The cost of neglecting child mental health

With mental health problems on the rise among children, UCL researchers are working with a leading charity to explore the complex interplay between antisocial behaviour, adversity and the brain.

By Ben Stevens | UCL Communications

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Feral children. ASBOs. Knife crime. Gangs. It’s a well-worn media narrative and one that usually fails to mention the childhood adversity encountered by the young people involved.

Finding positive ways of working with young people before they come into contact with social services or health services is one of the aims of UCL Clinical, Educational & Health Psychology. Or as Professor Peter Fonagy, head of the department, puts it, “preventing people falling into the river rather than having to pull them out afterwards.”

UCL has a longstanding relationship with children’s mental health charity the Anna Freud National Centre for Children and Families and Professor Fonagy serves as its Chief Executive.

The centre has a combined focus on research as well as clinical intervention and was set up in 1952 by Sigmund Freud’s youngest child Anna, who is considered the founder of psychoanalytic child psychology along with Melanie Klein.

“It’s a wonderful clinical and community centre, with a lab embedded within it, which is a child-friendly space for our research,” says Professor Pasco Fearon, a colleague of Peter Fonagy and Chair in Developmental Psychopathology at UCL Clinical, Educational & Health Psychology.

The centre has enabled Professor Fearon to conduct a raft of research projects. One particular strand of his research looks at attachment theory — a model of child development combining evolutionary theory, psychoanalysis and developmental psychology that originated in the 1950s in the work of John Bowlby and Mary Ainsworth.

The attachment model

Attachment theory looks at how young infants use their carers as a source of comfort when they are worried, stressed or ill. Much of the research on attachment has focused on why some children seem to do this much more instinctively than others.

“If you follow how those children are doing some years later, it seems there is some sort of developmental benefit to using the carer as that source of comfort,” says Professor Fearon.

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“The thinking has been for a long time that the reasons why children develop these different strategies can be understood as being related to the interactions and daily experiences that they’ve had with their carer throughout the first year of life,” he continues. “It’s an important issue to nail down, because the (attachment) model shapes how we think about intervention.”

Fearon and his team are concerned with the variations in early child development that might lead to better outcomes. The aim, then, is to devise ways of supporting families so that every child gets the best start in life — rather than trying to untangle a child’s difficulties when they have become entrenched and compounded.

While research has shown that genetic factors are a pervasive influence in other areas of child development, such as cognitive ability and personal and emotional traits, three important studies have shown that in attachment, environment is key.

Professor Fearon’s team conducted one of these studies, by comparing the reactions of identical and non-identical twins to everyday mild stresses, such as a stranger coming into the room, or their mother leaving the room. As the identical twins didn’t behave more similarly, environment was shown to be the prevailing influence.

The team also used parental questionnaires and observations — both in the lab and at home — to understand more about the infant’s environment, and their interactions with their parents and other carers in their first year of life.

Environment rather than genes

“All these studies converged on this answer — that there wasn’t much genetics and it was almost entirely to do with environment ,” says Professor Fearon.

“That was a ringing endorsement for the basic theory of attachment and how you might use that model as a framework to improve children’s life chances.”

Though attachment theory has been around a long time, he says, we are still in the very first stages of applying neuroscience to try to understand the multi-layered influences on brain development in the early years.

“Trying to understand how all those processes work is really important when thinking about how to improve children’s outcomes,” he adds, “and that kind of research programme tends to lead you in the direction of prevention.”

A key element in this preventative effort is the UCL Developmental Risk and Resilience Unit (DRRU), led by Professor Fonagy’s colleagues Professors Essi Viding and Eamon McCrory.

Once again, the Anna Freud Centre has supported the DRRU’s work in a number of ways, including jointly funding PhD students and facilitating the development of a joint MRes in Developmental Neuroscience and Psychopathology with Yale University.

Professors Eamon McCrory and Essi Viding

Vulnerability versus resilience

The work of the Unit has from the outset been based on two strands of research. One, led by Professor Viding, looks at the study of antisocial behaviour and how it emerges and develops. The other, led by Professor McCrory, looks at the impact of maltreatment and subsequent risk and resilience to poor mental health.

To understand the relationship between maltreatment and mental health risk McCrory and Viding recently proposed the theory of Latent Vulnerability. According to this model, children adapt to early unpredictable or dangerous home environments in ways that help them survive and cope.

However, it is suggested that the biological and psychological changes associated with these adaptations might come at a high price, and carry a lifelong increased risk of mental health problems. In other words, children might adapt to ‘fit’ atypical and disturbed environments in ways that are not helpful when they go out into the world to make friends, learn and develop as adults.

