We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the f 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 at the University of Cambridge. And I'm passionate about understanding and addressing the diverse mental health challenges that are faced by young people around the world. And in this series, as you know, I'm joined by renowned researchers and clinicians from different parts of the globe to discuss their cutting-edge research, their interventions, and best practise in child and adolescent mental health. Today, I have the pleasure of receiving Dr. Cummings and Dr. Dickstein. Dr. Cummings is a postdoctoral fellow at the PediMIND neurodevelopment programme. And Dr. Dickstein is the director of the PediMIND Programme and also the director of Child Psychiatry Research at the McLean Hospital, an affiliate of Harvard Medical School. And we're going to be discussing their most recently published paper at the JCPP Advances called "Patterns of Psychopathology and Personal Strengths Among Youth in Psychiatric Care." It's a huge honour to have you here, both Dr. Cummings and Dr. Dickstein. Thank you so much for agreeing to take part in this podcast. Thanks for having us. We're excited to be here. Yeah. Now, I'm really excited to have you. And I wanted to start by talking about your study because your study is looking at personal strengths and socioemotional skills in youth and psychiatric care, which I think is a topic that a lot of us clinicians are very interested in. And your study is based on data collected from this fantastic initiative called the Child and Adolescent Routine Evaluation Initiative. So I wanted to talk to start talking about that because I think it's a fantastic initiative that can inspire other clinicians listening to this podcast. If you could tell us a bit more about this and also how this inspired the research questions you wanted to answer with your paper. Sure. Well, thanks so much for letting us talk about this work. So CARE is the first child division wide measurement-based CARE Initiative that seeks to augment the art of clinical expertise with the science of standard assessments. We actually started this in 2022 as a way to ensure that every child or adolescent patient seen at any of McLean's sites could complete standard assessments relevant broadly to child mental health, including gold standard, research grade interviews for suicide and self-injury, also including child and parent assessments, questionnaires on topics of ADHD, autism, anxiety, substance use, sleep, discrimination and bias, and others. And the results, we actually summarised them mostly in a single page, much like you'd see a lab test with areas flagged for concern so that clinicians can use the information for more comprehensive diagnostic assessment to help the individual patient. Programmes could use the data to help their programmes figure out who they were helping, how to do a better job. And then, as Dr. Cummings has illustrated, we can then use it together to gain insight on mental health issues affecting kids and adolescents. Yeah. And so in this paper, we really thought to look at how psychiatric symptoms co-occur with youth's socioemotional skills and strengths because the strengths are often overlooked during routine clinical care when you show up at our clinics. And this makes sense because the symptoms and the impairment that are associated with it cause lots of problems and are really challenging to deal with. However, without considering a patient's unique strengths, we miss the opportunity for personalising treatments, to attend to the unique attributes and positive things going on in their life and really augment potentially their treatment outcomes. And then we also miss the opportunity to instil hope for them and their families from the beginning by showing them that they have a lot that's going well for them in addition to the things that they're struggling with. To add to what you were saying, Dr. Cummings, about how it's important to focus on strengths, but I think one of the points of your study that I really like is about its real world applicability because in your study, you're using routine outcome clinical measures. And I come from a background in epidemiology. And as we're going to discuss more later as well, a lot of the time, we design these really nice observational studies that are very neat. And they have very strict criteria. We also oftentimes focus on deficits. Then when we talk about translating the findings to real world scenarios, we often have a big important gap. Or those findings just don't replicate because we oftentimes do those studies in more artificial conditions, so to say. And yeah, your study doesn't do that. It does exactly the opposite. So I wanted to ask about the kinds of populations you serve in your programmes. How are the populations like? And do you serve a diverse community of children and young people? Because those are the young people who have been included, if I understood correctly. Yeah. Yeah, thank you. That is a really cool aspect of the CARE Initiative is that everyone that comes through the hospital doors between the ages of-- well, that's in the child and adolescent psychiatry division, are eligible to participate in CARE. And we serve a continuum of psychiatric care. So that's for children ages six to 22 years old across four different sites in Massachusetts. It spans about a 60-mile radius. And so anyone that comes in to our programmes, can participate in CARE. And the levels of care that we have are acute inpatient, residential, partial