We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids, 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, and I'm passionate about understanding and addressing the diverse mental health challenges faced by young people globally. In this series, I'm joined by renowned researchers and clinicians from around the world to discuss their cutting edge research, their interventions, and best practise in child and adolescent mental health. And today, I have the pleasure of receiving Elena Maringa. Elena is a PhD student at the unit of Psychological Medicine at the Queen Mary University of London, and she's also a clinical psychologist by background. Her research is funded by the London Interdisciplinary School of Science Doctoral Training Partnership. And today, we're going to be discussing her paper published at JCP called Sleep Disturbance as a Transdiagnostic Marker of Children's Mental Health Difficulties, a network analysis. So Elena is a huge pleasure to have you here today. Thank you so much for coming. Thank you so much, Clara, for such a great introduction. And I'm so happy to be here and to share with you from my insights about our paper. So our paper is focused on sleep problems. And it's known that sleep problems are part of the diagnostic criteria of many mental health condition. And also, were found to contribute to the onset to the maintenance and course of these mental health conditions. And among them there are emotional difficulties, such as anxiety and depression symptoms and behavioural difficulties, such as hyperactivity, inattention, and conduct problems like, let's say, aggressive behaviour and antisocial 1. And sleep problems is an umbrella term. So it's an umbrella term, including a set of difficulties around sleep, like, difficulties of falling and staying asleep, difficulties around onset, duration, quality, and quantity of sleep, abnormal behaviour during sleep, night awakenings, nightmares, sleep, anxiety, challenges regarding the bedtime routines. And often this challenging will lead to some consequences like daytime sleepiness and challenging during daytime in function. And our research is about middle childhood. Now, there are many research where sleep problems is included as the overall score named a composite score. However, their research, which looked at specific sleep problems, how they are associated with, for example, specific variable of anxiety and depression like emotional cues and specific sleep problems. How I associated with specific behavioural problems. However, usually they co-vary. What it means? For example, a child may have emotional and behavioural difficulties at the same time. And there is not so much research which looks into how sleep problems is related to emotional and behavioural. Other difficulties at once. A network analysis is the extraordinary analysis, let's say, which enables to see a multifactorial phenomenon, a complex phenomenon where we have mental health problems that usually are comorbid or co-vary. So network analysis enable us to see an association, for example, between a particular sleep problem with a particular emotional difficulty. When we take into account all of the variables included, so also the behavioural difficulties. So we take into account everything. Also network analysis enable to see to spot clusters. So communities where these items or variables of interest are aggregated. So you were mentioning you used network analysis to look at the relationships between sleep problems and mental health difficulties. And you've touched on that a little bit. But can you tell us a bit more what is known about the relationship between sleep disturbances and mental health difficulties? And what was this specific gap your paper was trying to address. You mentioned, for example, that we have lots of studies that use sleep disturbances as a composite score. But yeah, what is the novelty your paper brings? So just to speak a bit about sleep difficulties, how they relate with mental health conditions. So let's say sleep difficulties were once thought as a secondary, as if I pronounce correct subjacent feature of other mental health conditions. However now, sleep will take a more central role. And it's known that Professor Harvey, for example, showed this when she wrote about insomnia in 2001 as a standalone diagnosis. So sleep problems now are regarded as a transdiagnostic mechanism. So as a central feature, what this means, it means it contributes to the onset, maintenance, and course of other mental health conditions. And there is a beautiful research about this. And study on project from Professor Harvey and Saafan. And because sleep problems represent an umbrella term for many difficulties around sleep, it is important to know which specific sleep problem will constitute more of a co-feature for mental health in middle age children, because we want to look to target specific sleep problems, which will stay at the core of these mental health conditions. We want to target, like a more modularized approach, a tailored approach. So for a specific, if there is such a thing. So our network analysis showed. So like I said above before previously, there is a gap in looking into this context of comorbidity. Here there is a gap. And our study using network analysis enabled this to look into which specific item or variable will stay at the core of children with sleep problems in behavioural and emotional difficulties. And how this is more influential when we take into account all of the variables. So including the comorbidity which I mentioned, it happened to be also between sleep and emotional and behavioural problems. So between among them. Understood. And you said you did all this complex analysis and a feature of your paper that I found super interesting was this sample. So your participants, they came from this big cohort called the development of emotional resilience observational cohort, right? And can you-- yeah, can you tell us a bit more about the cohort? And what strengths it adds to your study? Because it seems to be a very diverse sample of people. Yes, we looked into this and we have some strengths regarding our cohort. So our data comes from the development of emotional resilience is an observational cohort. Examining the measurement on development of resilience in primary school-aged children is a project led by my amazing supervisor, Professor Jennifer Liao, and our amazing youth resilience team within Queen Mary. And this cohort is special because it's composed