SPEAKER; We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to mind the kids. I'm Dr. Jane Gilmore honorary consultant, clinical psychologist and child development programme director at UCL. I'm Umar Toseeb, a professor with a focus on child and adolescent mental health and special educational needs. In each episode of Mind The Kids, we select a topic from the research literature, and in conversation with invited authors, sift through the data, dilemmas, and debates to leave you with our takeaways for academics and practitioners. Today we're talking about social isolation, its impact, and how to address it. This episode is called "Only The Lonely." Loneliness, yeah. So yeah, I'm interested to talk about this because I would-- in my teaching of child and adolescent mental health and my research on child and adolescent mental health, I wouldn't have put loneliness up there, something that is pertinent enough to cover in my teaching. But after having read the editorial, I'm now reconsidering that because loneliness is uncommon in adolescence and, of course, talks about that in the editorial. And it's not surprising, given that adolescence is a social period of life where peers are important, friendships are important. And so people, adolescents, tend to be quite social during that time. I think that developmental push you is so much at the heart of this issue, isn't it? Because following a variety of data sets, and the most recent one is the Office of National statistics, showing that young people are probably the most likely demographic to feel lonely. But if we think about the teenage brain, there are lots of good developmental reasons for that, aren't there? So that pull towards peer integration. And this is a question that I'm going to ask Roz in a moment. This idea about-- because there's such a pull towards pure integration-- and some people have described loneliness as thirst, which I think is brilliant because it really brings to life the idea that there's a fundamental brain drive. But maybe that means that when we feel socially disconnected as a teenager, does that mean the brain signals that as an emergency more than you might in another age group? And I don't know if there's something in that. And that it might be that the same sort of objective experience might be experienced as more aversive because of that requirement from the brain to get connected. I think the other thing that I'm, again, talking about the developmental stage is that intensity of emotion. So any emotional experience is likely felt at its greatest intensity during this period. So if you're feeling socially isolated, you're certainly feeling that with great intent because of that sensitivity in the teen brain. So it's interesting. We think of lots of these things in child and adolescent mental health and development as a negative. And loneliness, we're going to discuss it in various different contexts, but it can be considered an adaptive thing. So in children and young people, it might be the trigger for them to then seek out social relationships, is, I think, what Roz is saying in the editorial. But we're going to find out about that. And I think on its own, it doesn't seem to be problematic because sometimes people feel lonely, and we shouldn't necessarily pathologize that experience if it happens sometimes. But for about one in five children or young people, it can become chronic and therefore become problematic. And I think that's a running theme in this podcast series where we've been talking about various experiences that children or young people go through, and that can be considered quite adaptive, yes, needed and necessary. But then they become problematic or abnormal or maladaptive when it reaches a certain threshold of severity, frequency. But the distinction between what is normal and what is abnormal and atypical is usually quite fuzzy and blurred, and it's not quite clear at what one thing becomes problematic. And I imagine it's not that clear for loneliness either, as in, what point does adaptive levels of loneliness become maladaptive levels of loneliness that are problematic? And I think that-- and again, that question, the reading of the literature-- and again, Roz will help us here as our expert. But the idea of loneliness as an acute experience is probably quite a positive thing. But if it becomes a chronic experience, that's when we would be concerned. And actually, loneliness has the potential to perpetuate. So some of the behaviours like social withdrawal or cognitions like self-blame could be consequences of loneliness, but they also might maintain it or exacerbate it too. So there is certainly an indication that we need to do some intervention, which is why we're very pleased to hear about Roz's work a little bit more in a little bit more detail in the moment. Conceptualization that you've made there is interesting because I think one of the more recent ways of thinking about mental health conditions like depression or anxiety is rather than thinking of them as symptoms that are caused by depression or symptoms that are caused by anxieties this is experiences that are interlinked to each other, and they are mutually reinforcing. And I suppose it'd be interesting to see where loneliness fits into That, So where loneliness might then lead to withdrawal, which then might lead to not finding pleasure in things that you usually find pleasure in, which then might lead to sleep problems, appetite problems, et cetera. So it'd be interesting to see where loneliness fits into that network of other characteristics that might indicate some sort of mental health difficulties. And I think that's something that Roz has raised in her work as well, about the idea that there is some positive evidence based outcomes for loneliness as a adjacent to mental health issues. But loneliness per se, as an opportunity to treat there's less or there are-- the evidence base there is not as well developed. So this is why this modular idea of looking at how to address loneliness as a concept in and of itself is really interesting. We need some expert ideas, don't we? I think we should bring Roz in and out this mess that we're in. So