hospitalisation, intensive outpatient programmes. And we also have specialised programmes for kids with OCD, as well as for kids with chronic self-injurious thoughts and behaviours, and emotion dysregulation, and emerging borderline personality, and other personality disorder traits. In our sample, we found that it was predominantly-- it was about 60% female identified at birth. But we also had about 12% of our patient population identifying as a non-binary gender. We're really thoughtful in the way we designed our demographics survey to allow an open-ended way for patients to self-describe their identity. And I think that's a really cool advantage of our approach because I was actually surprised. But we found that there were 14 different non-binary genders that were reported by patients in our study in addition to cisgender male and female individuals. We also had a higher level of care in our sample. Most of our patients were intensive outpatient or higher. And so those were two unique aspects of our sample that I think that we have. I think it's important to realise that-- I mean, you were talking about what's done in an epidemiology study, right? And so I think that's not what CARE is all about. So CARE was founded on the idea, how do we bring clinical care and research work closer together? So really, it's about elevating clinical care using standard assessments, not focused on trying to conduct a big research study. And so the measures we picked as part of CARE, including the ones used for the study, the lens was, how do we pick assessments that are clinically relevant across a range of disorders, again, as Dr. Cummings said, from specialty programmes to more general programmes across ages and to make sure those things would help clinical care, but could also fuel insight and innovation, which is really what the field needs? Thank you so much for that explanation. That makes a lot of sense. And I think as you both explained so well, that's the real power of studies that are based in routine clinical outcome measures because you are able to tap into a very diverse network of patients. And I think it's amazing that you were able to recruit such a gender diverse sample. I think that's also a real strength of the study. And speaking of strengths and also clinically relevant issues, you spoke about this a bit, Dr. Cummings in the beginning. But in your study, you used a strengths-based approach. And you even use an assessment to look into the strengths of the patients that come into your care. And that's very innovative because most of the studies, and even in our clinical life, a lot of the times, even diagnostic assessments, they are based mostly in deficits and not strengths. And I think it is a particularly interesting approach in the current context we live in because we are seeing an increasing number of children and young people coming to our services with difficulties. So I wanted to ask you, based on your experience, what are the main advantages you see to this approach and how it can be useful in clinical practise? I think that strength-based approaches are really focused on identifying and promoting the positive attributes, the skills that youth already has, and the positive and supportive relationships that they have with their peers and adults in their life and teaching them ways to leverage those different skill sets and relationships to cope with whatever life throws their way and then also skills to efficiently adapt to whatever challenging or stressful social environment they are encountering. Maybe they transitioned to a new from middle school to high school or elementary to middle school. So strength-based approaches are really about fostering these types of skills that can help people be resilient to different things that they encounter in life. And research studies have shown that these types of approaches that promote resilience also are promoting factors associated with not just reductions in psychiatric symptoms, but increases in psychological well-being. So psychological well-being refers to things like increased feelings of belongingness and community, increased autonomy and self-efficacy, and strengthening and broadening of social support networks. And when you consider that two of the prominent risk factors of suicidal thoughts and behaviours are social isolation and feeling like a burden towards others or on others, if these resilience-based and strength-based approaches are all about improving strength of social relationships and autonomy, it likely will go a long way towards preventing and reducing risk for youth that are experiencing suicidal thoughts and behaviours. Thanks for that explanation, Dr. Cummings. That makes a lot of sense. And moving to your methodology, so in your study you used this tool called Holistic Strengths Assessment. And I wanted to ask you a bit about that because it was the first time I came across this tool. I thought it was a very interesting choice. And if you could tell us a bit about it. Sure. Yeah. The Holistic Student Assessment, or the HSA, is a really interesting tool. In some ways, like you, I was less familiar with it before I came to McLean in 2020. Actually, it was developed by Gil Noam, who is a professor at McLean. A lot of Dr. Noam's work actually focuses on working with schools in helping to assess in schools how kids are doing and their emotional health. And so what it's really based on is a frame of development and developmental psychopathology called the Clover Leaf Model, so for leaves. It's about a balance between those four leaves, which include