On early trauma and neurodevelopment, with Helen Minnis

Helen Minnis is a Professor of Child and Adolescent Psychiatry at the University of Glasgow.  Professor Minnis spent time working as an Orphanage Doctor in Guatemala in the early 1990s prior to training in Psychiatry, and this stimulated an interest in the effects of early maltreatment on children's development.  Her research focus has been on Attachment Disorder and she is now conducting intervention research for maltreated children including a randomised controlled trial of an infant mental health service for young children in foster care.

You can find out more about Helen's work on her academic profile page or by following her on twitter.

The paper discussed in this episode is:
Dinkler, L., Lundström, S., Gajwani, R., Lichtenstein, P., Gillberg, C., & Minnis, H. (2017). Maltreatment‐associated neurodevelopmental disorders: a co‐twin control analysis. Journal of Child Psychology and Psychiatry, 58(6), 691-701.

Many thanks to Naomi Meiksin for editing the transcript for this episode. 

Transcript

Intro: 0:00

Hello. Oh, it is recording- I see the little figure. Okay, great. I will do my little spiel and then I'll introduce you. Nice. Okay. Here I go.

Sue: 0:16

Hi, I'm Sue from the Salvesen Mindroom Research Center at the University of Edinburgh, and I'm recording an episode of our podcast, PsychologiCALL. We are trying to, um, reach out to students who are maybe studying from home at the moment and also make, uh, an evidence-based contribution to the kind of conversations we're all having about child and adolescent wellbeing and development and learning and so on. And today's PsychologiCALL(very exciting) is with Helen Minnis, who is a professor of child and adolescent psychiatry at the University of Glasgow. And she's going to be talking to me about her paper, um, with the title:"Maltreatment-associated neurodevelopmental disorders: a co-twin control analysis". So I'm really excited to talk about this. Thank you Helen, for joining me.

Helen: 1:05

It's a pleasure. Nice to see you, Sue.

Sue: 1:07

Nice to see you too! Um, so tell me, Helen, what did you discover in this bit of research?

Helen: 1:14

So, two things- the first was that children at the age of nine, who've been abused and neglected, are much more likely than their peers to have developmental disorders like ADHD, autism, learning disabilities, et cetera. Um, and in fact, in this big population of children, the children who had had who had symptoms in three out of four symptom clusters that we looked at- so we looked to ADHD, autism, learning disabilities and tic disorders- the children who had three out of the four of those were nearly 10 times as likely to have an experience of abuse and neglect. And then secondly, because it was a twin design, we were able to look at causality and, to our great surprise, it looked as though the abuse and neglect didn't cause this neurodevelopmental complexity.

Sue: 2:19

Wow. Okay, there's, there's a lot of interesting stuff to unpick there, Helen, that's great. I can see why you picked this paper. But maybe first we should just go back in time and I can ask you what sort of led you to be asking this question in the first place.

Helen: 2:37

So it was in a clinical question for me. I had been doing research and clinical work with children who had an experience in abuse and neglect for many years. And what I began to notice over and over was the neurodevelopmental complexity and actually just the psychiatric complexity of these children. And it's partly because we were often doing clinical research with this group of children, so we were using standardized research measures. So when you use standardized research measures, it makes you very systematic. You know, you cover absolutely everything and if a child has a particular[inaudible] of cut-off point of diagnosis, you would say, yes, tick- they have a diagnosis. I only sometimes had children that had six, seven, eight, nine different diagnoses. And of course you would never, as a premonition, feed back to the family this big list of diagnoses. But as a researcher, I started to think my goodness, is it just, the people are referring me the most complex cases or is this real? So that was what stimulated me to look at this within a big, general population sample. And to be honest, I wasn't particularly interested in behavioural genetics, but this happened to be a genetically sensitive sample. And I probably would never really have even looked at causality, other than the fact that we could do that. And my goodness what a surprise it was, so I'm glad we did.