today, we're joined by Professor Roz Shafran from the University College London. Roz is one of the authors of the editorial, "How can we develop effective and timely interventions for young people with chronic loneliness," published in the JCPP. Welcome, Roz. Thank you. Jane and I have discussed what we think loneliness is, but let's start with a definition. So what is loneliness in the literature sense? And then what does loneliness look like in children and young people? Well, you're not far off in your conversations about expectations and discrepancies, because the literature would say that loneliness is subjective or unwelcomed feeling or lack or loss of companionship. And it happens when there's a mismatch between the quantity or quality of relationships that we have and those that we want. And I think one of the questions is, why is it something that psychologists might be interested in? And it's because it is that mismatch, that perception of a discrepancy between what you have and what you want that brings us into the psychological domain. If we think of-- oh, sorry, Jane. Go on. Oh, you go for it. If we think about a child and a young person in primary school or secondary school, what might be some of the characteristic behaviours of loneliness? Is it like withdrawal? Is it a lack of friends? Like, how might someone spot a lonely child or an adolescent? That's not as straightforward a question as you might think. It's not social isolation. So there is a relationship between loneliness and social isolation. So the less social support you have, the more likely you are to be lonely. But it's not a 100% correlation. It's about a 0.4 correlation. And it will look different for different people. So it might be that the child on the school bench is OK. They don't have a mismatch between what they want, and all the other kids are annoying them and that's fine. They don't want to play with them and so on. Or, and probably more likely, there's somebody that wants to make friends but doesn't know how to make friends. So they might have a social skills deficit. Or they could be somebody that knows how to make friends, but they're frightened of being rejected, so they've got social anxiety disorder. It could be that they are significantly overweight and they've been bullied or teased about their weight, and they feel like they wouldn't be welcome or they would be teased. So it's hard to tell just from the behaviour. But even beyond that, the kind of understanding, it's very heterogeneous. That's the challenge. And that's the key with loneliness that it's different for different people. But certainly the heart of it in terms of behaviours of avoidance and lack of opportunity, those sorts of things, anxiety at the thought of the relationships that all of those can and will be part of some people's experiences, some children and young people's experiences of loneliness. I guess that was why the idea of the modular treatment was so appealing, because of that heterogeneous nature of the presentation. There's many routes to one presentation. And going across the age range, so you touched on the fact that it really is quite surprising. Many people think that loneliness is associated with the elderly. And it is true that there is it can peak in much older adults. And if they've experienced a bereavement and their social networks been dependent on that, then you can absolutely understand why they might experience loneliness. But you've also, at the other end, might have someone a young person who just lacks those social skills and wants those relationships. So how do you develop an intervention for the older adults that's been bereaved, or might be having difficulties with their physical health and can't get out and about versus the younger person who might lack social skills and might have an idea of how to form friendships, but can't really implement that or maintain those friendships once they're formed? And do you think there's anything in that hypothesis that perhaps because of the unique state of the teenage brain that even though sort of in theory, they have good social connection, that because they are pulled towards really wanting to be integrated so strongly, that it might feel more pernicious to feel lonely as compared to, for example younger kids? I think there is definitely something in that, and there's something in it about what they're seeing all around them and the social opportunities that there are in teenage and adult early adulthood that maybe there are fewer of those as you go through life and have different sorts of responsibilities. So, absolutely, I think if you think about in terms of that sort of discrepancy the desire for relationships might be stronger because of the teenage brain, the kind of missed opportunities might be-- and looking on social media at all other people, having all of these fabulous anxiety free social experiences as far as you can see, widens that discrepancy. So I think it's all of those things make teenagehood a very vulnerable time. And the other thing that I think is really critical is it isn't the use of social media per se, and just seeing all of those, but it's actually the digitalization of social connection. And that's a different concept, and it's a very important one. So I think that sort of idea that, how deep can you have those relationships, how meaningful can those relationships be if they're on snap as the majority are. And then it never gets to the face to face stage, then you might have a lot of social connections, but they're not the ones that you want. They're not the meaningful ones. They're not the people that you can rely on in times of trouble. So they lack the intimacy that might be required to feel connected. So they're thin, but not deep. So it's an interesting point you make there, Roz, which is around the digitalization of social connection. And so digitalization, the intention might have been to facilitate social connection, and you'd hypothesise that it might reduce loneliness, but then it seems counterintuitive. And Jane just touched on that. Why might that be? Is it because it's not as good quality or what you'd expect or need from a social