assertiveness, which means executive function, and self-control, belonging, which means the need for relationships, active engagement, which is how one connects with the world physically, and reflection to how one develops a sense of one's own experiences. And I think what's interesting also about the HSA, which attracted me to it, besides the fact that it was developed at our institution, interestingly mostly in a non-clinical setting, which we then started applying in a clinical setting to learn about it, was that the HSA and the Clover Model are really about traits that can change over time and that can be amenable to help and intervention rather than, again, a sense of pathology, this is a problem and you're stuck. And so again, I think that idea of developmental psychopathology and strengths and to see how this measure that was used in schools could be used in clinical populations really attracted us to putting it into the CARE approach. Absolutely. And especially when we're talking about child psychiatry, and developmental psychology, and the fact that young people can change as they go through life, it makes even more sense to use a tool that focus on traits and not treating traits as permanent traits. And speaking of traits, and strengths, and weaknesses, I wanted to focus a little bit about the findings you've had. So basically, you use this technique called latent profile analysis to establish profiles of strengths and also weaknesses, but mostly focusing on the strengths, depending on the profile of that the young person that-- you had such a richness of results. I remember thinking, oh, my goodness. This is a huge study. And you had different groups of patients. I wanted to start with the internalising group. So internalising disorders, for those in our audience that might not be familiar with this term, they are a group of disorders that usually refers to depression, anxiety, or obsessive compulsive disorder. And you found two different profiles of strengths and weaknesses for this group, which was one of your largest. I wanted to ask if you could tell us a bit about the strengths and weaknesses you found and if anything surprised you in terms of those profiles. Yeah. Thank you. I also just wanted to make a comment about our methodology, the latent profile analysis approach. I think that the real advantage of using this approach is that you go into the data set without any sort of expectation of what to find. And it's a rigorous way of finding which participants in your data sample hang together more closely. I just wanted to clarify we didn't go into this project expecting to find a huge divergence. It was what we found. And it was really cool. And I think it has meaningful implications. But it wasn't that we were trying to find or we were aiming to show this. It was what happened through the statistical approach that we had. But that being said, I think that the-- so the seven profiles can be grouped into three different categories or groupings. And so we decided to group them based off of the psychiatric symptoms that they were presenting with. And when you look at what we would call the internalising disorders grouping, it's really striking because they have nearly overlapping symptom severity in terms of anxiety, depression, OCD, ADHD, and cognitive disorders symptoms. But then their socioemotional skill development is quite different. And this large divergence really suggests different opportunities to personalise treatments for youth with otherwise nearly identical symptom presentations. So for example, one profile shows relatively typical levels of socioemotional skill development with strengths and the ability to form meaningful and trusting relationships and feel part of a community. And these strengths suggest that use with that profile could benefit from interventions that leverage these peer and adult relationships both to increase treatment buy-in. Or if you're doing things like exposure therapy, it might be helpful to motivate them and push them to do challenging exposures. They also might benefit from group-based therapy, identifying mentors and family-based work. And they may also, given their strengths, and trust, and empathy, may more easily acquire some interpersonal effectiveness skills than other skills. And so teaching those skills first may help to accelerate treatment progress and target other areas down the line. And on the other hand, the other profile shows relatively weaker socioemotional skill development with challenges in many skills, especially the capacity to think critically about their experiences, and emotions, and values, as well as their assertiveness skills and the ability to express their needs in a respectful way. So these individuals may actually benefit, rather than a group-based therapy, may actually need a more individualised one-on-one approach that focuses more on values and mindfulness-based. I think that their typical levels of trust and empathy and relationships with others indicates that they do have a safe environment so that as they are learning different skills, they can practise this and feel safe at the same time. And so just to hit this point home, if a clinic is overwhelmed with referrals for patients with internalising disorder symptoms, thinking about these profiles in terms of who might benefit more from one-on-one versus who would be OK with being in a group-based treatment, clinics may be able to use these sorts of results to triage or determine who could still benefit from group-based therapy if there aren't enough clinicians, for