Sue: 4:10

Um, so tell me a bit more about the sample then. It sounds like you were quite fortunate to have this clinical question and then I guess find a sample that was available that would help you address it.

Helen: 4:22

Exactly. So we've been collaborating for many years with the Gillberg Neuropsychiatry Centre in Gothenburg, and Chris Gillberg was involved; he was one of the founders of the Swedish CATSS study, the child and adolescent twin, em, study of Sweden. So I knew that we potentially had access to this big sample of 13,000- more than 13,000 children. Um, so you know, that, that, that was a big advantage, but of course, because it was a twin sample it- basically, it's the biggest twin sample in the world and it's, what they've tried to do is to have a register of all twins[inaudible]. Um, so you have monozygotic twins, identical twins, who share a hundred percent of their genetic material, and then you have dizygotic twins, who share 50% just like ordinary siblings. And that allows you to model the degree to which, so for example, if, if a disorder was 'purely genetic', and I'm putting that in inverted commas because nothing's ever completely purely genetic, but single gene disorders like phenylketonuria or cystic fibrosis, if you're an identical twin, your identical twin would definitely have the same discipline as you. But if you're a non-identical twin, your, your siblings, your twins, have a 50/50 chance and so you can model by looking at the correlation between the twins, by looking across identical and non-identical, you can see the degree to which things are actually heritable. So it's just a big opportunity.

Sue: 6:08

Yeah, absolutely amazing. And so just recapping then that finding, um, if I've interpreted correctly, then, in terms of causality, you, you didn't find an effect of twin type, is that right?

Helen: 6:22

That's right. So basically what we did was we looked at, in both the identical and the non-identical twins, we looked particularly, the focus was particularly on twins where one twin had been abused and neglected, and the other hadn't. And you would think,'gosh, how could that happen?' but if you think that 30,000 individuals, you know. And I can't tell you how the part- exactly how this has happened, but it's common in the population and maybe the one was living with mum, one was living with dad. You know, I can't tell you exactly why, but there were in this huge population, there were enough identical and non-identical twins where one had been abused and neglected and the other one hadn't. If the abuse neglect had caused the neurodevelopmental complexity, then you would expect that the twins who hadn't been abused and neglected wouldn't have complex neurodevelopmental disorders, but they did. They were just as likely to have these neurodevelopmental problems as their co-twins who had been abused and neglected. And that means that maltreatment isn't causing this, which was a really big surprise to me, that was not what I expected to find. That's partly why I picked this paper because, as a scientist, it's the findings that you don't expect that really change your clinical practice.

Sue: 7:44

And so do you think there's an element then of, of causality in the opposite direction? That children who are developing atypically are more vulnerable to abuse? Um, because they are, um, well, because they're more vulnerable. Yeah. Because they're not developing typically.

Helen: 8:03

So, that is not proven and we can't prove it from this study, but we're doing a study at the moment using Danish intergenerational datasets to look at that. And I think there's quite a bit of gathering evidence in that direction. So,[inaudible]'s group in the Institute of Psychiatry, for example, has been looking at this using longitudinal, a new longitudinal design and what they've shown is that ADHD and cognitive problems, is that they tend to occur in the lifespan before the abuse and neglect. The other kind of suggested evidence is that it's been really robustly shown now that symptoms of ADHD - and I very carefully say the symptoms because you cannot blame the children, no child child ever deserves to be abused or neglected, but it has been shown robustly that the symptoms of ADHD make parenting very stressful. So parents of children with ADHD tend to be more stressed in the population. And for me, that is, has been a profoundly important finding for me as a clinician, because it's made me much, much more compassionate with parents. It's made it far more obvious to me, and it was kind of hiding in plain sight, but we ignore it in cams, but the parenting task is not the same for every parent. Some parents have children born to them with kind of easy temperaments, who are, y'know, quite flexible to changes in the environment - they're willing to be fed when the parent's ready to feed them, they sleep through the night from a young age...and other parents have children born to them - and sometimes these things can be really positive, you know, big feisty personalities where they're not interested in sleeping because they're too busy engaging with the world - but that can be very stressful for parents. And my hunch is, it's still a hunch, but if there's, y'know, if the parents lack support, y'know if they're living somewhere without extended family support, they don't have the money to buy in babysitters, from time to time give themselves a rest. And, perhaps, also, y'know, parents themselves have got vulnerabilities, then perhaps abuse and neglect can arise. So I can't prove that, but it's really changed my thinking around that.

