We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. I'm Mark Tebbs. And I'm your host today. I've spent my whole entire career working in mental health in various facets, from frontline service delivery to director of mental health commissioning. And now I'm a chief executive of charity. So I'm really interested in grassroots organisations and their impact on community well-being. I'm also a parent. And I've seen the mental health system from that side too. So I'm delighted to be hosting these podcasts. Today we will be speaking about anxiety, memory, and sleep in periadolescence. I'm really pleased to be speaking with Liga Eihentale. And we're going to be talking about her JCPP paper, entitled Anxiety Severity in Adolescence is Associated with Greater Generalisation of Negative Memories Following a Period of Sleep Relative to Wake. Hello, Liga. Great to meet you today. Thank you for having me. Glad to be here. Great stuff. So let's start with some introductions. So, I'd be really interesting to hear about your research interests, where you're working, maybe some of the people you worked with on paper. Absolutely. So I'm Liga Eihentale. I'm an early career research scientist at Florida International University. So I'm a doctoral student in my fifth year of training. And my research here really focuses on mechanisms of anxiety and depression and periadolescence, with particular focus on sleep. And this particular paper or project was a team effort with my mentors, Dr. Dana McMakin and Dr. Aaron Mattfeld, who are both faculty here at FIU. And they're also really leading interdisciplinary effort by bridging clinical science and cognitive neuroscience to better understand and explore how sleep relates to memory and emotional functioning during these pivotal years of development. --stuff. So, what motivated your interest in this area? Yeah, so we're really interested in periadolescence, as it is a transition between childhood and adolescence. So it's a very sensitive neurodevelopmental period. A lot of changes take place during this time. So with brain, emotional regulation, sleep patterns change. And what we see is that anxiety disorders often emerge during this time as well. So we wanted to explore what role does sleep play in emotional memory consolidation, specifically focusing on generalisation, which is a feature of memory consolidation. And we really wanted to see it in an anxious sample in a periadolescence sample. So that was motivating factor. And just, more broadly, understanding what might be some mechanisms that are contributing to the development and persistence of anxiety disorders, and then hopefully, down the line, also inform treatment targets. OK brilliant. So what's happening at that period in terms of brain development in that kind of periadolescent period? Yeah, absolutely. So the periadolescence is really the ages between 9 and 14. And there's a lot of change happening both physiologically, emotionally, and then also with sleep. And it's related to both your biology but also to the societal changes and pressures with this age group. So there's increasingly more academic responsibilities. There is more pressure to fit in with your peers. There's also later bedtimes that happen both because of social factors and also because the biology changes. So, really, this time is a very sensitive period where preteens are particularly vulnerable. Vulnerable to insult is what we call it but we also see it as a window of opportunity to intervene and potentially change the trajectory for children who are at risk of developing these disorders. So this very sensitive period of change, so what's the level of anxiety in this period of time for the young people? So it really depends on multiple factors. Of course, there's always genetics that might predispose someone to be more likely to develop anxiety. There's environmental factors like the things that I mentioned. So some children might experience the same things but won't go on to develop anxiety but others will, which is why we're trying to figure out what are the mechanisms. And sleep is increasingly becoming one of those things that people are trying to understand better and see how it might contribute. And we know from literature is that in anxiety, we see that sleep is impacted. And certainly, more anxious children tend to have poor quality sleep, which then also fuels their anxiety the next day. So understanding what comes first and what contributes is also part of this work that we're doing. So is it like a reinforcing cycle, the generalisation impacting on sleep and sleep impacting on anxiety? Yeah, exactly. And generalisation itself as a concept is an adaptive trait. So it's really a feature in our memory that helps us learn and guide our future behaviour. So from an evolutionary perspective, if we see a bright poisonous bear and we eat it and we feel bad, we're more likely to avoid other similar berries. But the tendency to generalise negative experiences more is what we think becomes maladaptive in anxiety. And what we talk about in our paper is really negative overgeneralization, which means that instead of adaptively in generalisation, when you take one experience and apply it to other similar situations, in negative overgeneralization, you take one negative experience and apply it to other similar but nonthreatening situations. So an example