from children from primary school in East London. And East London, is known to be an area with high level of child poverty. And it's known that, for example, socioeconomic deprivation always in research is very significantly correlated with sleep problems as well as with behavioural and emotional cues. So let's say this is one of the strength. And also we have a sample, which is very diverse ethnically. So we have more than 50% Asian-British, followed by Black, and just 16% is white. And our sample includes children from 7 to 12 years old, almost 50% females. And let's say there are a lot of research which include clinical samples. So our sample is a school-based sample. And we wanted to look at this relationship in general population. Our conclusion to have a meaning for every child. I think that's such a big strength of your study because usually we have the opposite problem with British cohorts. Usually, we have an overrepresentation of young people that come from white background. So yeah, I thought that was such a really good point and strength of your study. The other thing I thought, it was a huge strength and I thought it was really beautiful. Your main figure, when you represent the network, the main network, you found. It such a beautiful figure. And I think what really got my attention was the fact that you had all the 56 nodes and the symptoms clustering. And I wanted to ask you, given the density and the richness of your findings, what do you consider the headline or a few headline findings of your paper? Yeah, so we are very happy. We thought of network analysis because this enables us to include all the relevant variables and to enable to this variable to cluster, to form communities. So to see where the shared variance go and how they aggregate within each other. So let's say, first of all, we speak about symptom level associations or patterns of association. So there was some cluster just with emotional symptoms, a cluster with behavioural symptoms and some cluster with sleep. But the cluster where there were patterns of co-occurrence of emotional and sleep difficulties within the same community. And actually our research is not the first one who found this. And there is another research of Dr. Thomas and colleagues. However, they have a clinical sample with autistic children, so they also found strong links between sleep and emotional problems. And this may be related to many factors, but also that our sample is composed by middle-aged children. So it's about middle childhood. But of course, the most important finding was that, let's say at this developmental stage, we found that anxiety and sleep anxiety to be the most influential nodes. So at the core of the network. So we name a core mechanism, a transdiagnostic feature in relation to emotional and behavioural problems. So as we found this, we can refer now to a modular intervention approach, perhaps a more tailored one. So focus on anxiety and sleep anxiety for children also with sleep problem but also with emotional and behavioural symptoms. And this particular intervention I think is very useful for parents, teachers, medical staff, and policymakers, let's say. Still on the results of your paper, one result that I also found really interesting was that you found-- if I understood it correctly, you found that emotional symptoms, they were more proximally connected with various types of sleep problems, but actually behavioural symptoms. They were more of a peripheral cluster. They were more distant. Do you have any thoughts on why that is? Yes, thank you so much for this wonderful question. Actually, we were surprised a bit as well, but not so much because we speak here about this developmental stage, middle childhood. At this developmental stage, children are more characterised by emotional cues. And behavioural problems as research shows are more prominent in early childhood, as well as children go towards adolescence. And also, if we look at the models in behavioural genetics, they indicate higher genetic correlation between sleep and emotional problems rather than with behavioural problems. And also, I know there is this wonderful work of a great specialist of sleep, Professor Carskadon and colleagues, where sleep is seen as an environmental exposure for emotional symptoms like depression, for example, mood. However, we cannot disregard so many studies about behavioural symptoms related to sleep in children. So there is plenty of research which shows this. Just the relationship with emotional symptoms seem more tighter because here, as we found emotional symptoms with sleep problems, they seem more interwoven. And of course, I think there will be more to discover perhaps about this. So science can have more to say, perhaps in the future. Why not. Absolutely. And yeah, I thought it was just such an interesting finding. And the other thing I wanted to ask you, Elena, is so-- as you said before, your sample and your study focused on this East London cohort of primary school children, and as you said as well, and I think this is a wonderful strength of your study, because as we were talking before, most British cohorts, they're overrepresented by white British children. But I suppose, do you think that the fact that your cohort is mainly composed of East London primary school children, do you think this is going to be a problem in terms of generalising findings, do you think this affects generalizability of findings? Thank you so much for this question. This is a very important question. I will begin a bit broadly and after I will answer more concretely. So when we speak in general about the characteristics of a sample, always speak about strengths and also limitations regarding the findings, the generalizability. So findings must always be taken cautiously accordingly to the characteristic of the sample, of course. And first of all, our sample is a school-based sample. So it is not a clinical sample. So we cannot generalise on a clinical population where results may look let's say more or less differently. Second sample is taken from an underserved community of an urban area where maybe that children may disclose mostly problems. And we know there is a wonderful paper of Dr. Alice Gregory, a sleep specialist who spoke about sleep privilege. So let's say our sample may be a characterised of children who disclose mostly problems. However, let's say nothing is perennial and we emphasised our results upon stability indices. Also, we have a very good number of participants, but