Sue: 10:30

And I guess the other factor that it seems to me is really interesting in here is the kind of role that, that stigma plays, you know. That the difficulty of seeking or getting support when, um, when behavioural profiles that are, that are atypical in children are so poorly received in the community, there's so much parent blame that goes along with that. You know, so it's not just the kind of objective if you like, if, if we can have a catch us up to thing kind of, um, uh, profile in factors, but also the subjective experience, of those and the way that they are viewed by, you know, your neighbours or the people in the supermarket or whatever.

Helen: 11:15

Exactly. I think I, I'm glad you kind of made that leap, Sue, because that is a leap that I've taken in my thinking. And actually your students might be interested to keep an eye out for[inaudible] psychiatry, because I've got a paper on stigma coming out in[inaudible] psychiatry just, it's just a messy. But these findings, and then my, you know, my subsequent clinical work have really made me see that. We make judgments about families in our clinics and you know, sometimes clinicians talk about the feeling in the room. But what I notice is that we're much more likely to feel comfortable if the family is like us. So I think if you had a working class family, if you're a black family, and I think particularly if you're, if you, as a parent have a history of maltreatment yourself, I think clinicians are much more likely to leap towards these problems being'social' if you haven't caused them. I think we do that all the time and we really have to stop doing that. It's- in my reading around this, I've discovered that, um, children who have a history of adverse childhood experiences are more likely to have a late diagnosis of autism, for example. Which fits in with what we're seeing really here. So I think we have to really be on our guards that, first of all, these parents might actually have a bigger parenting task than other parents and so we should be compassionate. We should remember that if we took their child home for 24 hours we'd also have a headache.

Sue: 12:52

Yeah. I think that's such an amazing point. And this is something we've been talking about, is that, you know, of course what we, one of the things that we need to see is greater diversity in our kind of, um, expert clinicians and in our, you know, kind of research leaders in the field and so on. You know, we need are the people who are pioneering this work to better reflect the diversity in the population, but at the same time, you know, there's never going to be a point where, where a particular family is guaranteed to sit down with a professional who shares their background. And so, you know, empathy across that divide is such a key part of it.

Helen: 13:32

Absolutely. Absolutely! And, and also, you know, all of this stuff about, you know, um, cultural awareness, you know, no two Muslims are the same, you know? So, you know, you could, you could learn about which cultures endorse eye contact, though it's not necessarily going to help you while they sit in front of you. And so really what I would argue is, you know, we need to be respectfully curious. And if a parent is convinced that the child has a problem then we should have the attitudes of that parent is probably right. And our job is to go on a journey with the parent and with the child, try and find out what that is. There is so much, um, you know, that, it is so often said in child and adolescent mental health"oh, you know, I think this parent is really quite difficult because they're convinced the child has a diagnosis". Well, in my experience, those parents are often right. It's just that we don't know what it is yet.

Sue: 14:36

Yeah, yeah. It's not, it's not terrifically constructive, is it? To immediately[laughs]. Um, so, um, I want to ask you two more questions if you've got time, if that's okay. So before we go on to the words of wisdom, I just wanted to ask you about this concept of kind of trauma informed care, right? Because this is a phrase that I see around increasingly, and it's definitely being used in terms of how we support people who are, um, developing atypically on various kind of pathways. And I just wondered what you, what you think of the concept of trauma informed care. Obviously your research is very relevant to that. And is it a useful concept? How would you define it? What do you think about it?