example, for everyone to receive one-on-one therapy at a given time. I love that you made this connection with clinical implications. So for example, just to give a different context, here in the UK, we basically we follow NICE guidelines. And one of the interventions that is recommended, for example, for generalised anxiety disorder as first line in NICE guidelines is group-based CBT. And oftentimes as well, because of capacity group-based CBT is offered fast as a blanket approach to everybody, but actually, a lot of some of the patients find this unhelpful. And it would be really interesting if we could triage people into what treatment might be best for them based on their strengths and their weaknesses. And yeah, I think the work you're doing opens very interesting avenues for that. I should also just put the caveat out there that when I'm talking about clinical implications, these are possible findings. But our research data can't speak to that specifically. So I just want to put that big caveat that our findings show these patterns of profiles and what might be helpful. But of course, it'll require more research studies to really test whether individuals in one profile versus the other would benefit from group-based versus individual therapy. So I just wanted to put that out there as well that our data aren't saying that these clinical implications absolutely are true and should be followed. Thanks so much for reinforcing this. Yeah. I think it just opens really interesting possibilities in terms of even replicating the same study in other places and seeing what kind of profiles emerge. But still on the profiles topic, another profile I was really interested in your reading your results was there was a group which was basically young people who had comorbid internalising and externalising disorders and who had moderate severity because as you both said in the beginning, a big part of your sample was intensive outpatient. So actually, you already have a bit elevated baseline severity. And you also found a really interesting split when you looked at the comorbid internalising and externalising group. So yeah, could you walk us through these results? Just for folks who aren't familiar, externalising disorders are really characterised when an individual is experiencing a lot of distress, but the distress is expressed outwards and more visible to others in their environment. So these are things like fidgeting, or interrupting, or irritability and aggressive behaviours, lying. Those types of behaviours is what we would refer to as externalising problems. And what we found is that there were two profiles with a moderate severity of both internalising and externalising behaviours. Among those two, one profile had higher levels of what we would call conduct symptom severity, conduct disorder symptom severity. So these are things like violation of others rights, severe aggression. And we found that while they had typical level-- or they had relatively weaker socioemotional development overall, but especially in the capacity to think critically about their experiences, and values, and emotions, and their assertiveness skills. One thing that I do want to highlight about this profile, though, was that they had typical levels of emotional control and distress tolerance skills, which was a relative strength for them. So I think it's important that despite these elevated symptoms, they also have typical skills as well. And they have strengths for within themselves that they can really lean on. And so given that, they actually may benefit from treatments that teach distress tolerance skills and what we call acceptance-based skills first before moving into a change-based cognitive restructuring type of approach. The other profile was notable for their typical socioemotional development across all domains with a relative strength and the capacity to form meaningful relationships and feel like they're part of a community. So similarly, they may, if they were choosing different treatment approaches, they also might benefit from a group-based therapeutic approach and approaches that teach youth how to quickly adapt to challenging and stressful and otherwise complex social environments, given that they do have these typical levels and even a strength and empathy. So that could really go a long way in terms of their ability to benefit. Yeah, I was really interested in that group, actually, because one of your initial hypotheses that you state in the paper was that and I think a hypothesis that a lot of clinicians would agree is that young people that have very high externalising symptoms. So for example, as you, Dr. Cummings, really nicely explained, young people who would have very outward behaviour, so for example, a higher frequency of aggressive behaviours or irritability in the classroom. So your hypothesis was that they would have strengths in being assertive and action-oriented, but that they would have challenges in emotional control, and reflection, and empathy. But in one of the profiles that emerged in your comorbid internalising and externalising group was actually that they had low assertiveness, but they had a lot of empathy. As you said a bit before, empathy was identified as a strength in that group, which as a training clinician, was actually a result that surprised me a lot as well and that I found really positive and inspiring. And how did you make sense of these findings with your initial hypothesis? Yeah. I think this is one of my favourite findings as well. I think it shows that children and youth are a lot more complex