might be a child might have an interaction with a angry dog, which could be a frightening experience. But then they become fearful of all dogs, including cute little puppies that pose no threat. So this is the overgeneralization that is really a core feature and symptom in anxiety disorders. And so we wanted to again mechanistically understand how sleep relates to the process of generalisation and negative overgeneralization in anxious children. OK. I'm just thinking about what the gap of research was that you were trying to address through your paper. So what was known about that relationship between anxiety, memory generalisation, and sleep? So, broadly speaking, the role of sleep is fundamental in memory consolidation and emotional memory consolidation. So there's a lot of literature to support that, especially in adults. There's a lot less in youth. And there's almost no research done in anxious, so clinically anxious children. There are some studies that look at anxiety symptoms in typically developing children. But specifically in clinical populations and during this periadolescent period, these critical years, there may be one other study that looks at similar processes. Yeah, OK. So I'm just wondering, could you give us an example of what it would feel like for a young person? So how does this mechanism work from a child perspective? Absolutely. So what we see in our clinical practise a lot is also children who are more highly anxious, they tend to be high achievers. So, perhaps they go to school, and they get a bad grade on a math test. So they take that experience. And they go home. And they think about it. And they ruminate about it before sleep. And so the next day, they might feel as bad or worse about it. And then they might actually apply that experience to a broader context. Now, they may think that, well, I failed this test. I'm surely going to fail the whole class. Or maybe I'm going to fail all my classes. So this is what we see in anxious children. Normatively, children would have an emotional experience, maybe a bad experience having a bad grade. But they may fall asleep and wake up feeling better about it. So when you heard the expression, sleep on it or go to bed to feel better the next day. It's really very true because sleep has a therapeutic effect of-- and mechanistically, this means that it strips the emotional tone from your memories and really consolidates the core memory so that it can inform your future behaviour. So for nonanxious children, they might think, well, I failed the test. Fine. You wake up in the morning. You feel better about it. And you're like, I just have to study harder. So you're forming your future behaviour. Versus anxious children, overnight, these processes might be affected in the first place, how this memory is consolidated. And this emotional tone might not be stripped from the memory. So in the morning, they wake up, and they feel as bad or worse about it. And even more, they might feel more emotionally reactive. And then they generalise this experience to other contexts. And then so it feeds the anxiety. And so it continues in a loop. So very different in an anxious child to a nonanxious child that impacts the sleep on the processing of those bad memories. OK, brilliant. All right. So should we dive into your study a little bit more? So it'd be really interested to hear just about how you carried out your study and what you were hoping to test, what your research hypotheses were. Absolutely. So we recruited 9- to 14-year-olds for our study. We had a sample of 34. Half of our participants were in a sleep group, and the other half was awake group. So all participants did an emotional memory test, which involves seeing images. So at encoding or learning the images, they would look at neutral, negative, and positive images. And then 12 hours later, they would be given a surprise memory test. So the sleep group would return after a night of sleep. And the wake group would return after a day of 12-hour wake window, essentially. And so then, they would have to tell us whether they recognise the image that they've seen it, or it's a completely new image they haven't seen, or whether they generalise an image that is very similar to the one they've seen but not identical, which is the measure of generalisation. And this project was really a pilot study that informed a next project, which was an RO1, a big project of much bigger sample that is currently ongoing in our laboratories. And so, hopefully in the future, we're excited to dig into this data and replicate this pilot study in this paper that we wrote up. OK, right. So before we go more into the results, are there any-- you said it's like a pilot study. So are there any conversations that we need to be aware of before we go into details? Yeah, absolutely. So as I mentioned, sample of 34 is relatively small. And it was also a cross-sectional design, means we're just looking at one time point. So, certainly, these findings need to be replicated in a larger and longitudinal study, which is exactly what we're hoping to do with our RO1 data. And we also used actigraphy and sleep diaries for assessing sleep, which is great in the sense that it allows us to see really natural sleep patterns in their own environments, as opposed to a sleep study done in a lab where you can utilise something called polysomnography. However, using