Helen: 15:21

Yeah, I think there have been advantages and disadvantages to this concept. I think a big advantage has been that it has increased the compassion for people of frontline workers. But I think trauma-informed care does need to expand. And it needs to encompass new atypical developments, informed care, because our research has shown that the two so frequently go together. My hunch is that we'll what find, you know, if we were to look back in 10 years, time, we'll find daily parents who have had their children taken into care, actually themselves have neurodevelopmental problems. So, and one of the things I find really interesting is that we, that, um, when trauma-informed care works well, it often encompasses really kind of critical thinking about someone's stress, um, adaptability. Their adaptability to stress and whether the environment can help them with that. I think generally there's an assumption that the problems with adapting to stress are all caused by trauma. My hunch is, that sometimes they're caused by trauma and sometimes they're caused by the neuro-atypical presentation that this person has. And so I think if we could take next step and realize that there's a'both and' here, at the, if you've had a history of trauma, you're more likely to also have ADHD, a tic disorder, learning disability or autism. And if you can remember that, then actually the interventions are probably the same, but you're going to do better interventions if you've actually thought about the person's neurodevelopment as well.

Sue: 17:21

Thank you, Helen. That's amazing. So, um, before we draw to a close, um, I think there are probably some, um, students, PhD students, early career researchers listening. And I wondered if you had any kind of words of wisdom that you wanted to pass on to them.

Helen: 17:39

I think um, hang on I'm just going to cough for a second.[pause] I remembered to mute and unmute myself! I think there's two. One is always keep an open mind and if you get a surprise, then embrace it. So this was a surprise for me- I spent 20 years of my career being absolutely convinced that the increased rates of ADHD[inaudible] children was because they'd been maltreated, and these things turn on my- on their head. And it's opened up a whole new fascinating area of research, so I would say keep an open mind. Second thing I would say is bring basic scientists and researchers together and accept that you each have expertise that the other doesn't have. So in this particular study, it was so much fun because our geneticist colleagues were not clinicians and they could not get their head around, for the longest time, why we wanted to think about, not just individual diagnoses, but multiple diagnoses. So it took us ages to explain that to them and then it took us, took them ages to explain the behavioural genetics to us. So just accept that no one person can have all the knowledge. You need to work as a team and you need to be accepting and respectful of your colleagues and really listen so that you learn from their expertise and they'll learn from yours and then it means you've got more than one brain on the project.

Sue: 19:18

That is a great recommendation. And I, and I, I admire you for it because it's, I think it's, um, it's easier said than done, isn't it? When you're used to being, uh, you know, a pretty knowledgeable person in the room to put yourself in a space where you have to say, I don't understand what you're saying to me, you're going to have to make this simpler. It's quite, it's a bit harrowing. You know, when you, you kind of fought to get to where you are and everyone looks up to you and suddenly you're back in this position of being, you know, having to be taught something new. I think that is quite scary.

Helen: 19:52

It is scary, but for me I would say that is the big, the really the big kind of real research for me. And it's being humble enough to allow yourself to look like an idiot, but also to remember that if someone provides you with a table or a statistical analysis output that you don't understand, part of it is that they would be happy to explain it carefully enough. So there's a kind of onus on, you know, there's an onus on us to, to not use our psychological jargon in a way that statisticians wouldn't understand us. We need to respectfully talk them through that carefully and then we need to expect them to talk us through their expertise, ask them as many times as we need to to get the answer. So that sense that you have as a student of"oh my god I don't know what's going on", if it can stay with you, you'll be a good scientist.

Sue: 20:47

That's amazing. Um, well thank you so much for your time, Helen. This has been fantastic. Um, anyone who's listening, you'll be able to find out more about Helen's work, including a link to the paper that we've been talking about, in the podcast description, um, on your podcast app or on our Buzzsprout page. And, um, just remains for me to say thank you so much, Helen, and goodbye, and have a great day!

Helen: 21:10

You too. It's been really a pleasure. Thanks a lot, Sue.

Sue: 21:14

Thank you!

Helen: 21:19

Bye for now.

Outro: 21:19

I thought that went quite smoothly!