than we give them credit for. I also want to clarify the difference between a relative strength and a normative strength. So a normative strength is when an individual's ability on something is at least one standard deviation above the population average, whereas a relative strength means that their score on that measure is one standard deviation above average for that profile. And so in this comorbid externalising internalising moderate severity group, we found that profile had a relative strength and empathy. So they were still at typical levels of empathy relative to the population. But that was the strongest thing that they had going for them. Nonetheless, I think that it's important to even emphasise that they have typical levels of empathy. And I think that this can be interpreted through several frameworks. But one that comes to mind is Marsha Linehan's biosocial model, which states that biological factors like genetics cause some individuals to be more intuitive, sensitive to, and readily experience the emotions of others, so more or less empathetic. And while sometimes this can lead to mental health challenges because individuals might not have the skills to effectively regulate these emotional experiences that they're receiving and experiencing in everyday life, I also like to think about empathy as a superpower. And that's how I describe it and teach it to kids because when used effectively-- there's that Spider-Man quote. With great power comes great responsibility. Yes. Exactly. So when used effectively, empaths have an advantage with understanding someone's emotional state and what someone might need in any given moment. And so this actually allows them to navigate complicated social situations more easily than those who actually have lower empathy. And so I think that really hitting this point home early in treatment for individuals that come to our clinics with lots of comorbid problems and a lot of distress, kind of showing, hey, let's look at the other side of the coin. And this ability you have is really unique. And you can use it and go a long way towards improving your life. And we just got to help you fine tune that ability a little bit differently. That was a very, very beautiful explanation. And I think it's also very helpful to-- as you said, children and young people, they are incredibly complex in their different presentations. And I think especially when you talk about externalising disorders, there is a lot of stigma still associated with externalising behaviours in kids. And parents oftentimes are understandably worried, especially when these externalising behaviours and symptoms comes in the form of aggressive behaviour, for example. But it's also wonderful to think that actually, some of those kids, they might have really high levels of empathy. And actually, the externalising behaviour is an outward expression of something they're not being yet able to emotionally process. So yeah, that's a very nice way to look at it. In terms of your results, did you have a result that surprised you or that it wasn't really what you were expecting, even though you said that one of the nice things about latent profile analysis is that you don't go in with an expectation? But yeah, any results that you were scratching your heads trying to understand? Yeah. Well, I think that the-- piggybacking on what we were just talking about with the empathy, I was surprised that we didn't find a predominantly externalising disorder group or profile. We found an internalising disorder grouping, but not profiles characterised by only externalising disorders. And I think there are several reasons why that might be the case. But I think that what that goes to show you is that oftentimes, we think about patients in two different buckets of internalising or externalising. And they might be referred to a higher level of care due to severe aggression, or irritability, or other types of externalising behaviours. And if we don't use a measurement-based care approach, we might actually miss the internalising symptoms that they're struggling with. Or we miss the opportunity to identify the empathy and other socioemotional strengths that they come to our clinic with. And so by not using these approaches, we actually are missing a lot of information. And so I think that surprising finding is actually really confirming why measurement-based care is important for us to use. And I also want to say, bridging on that-- and I think it's less about a finding as much as a process outcome and learning. So I think it's just shocking how few mental health clinicians, or really, how few clinicians in general, not even just mental health, use standard assessments. There are studies showing that fewer than 12% of clinicians use some measures sometimes for some patients, whereas measurement-based care is about using the same assessments for all patients all the time so that you're not applying them with bias or randomly. And so I think that it just is surprising that-- there are lots of good measures, lots of good applications. How do we catalyse people getting into measurement-based care so that they can do it wherever they're practicing, whatever their practicing as a way to help use the information to provide better care and insight for their patients? I think that's a process outcome that we learned as a team working on the CARE Initiative. Thank you for that, Dr. Dickstein. I think you've made a very important point. I think this is something that I've discussed a bit with my supervisor because she's also a very big enthusiast of