actigraphy and sleep diaries do not give us these more finer details of sleep that polysomnography does, which we really think might be key as mechanisms in these emotional memory processing in these processes. So what did you find? What were the main findings from your study? So our main finding was that anxiety severity was positively associated with a negative generalisation after sleep but not after wakefulness. So in other words, children who were more anxious tend to endorse images that were similar but not identical. So the negative ones, they were more likely to endorse them after sleeping but not after wakefulness, so they were more likely to generalise. So that was our main finding. And it was our a priori hypothesis that we confirmed. So what are the implications of this finding? Yeah. So, really, the implications come down to understanding the mechanisms and informing treatment targets. So before we can do that, we, of course, have to really look at finer details of sleep, like I mentioned, or finer features, so the brain activity that happens during sleep, and what are the particular sleep features that drive these mechanisms? So there's slow wave activity that happens in the brain and spindles. And these are really critical for memory consolidation and emotional memory consolidation. But broadly, we know that sleep-based interventions could really aid the current behavioural interventions with anxious children, for example. Sleep, really, could inform-- or not rather inform, but sleep could aid in exposure therapies. So if we know that certain responses are generalising, perhaps fear extinction, which is used in exposure therapies for phobias, might generalise during sleep and aid in reducing the phobias. It could also be utilised as potentially with the positive effects of therapeutic intervention. It could also help generalise those. Then there's other more interesting interventions that are related to memory, specifically like targeted memory reactivation, which means that during sleep, certain memories might be cued to override the overwrite the negative memory. So, for example, neutral or positive memories might be cued to then hopefully extinguish the negative overgeneralization. So what was the optimum intervention period? So is it like working with the young person just before they go into sleep? Yeah. So, the reason we're interested in this particular age is because we think it's a window of opportunity. So most people think about the early childhood years, so zero to three, as a rapid brain development when it's particularly plastic. And the notion is that once that age has passed, then you're dealt and you're dealing with symptoms. But now, more increasingly, research shows that these periadolescent years is actually another very plastic time when brain is rapidly developing. And this is, like I mentioned, it's a prime time for insults. So it's a perfect storm where things can go really wrong considering all the changes that are happening physiologically and socially with teens. And it is also a window for opportunity where we think if we can really get to these children before they enter their puberty and provide them interventions, we could really change the trajectory for those kids that are at risk for developing anxiety disorders. Was there anything that particularly surprised you about your results? Yeah, so we were surprised to see no relationship between anxiety and recognition accuracy in our sample. So recognition is probably the primary measure of memory consolidation in the research that exists, especially in adult literature. So this is really purely retention, able to remember the images that you saw. And in our sample, we didn't see this relationship. But our hypothesis is that these memory consolidation processes might be really affected in anxious youth, which is why we did not see this relationship here. And another hypothesis is that what literature shows is that in anxiety, there's more generalisation at the expense of detailed memories. So perhaps, that was the case also in our sample. We did see the increased generalisation but did not see increased recognition of negative images. Another surprising study-- or another surprising finding that we had was that-- surprising but also just affirming of what we had already hypothesised is that at low levels of anxiety, sleep tend to decrease negative overgeneralization, as opposed to at moderate and high levels, it tends to increase it. And so this affirms the notion that sleep is overnight therapy. So in normative or nonanxious children, sleep should really remove that emotional tone of memories, and then the next day, they feel better. So we do see that in our sample, in the nonanxious, or the very low-anxiety severity children. But the opposite is true for moderate and high anxiety in our sleep group. So I'm wondering, how might these findings influence clinical interventions and therapeutic approaches? Yeah, so as I mentioned, really aiding the existing cognitive behavioural therapies, like exposure therapies, hoping that generalisation really aids the fear extinction and any positive therapeutic experience that children may generalise. This might also inform some other more recent techniques like savouring, which really means trying to emphasise positive memories and experiences right before you go to sleep and