of course, nonetheless, we must take into account the specific of our sample when we generalise our results. I hope I answered your question. Yeah, no you did. Thank you so much about for mentioning the paper about sleep privilege. And I think, as you said, obviously, your sample, your study focused on school children, and obviously, then the results are only applicable to other school children. But I think, it's really interesting that it does because if we look at current mental health prevention strategies, we know there's a lot of focus on school-based strategies and an increasing focus on universal prevention, or even when it is targeted prevention is targeted prevention that often starts at school. So I think it's wonderful and super policy relevant that your sample is school-based. I was wondering in terms, as you answered, in terms of there are characteristics of the sample, because we know that East London is an area with higher indexes of deprivation. But you spoke about that as well. Your study fills a really important gap in the literature, and in thinking about gaps and implications. So your study was innovative because it used the networks approach to look at sleep disturbances. And as we said, it did that in a school sample, a large school sample of children. And you've mentioned this briefly before about the policy impact that your findings could have. And I wanted to ask you directly about that. So thinking about the implications from your findings, especially considering that, as you said, your paper focused on mid-childhood, so on primary school children aged 4 onwards. What do you think are the main implications-- for clinical psychologists as well, I just found out. So I think. Yeah, you're super well-positioned to answer. What do you think are the possible implications for clinicians and policymakers as well? Yes, of course. Thank you so much for this question. So my insight is that one of the key implication is that sleep should not be viewed as a secondary or peripheral to child mental health. So as our results showed, sleep is a transdiagnostic feature. So a core mechanism. And specific sleep problems, for example, sleep anxiety and bedtime related fears may actually sit near the centre of children's emotional and behavioural problems difficulties. So let's say my insight for parents would be-- they maybe should take a more seriously, when their children have bedtime worries or sleep difficulties, such avoiding bedtime, worrying about sleeping alone, or struggling to settle. Even if these problems seem to be mild. And for schools, sleep may represent an important but often overlooked target of early intervention and well-being promotion. So schools may be aware of emotional well-being. But sleep education and sleep supportive routines are not always integrated into mental health approaches, so maybe this is a good findings for them to do more for their students. So maybe they will find something regarding sleep education and will communicate more on this. And for clinicians, the finding, I guess, support the value of more targeted of a modular intervention. So rather than treating sleep as a single construct. So perhaps affective, behavioural, and cognitive behavioural interventions could focus on targeting sleep-related anxiety in middle childhood. Super interesting. And if you don't mind me asking because you're a clinical psychologist, are there specific modular interventions focusing on sleep developed for children, like in cognitive behavioural psychology, for example, or in other psychological schools? I know there is a lot of cognitive behavioural therapy around sleep for insomnia and for other sleep problems. Also light therapy and other behavioural therapies around these and perhaps can the medical staff and the policymaker can do more around sleep. As it's a very hot topic. There is more research about sleep seen as a core feature around mental health in children. And we know that emotional and behavioural difficulties arose after coronavirus. And there is some big figures now. So targeting sleep difficulties as a core feature, I think would be beneficial for our children. Yes. Absolutely. I think as you said, it's interesting, right. Because in the space of school-based interventions, a lot of it is focused on emotional awareness and mindfulness-based interventions. There was a big trial like myriad in UK schools, but as you said, less of it. Obviously, some mindfulness components do help with sleep, but as you said, is more peripheral. It's not treated as a core component and your paper and also the work of other people that you mentioned. They do add to the evidence placing sleep as a core component. And actually, sometimes, as you said, even precedes the development of emotional problems in children. So it should be at the centre of prevention. Absolutely, absolutely. Of course, because sleep problems are in-- the prevalence of sleep problems is quite high in typical as well as in atypical children. So should be treated more seriously. And we know that children that not sleep well at night, they will have behavioural problems, emotional problems also will affect their academic capacity and overall functioning. So it is a very important. Yes. 100%. And well, to wrap up, finally looking ahead, if you could highlight one area of research or a research question that you really would like to see developed in this area in sleep problems, or it could be something also related to mental health networks. What it would be? So actually, I'm preparing a new research and I'm looking into longitudinal network analysis. So I have already a network, which is comprised everything. One year later, let's say, and I compared the network and I wanted to see if this symptoms, which will stay at the core of the network, will be stable over time. And also I'm interested about the underlying mechanism of sleep problems. And my idea is that in the future, we'll need perhaps a multidisciplinary team to not tackle everything just within one approach, because my insight is that sleep is very complex topic an area of research, and it helps us to optimally function. So it is very important indeed. 100%, yeah. Well, thank you so much for being here today with us, Elena. I've learned a lot about sleep and even more so about your wonderful research. And I look forward to seeing your paper on longitudinal network analysis on sleep. When it's out. Thank you very much. It was a pleasure to be with you today. Thank you. [MUSIC PLAYING]