measurement-based care. And it is difficult to convince sometimes people to implement it more widely because as you said yourself, a of people, they don't understand that it's about using the same measures over and over again and that will give us a very rich data set eventually on-- much more than a data set. That will give us rich information about how our services are behaving and how can we improve them. But I think there's still a lot of resistance, especially in terms of the time it takes to complete those routine outcome measures. A lot of people think that it might not be worth it because it takes a lot of time and it deters from clinical time of patients. But actually, I think your paper proves a nice point that precisely, it is the process of filling these measures. And that creates the information that then we can use to create clinical insights, which can revert back to patients. Yeah. So I think guys have a very done a really important work with the CARE mission. Thank you. Yeah. And I think, just to add to that point, it does take time to collect this information. I think that it takes about-- correct me if I'm wrong, Dr. Dickstein, I think about an hour, 45 minutes to an hour to collect all of the surveys. And at the same time, I think it's important to do that because if you only have a 30% understanding of what's going on in a kid's life, your conceptualization of a case is only 30% full. And so you might be missing key mechanisms that are prolonging, and maintaining, and escalating the symptoms that they're experiencing. And so you might be targeting the wrong thing if you're not fully aware of the full clinical picture. Yeah. Absolutely. And we kind of already talked a bit about what I'm about to ask next, but I'm going to ask it anyway. We spoke about the strengths of your paper today and basically the CARE Initiative and your work, which taps into the CARE Initiative. And it was the first study to use routine outcome measures to study strengths in young people that are currently receiving psychiatric care. And I wanted to ask you mainly about the implications of your findings for clinicians and also for even intervention development. We spoke about, I think, a consequence maybe of your paper that might encourage other clinicians to also adopt routine outcome measures in their services in terms of the findings. Any other implications you can think of? Yeah. We talked a little bit about empathy. And another thing that I wanted to emphasise was that if you look at the profiles, a lot of them struggle with normative challenges and optimism, which wasn't a huge shock to me. I think it makes sense that most kids that are receiving higher levels of psychiatric care probably have lower levels of optimism. And at the same time, I think that this underscores the important point of providing feedback to youth and their families about the skill sets that they do already have going for them and in a really concrete way. And I think that providing that type of information to them and telling them, this is how we're going to leverage what you already have going for you and why what you're showing up with gives me confidence that this treatment is going to work better if we do this approach and really using that personalised treatment approach, I think that that could go a long way towards improving someone's optimism and treatment buy-in because when we think about the-- the statistics are probably a little different now. But I think when I was in training, I heard the modal number of sessions that someone comes to therapy is one or two. And so if we can increase optimism for patients at the very first session, we might actually get them to come back for more than one or two sessions. So that's something that I just wanted to highlight in addition to the empathy and the other treatment implications we've already discussed. I think for me, I think the most important implication is we hope that we inspire other people anywhere, regardless of clinic size, location, population served to think about, is there an opportunity to get involved with measurement-based care to use it as a tool to augment the art of clinical assessment with the science of standard approaches? Kids aren't one note. They're complex symphonies. And I think what this study highlights is that if you don't do measurement-based care, you risk missing out on a kid's life and a family's functioning that could be used to better understand them, to better help them, and then ultimately to improve outcomes. And so measurement-based care isn't one size fits all. We're doing something at McLean. Other people are doing other things other places. We just want to inspire folks. You don't have to be a, quote, unquote, "researcher" to do this, right? You have to be curious about your patients. And I think that's a challenge that's really not just mental health care and not just about kids. It's really about all of health care. We need people to be curious about their patients to figure out how can we innovate a brighter future for them. Yeah. I think on that lovely, lovely, inspiring advice, be curious about your patients and about services. I just wanted to say a huge thank you to both of you for your time today and for taking the time to talk to us about your paper. Yeah. Thank you so much, Dr. Dickstein and Dr. Cummings for sharing your wisdom with us today and for your time as well. And if you want to read the full paper, there will be a link in this podcast. And thank you so much for the listen. Thanks. Thank you so much. Thanks, everybody. [MUSIC PLAYING]