de-emphasise the negative experiences so that not to make them even more likely to be reactivated during your sleep, and then, of course, targeted memory reactivation, which could really help with overriding the negative experiences with positive or neutral memories. And the way it's usually done is by associating certain memory with an odour or a sound. And then when you're asleep, it's cued while you're asleep in a specific sleep stage. And then, hopefully, that translates into memories. The neutral or positive ones take precedence. And this is also something we-- the work we've done with our RO1 project that we're excited to now explore. Brilliant. And you mentioned savouring. What does that mean? What's that as an approach? Yeah, savouring is a really excellent technique that we also in our clinical practise, we suggest to parents and children as a very simple thing they can do at home before bedtime. And there's research to back that. It really works. So savouring really means just thinking about experiences by really visualising them and thinking about the fine details of experience so you can really immerse yourself in it. And what we suggest teens, or children, or parents is that before bedtime, as opposed to what commonly happens, is rumination, which is really just overthinking all the things they did wrong or said wrong, so instead of really activating those experiences before bed because they are more likely to be consolidating, as opposed to that, use a positive experience, either from the same day or maybe a recent experience you had, and really think about it. And not only it will help you to reduce your physiological arousal and make you more calm, but hopefully those memories will be more likely than consolidated and generalised rather than the negative experiences you're really thinking about right before you go to bed. Yeah, that's fascinating. So are there any other tips for maybe parents or teachers working with anxious teens? Yeah, I think for working with children, teens, or anyone, adults alike, but particularly for those that are at risk or anxious preteens, I would really stress thinking about sleep health or sleep as important as about healthy eating habits and exercising. And more increasingly, people are paying attention to sleep because there is really a lot that happens while we sleep. And so I just trust that parents and teachers to really protect the sleep of adolescents or periadolescents and small children, to really implement consistent sleep routines. So going to bed and waking up at the same time every day of the week, trying to reduce activating these negative experiences that might come from scrolling or doomscrolling right before they go to bed on Instagram or social media, and really taking time to just wind down and relax and trying to think about positive experiences they might have with their family or friends, and then just really protecting their sleep. Yeah, that's good advice, actually. So, I'm just thinking about the next steps in terms of your research. You mentioned that you're doing a further study, so it's be great if you could us a little bit about that. Yeah, so the next step is really to dive into more specifically the brain activity and the waves that happen while we're sleeping. Like I mentioned, we really think-- and there's literature to support this-- that the finer details of sleep, like the spindles or slow-wave activity, are really the driving factors in these memory consolidation processes. And so one way we see this play out is that commonly, both anxious and a nonanxious children may report the same amount of sleep they had during the night time. But anxious children tend to report less quality sleep, or they feel like their sleep was not as restorative. So we know that there must be some underlying brain activity that differs between anxious and nonanxious youth. And so we think that this, of course, might then affect the memory consolidation processes as well. So this is something we are collecting as part of our RO1. So we're going to be excited to look at that data more in detail and hopefully replicate the findings we had in this paper. Good stuff. We're coming to the end of the podcast. I just wondered whether there was a final message that you'd like to share with the listeners. Yeah, absolutely. Like I said, protecting sleep and really paying attention to it and making it as important as your sleeping habits and your exercise. And if I had one thing I could just make happen, I would probably really advocate for later school start times, which we think would really help for adolescents as they are naturally going to bed later. So the really early wake-up times don't help with their sleep and the amount of sleep they're getting. And I know that there is legislation being passed here in the United States. And the state of California has already implemented later school start times. And our state, Florida, here is soon to follow that suit, though I believe we'll pass the law here in July this year. So just giving our children the sleep that they need so that they can grow up healthy and happy. And yeah, that's the final message. Great stuff. That's a really interesting podcast. Thank you for your time, Liga. And I hope you enjoyed the podcast. If you enjoyed the podcast, please leave a review. and thank you for listening. Thank you. [MUSIC PLAYING]