connection, and you're not getting that on the digital spaces? Or is there something else? I mean, I think all of those are really reasonable hypotheses. And again, it comes back to that definition that you might have a huge quantity of social relationships. And if what you want is lots of people to go out with, then there's not going to be a problem with that, because you can do that and you can meet up and you can go to the parties and that's fine. On the other hand, if what you're really looking for is someone to connect on a deep level, to understand-- you understand the way that you think be there to support you and your support them, I think that is less facilitated. I think that is harder if you're not meeting up face to face. And it's harder to go from the quantity to the quality. So it's very dependent, I think, on the individual in that personal kind of discrepancy. And it depends on what they want, a best friend or actually lots of friends. It's different for different people. I'm stuck on this idea of and you've-- I've asked you this already. I'm going to ask you in a different way, which is I said, what does loneliness look like. And I understand that it's very difficult to pin down and spot the signs of loneliness, but in other areas of child and adolescent mental health, we can think about which groups are at most risk. So you might find that, for example, if I was to guess with loneliness, I might think that neurodiverse kids might be at increased risk because their social connection looks different, or sexual minority kids might also be at increased risk. Do we know what those at risk demographic groups look like? Yeah, we know something about that. I think there are two different questions, aren't there? What does loneliness look like? What are the-- I'm a CBT therapist-- what are the thoughts, the feelings, the behaviours that encapsulate loneliness? And then the second question is, what are the risk factors for loneliness? And there can be emotional loneliness and social loneliness. And those are different. And those have different thoughts, feelings, and behaviours attached to those. So it isn't as straightforward. It's not like you can say these are the typical thoughts, feelings, behaviours that you would characterise, depression and so on. But the cognitions are about wanting more and better friendships. The emotion is one of feeling distress, anxiety, feelings of failure, lack of self-worth, lack of self-efficacy if you can't form those sorts of relationships. And the behaviour might be avoidance, withdrawal, or trying too hard in the social domain. All of those can be behaviours associated with loneliness, alongside anxiety, depression, and the emotional states we're familiar with. So that's the first question. Then the second question in terms of risk factors, age is a risk factor we've talked about in an associated u-shaped way. Female sex looks like that's a risk factor. Your health, mental health, is a big risk factor. And Jane you touched on that at the beginning about perhaps the bidirectionality with mental health. But also physical health is a risk factor. Predictive loneliness, genetic, socio-environmental factors, workplace factors. There are lots of risk factors and we do know about them. And there in terms of your demography, in terms of your health, in terms of your brain biology, genetics, and socio-environmental factors. So it is a multifaceted difficulty. And I think for us, knowing that really quite strong evidence showing, unsurprisingly, that mental health problems can precede loneliness. And I think this is so interesting, Roz, because the idea that, as psychologists, we're at the intersection-- if we're looking at loneliness, we're at the intersection of so many influential factors. And you touched on those environmental factors, socioeconomic status, and that we are addressing using psychological techniques, the internal factors, aren't we? But you quite rightly are talking about those environmental issues that-- talking about, for example, if you have a third space to go, you're not at home, you're not at work or school, you're somewhere else, you might make a social connection. But that very much depends on the community you live in and potentially your socioeconomic experience or your capacity to even get there. Do you have the bus fare to get there? And all those things. So I think it's one of the challenges of this, because it's at the epicentre in some ways, but it's so much a systemic issue as well. Yeah. And when I first worked in this area, I was really quite shocked at how siloed it was, because clearly, if somebody is highly socially anxious, that is going to impede making of social relationships and low impact loneliness. So you want to be pretty good at treating social anxiety now. We want to be able to help that person so they can form those relationships. On the other hand, if they don't have the social anxiety, but they've got nowhere to go to form those relationships and no social opportunities, then that isn't going to help either. So you absolutely need the social mapping and the navigation aspect of the social world alongside the individual mental health interventions, I think. And it was really quite strange to me how that's even a question, or why-- it's the way services are set up. It's an age old question, but in my mind you absolutely need the two to go hand in hand. In the editorial, I think, you would say that you advocate for the routine screening of loneliness. And I would say, why? Because if for example, the risk that you have with screening is you then identify kids who are at risk or are experiencing loneliness, but then if we don't have the support in place and the resources to be able to support these kids, then all you've really done is identified kids who are lonely, maybe told them that they're at risk of being lonely, or they are lonely, or you validate it or put a label on their experience, but then no support has followed. So I think that, again, that's quite a difficult question, just because you don't know about it doesn't mean it doesn't exist. So I think a more general question is because we don't have the resources, should