's really over and above the aggression problem and the emotionally reactive. Same thing for the adolescent sample. So I think that by having these other measure and taking their influence on academic achievement at the same time, while also adjusting for cognitive abilities, this is why we were able maybe to highlight the one that is a little bit more salient, while considering how they are correlated with the other traits. Yeah, OK. And I'm wondering what some of the implications of these findings are. I would say that the key implication in our study is to realise that genetic predisposition does not mean causation or determinism. Genetic is only a tool to examine social and economic dynamics from a different and additional angle. And I would like parent, teacher and clinician to remember the early and long-term association that we found between attention problem and academic performance. Comparatively to externalising behaviour, neurodevelopmental traits and especially attention problem can be harder to notice, especially in the classroom environment. Because they are not as salient as aggressive behaviour, for example. However, in our study, while accounting for the presence of the other traits and behaviour, we found that attention problems were over and above the externalising and neurodevelopmental traits associated with academic performance. Therefore, increasing awareness toward attention problem, with or without hyperactivity should be our scientific and also practitioner priority. And is there-- I don't know whether from a public health perspective, is there an evidence base of things teachers and clinicians can do to improve attention or of focus in the classroom? Yeah, my answer will focus more on the preventing and promoting approach for attention. First, if you look at the early childhood literature, you really see an association with screen time during the first years of life. So I think this is something that clinician paediatrician can also be having a discussion with parents about the importance of limiting screen time. The second part is related to childcare attendance, which I did some research about. In a prison study, we tested the moderating role of childcare attendants, but we didn't find any significant result on the full mechanism. However, the question was a bit more complicated in our project than just childcare attendance and attention. Specifically, we were looking at the moderation or buffering effect of childcare on the full mechanism from genetic predisposition to academic achievement. But we did not specifically test the role of childcare attendants on attention problem. However, previous studies have shown that attending childcare of good quality improve attention and self-regulation skills for children from families with lower socioeconomic status. And finally, looking at moderation of genetic association with attention problem, using data from MOBA in Norway, there was a team that showed that school quality can attenuate or even render null the association between genetic predisposition for ADHD and ADHD symptomatology. Such findings are extremely relevant and inform us about the role of the quality of the environment to conceptualise resilience and integrated system of influence from genetic to school environment and public investments. So were you surprised that there you didn't find that association with childcare? Because I know that has been found in other studies. I was a little bit surprised, but at the same time, it was a little bit expected, also considering the cohort we were doing the analysis with. So in the ALSPAC cohort, it's from the early '90s, and I've been doing trajectories of childcare attendance. And we see that childcare was extremely expensive, still, is a little bit. But at that time, there was not a lot of structural component to help people, especially with lower income to access childcare. So you really see a small percentage of children going to full time childcare and also to part time. So the biggest group was no childcare attendance because we really focus on centre-based childcare attendance. So here, we didn't necessarily have the statistical power or the environment to really buffer some-- either socioeconomic or genetic propensity for later outcome. In the Generation R study, childcare is a little bit more common, but really into this part-time attendance. And from previous literature, we see that the part-time attendance is a blurry zone, where we don't really see association with later outcomes, such as school readiness or later academic achievement. OK. And then the other finding around the conduct disorder, is there any research around what the best approaches are for managing the conduct disorders in schools? Yeah. So overall, the most effective strategy are comprehensive, involve multiple components, and comprise collaboration among school, families, and the adolescents himself. So these approaches focus on building relationship with teacher, reinforcing relationship between the teen and their parents. Teaching new skills can be soco-emotional self-regulation skills, and providing support, rather than simply relying on exclusion and punishment. Yet, there are two important caveats that I would like to emphasise here. The first one is to remain engaged in school. The cognitive and learning ability of the young person need to be at a sufficient level. So this supportive previous point where intervention need to start early and socio-emotional learning programme in childcare and in the school context are necessary to ensure that children's develop the necessary social emotional skills for dealing with the ups and downs of school life, especially when they go to the teenage years. The second caveat is the necessity for a community-based approach, still evidence-based, but an intervention that makes sense in the environment and with the population with whom it's implemented. So I think here, an important finding is that it's not at all that children or teens with externalising behaviour do not have the cognitive or learning capacity to achieve in school, but rather that their symptomatology is driving them away from the school environment. And that intervention needs to support and nurture this bond between home and school instead of putting it in opposition or using blaming strategy. Yeah, brilliant. So we're coming towards the end of the podcast. So there was two questions I wanted to ask, really. So is there further research that you're undertaking that you'd like to share? And maybe is there a final message you'd like the listeners to go home with? Yeah, the next project, I'm really interested in digging a little bit more into the childcare attendance exposure. Because here, it was really an add on. But I would like to focus more specifically on it, because that's also what I've been doing before. And we know that childcare, as a social selection process, that it's based on parents' economic status or cultural perspective on child care. So to really have a genetically-informed approach on how child care is associated with child development in context of intergenerational transmission of mental health problem or academic achievement. And what I would like to restate, potentially, is really this increased awareness for attention problem, because they are not as disruptive. And they tend to go unnoticed. So really, to have not just this person is not attentive, is not paying attention, or to downplay the importance of these early behaviour. Because in the Generation R sample, we were looking at these traits as early as two years old, and we still saw an association with academic achievement at the end of primary school. Brilliant. Thank you so much for your time today. Really interesting conversation. Thank you very much for having me. Such a privilege to be talking to Marie-Pier. I hope you enjoyed that as much as I did. As always, please leave a comment or review or suggestion. Don't keep these podcasts yourself. Please share them. Help get the word out. And remember that you can sign up for a free ACAMH learn account at www.acamhlearn.org. And you'll be able to get a free CPD CME certificate for listening to any of these podcasts. And next week, we're off to Utah to speak to associate professor Meeyoung Min in a powerful move in discussion about her JCPP paper on intergenerational transmission of maternal childhood maltreatment through prenatal substance exposure. I'll see you next week.