we not even ask the question. I think that's the same principle applies to loneliness and everything else. But I also think that until you know about it, you don't get the resources. So I think we have to identify what the need us. And I think you're right about your earlier point about not pathologizing normal experiences. Episodic loneliness can motivate you to do things, can be adaptive in terms of social connections and so on. But chronic loneliness is different and much more associated with the kind of psychopathology. And I think if you're doing screening and we know that this is a risk factor for the development of mental health problems-- so we're interested in early intervention, we know that early intervention is cost effective. And the idea that we don't have anything that we can do, I would question that. I think there are things that we can do. There are different things. They're not always psychological. Social skills training for those that don't have it. Pretty effective, relatively short interventions that can truly make a difference-- online, digital, low cost, scalable, all of the things I'm sure that features of your other podcasts, to enable it to be detected early, intervene early. Let young people develop and their brains develop in the social way which they were designed to and really prevent some of the more significant mental health problems. And this idea, loneliness is more deadly than smoking, which is around from a study, actually, people really minimise its impact. It has really significant health impacts, physical and mental health. And so yeah, why shouldn't we try and catch it early, intervene early and make a difference to young people's lives. I also think-- I wonder, because we know that young people who are autistic are more likely to feel lonely. There may also be an importance in naming that sense of disquiet, if you like, and that young people might need some support to describe what it is that's going on. So, I wonder if it's a feeling of lonely or whatever. And then defining that problem, talking about problem doesn't create a problem, and that then we could support young people to find ways around it. And as you say, some of these interventions are not about internal processes. Some of them are about connecting and finding a way to connect. Sometimes using digital means, I imagine. I mean, the world is a tiny place if we're thinking digitally, that's a start. At least finding a tribe, somebody who loves the same thing that you do and so on. So I think identifying-- and I hear what you're saying more about so what are we going to do now we see the size of the storm. Well, at least we know the size of the storm. And we can put our wet weather gear on, if you know what I mean. I think that that's-- but it's an interesting question. Getting the screening, I think is a challenge, across trusts, the feasibility. And every time we do these podcasts, there's a new issue that we must be exploring. And loneliness is definitely another one that we must be exploring. But how do we get that feasibility-- explore that feasibility and do systematic screening across different trusts that are very different countries? Each trust has their own challenges, and ways of doing things. So how do we get that across, I think, that's one of our challenges. I mean, one of the advantages, I think, in loneliness, maybe perhaps compared to other areas, maybe, maybe not, is that there's quite a lot of population based work. Population based surveys in order to assess the scale of the problem. And it's interesting and I thought, well, loneliness, shall I cover it? But it's actually been the subject of a US Surgeon General's Report about the epidemic of loneliness. And he's written and spoken very eloquently. And I think because he had experienced it personally, it resonated with him. So I think once you have that experience, it really can impact you in all kinds of ways. And he would be very clear about the impact that it has and the need for screening, not just in mental health trusts, it's not just a mental health problem, but in trusts and on a population level. So we have pretty good screeners and they're not very long. And I think that's a bit different and makes it more feasible, at least in principle than, let's say, where you have to have very long screening questions. But we've screened for depression in primary care. Add a question on loneliness. Yeah, I know everybody thinks their area is the most important. [INTERPOSING VOICES] What screener would you recommend? Are you thinking UCLA loneliness or what would you-- Yeah, and there have been some national surveys. We've had Loneliness Czar doing it on a population level. So I think it would depend on how much-- are you going for the absolute one item, are you lonely? Or are you going to go for a four item, UCLA? So it depends on your purpose. And I know it is very difficult. There's a PhD student at UCLA who has managed to get loneliness measure in IAPT services at the beginning. And that's taken a very long time and longer than you would think. But I think the reason they will have done it-- and the work led by Sonia Johnson-- the reason that they've done it, is the argument about how important it is to mental health and important to understanding the trajectory of mental health and the outcomes for mental health disorders more generally. I think the reason I was asking or making the point was, like, you've picked up on a lot of-- and we've had on this podcast series. Anyone who's come onto the podcast has advocated for their area of whatever it is that they're investigating and all of them are important. So we've talked about friendships, we've talked about family environments, we've talked about social media, we've talked about digital spaces, we've talked about neurodiversity, social anxiety, paranoia. And I think that everyone maybe to a greater or lesser extent, would advocate for some sort of screening. And I was thinking that if I was a parent listening to this, I think rather than thinking of this as a formal screening process, where a parent wouldn't think, oh, I'll get a questionnaire out, but it's just it's another thing--