“The most striking thing about our neuroscience findings” McCrory observes, “is that even ‘healthy’ children exposed to adversity, with no diagnosed mental health disorder, show significant changes in brain structure and function”.

This is consistent with the view that such neural differences do not reflect ‘damage’ but rather patterns of adaptation. For example, in one study McCrory investigated how children who had experienced documented maltreatment (after being referred to social services) differed from closely matched peers when processing threat cues during functional neuroimaging.

As the team had predicted, maltreatment experience was associated with heightened activation of both the amygdala — a key brain structure implicated in emotional processing and threat detection — and the interior insula, an area that is implicated in pain anticipation.

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A battlefield-like response

“Angry faces trigger a heightened threat-vigilant response in the children who have experienced maltreatment,” says McCrory, “and what was interesting to us, is that the same pattern has been observed in soldiers who have been exposed to combat.”

In other words, despite being exposed to very different kinds of threatening environments children and soldiers show similar brain responses — increased reactivity to social threat cues. While this response may be adaptive in the short term it may also increase risk for anxiety in the longer term.

“If some individuals,” adds McCrory, “are not able to recalibrate these responses once in a safe and normative environment, then heightened vigilance to threat cues becomes maladaptive, and may increase ‘latent vulnerability’ to anxiety in particular, especially following exposure to a future stressor”.

In a follow-up study, the DRRU team wished to explore whether such hyper-vigilance was evident even at a preconscious level. This time, faces were presented subliminally in the task. Again, children who had experienced maltreatment showed heightened neural activity in the amygdala in response to the angry faces — even though they had no conscious awareness of having perceived a face, let alone an emotional expression.

This suggests that the nature of the hyper-vigilant response is deeply embedded and beyond conscious control.

McCrory, E.J., De Brito, S.A., Kelly, P.A., Bird, G., Sebastian, C.L., Mechelli, A., Samuel, S. and Viding, E., 2013. Amygdala activation in maltreated children during pre-attentive emotional processing. The British Journal of Psychiatry, 202(4), pp.269–276.

“So in a classroom or playground situation,” McCrory says, “these children may show heightened aroused states without even knowing why that might be — because, for example, they have processed a threatening face from their peripheral vision — which may be one factor that contributes to their difficulties with attention and concentration.”

“Our research has now broadened to look at other aspects of functioning, including autobiographical memory processing,” concludes McCrory. “Our goal is two-fold. First, to identify early on those children most in need of help and support; and second, to use what we are learning about the mechanisms implicated in latent vulnerability to develop new preventative interventions, so the likelihood of a mental health problems emerging in the first place can be reduced”.

“The whole team” Professor McCrory adds “has been greatly inspired by the enthusiasm and generosity of our young participants and their families — their experience really holds the key to advancing our understanding of what resilience really means”.

The two extremes of antisocial behaviour

The DRRU has also conducted research into the development of antisocial behaviour (or conduct problems as they are known in children) using subliminal stimuli.

For this study, the team recruited two groups from specialist schools for children with emotional, social and behavioural difficulties.

“There are children who are very reactive to emotional stimuli around them,” says Viding, “so they have difficulty in controlling their emotional reactions and fly off the handle — probably partly due to adaptive reasons; it’s a defence mechanism.

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“Then, there is another group of children who appear very cold and calculated. Those children have a different kind of vulnerability to antisocial behaviour in that they don’t feel the normal empathy towards other people and, therefore, it’s easier for them to use other people to their own ends. So they are what we call children with callous, unemotional traits.”

In this study, the children were presented with emotional ‘fear’ faces that were immediately masked by a calm face of a different person, or a calm face that was then masked by a calm face of yet another person.

When shown the subliminal ‘fear’ faces, the emotionally reactive children showed automatic, heightened amygdala reactivity, while the children with callous, unemotional traits had showed very low amygdala reactivity to these emotional stimuli. Typically developing children had amygdala reactivity patterns that were somewhere in between.

So what about feelings of empathy? Further DRRU research found that those with callous traits showed the lowest reactivity in the insula when shown pictures of people in pain.

“We are not in any way suggesting that these patterns of brain activity indicate that children with conduct problems cannot change,” insists Viding, “but we think that particularly those children with callous, unemotional traits will be challenging to parent because they don’t respond to other people or affiliate in the normal way.”

“Although we have a crude idea of what different groups of children with conduct problems look like in terms of their emotional landscape, there is still a lot we don’t know that needs to be mapped out in order to for us to be able to design more effective therapeutic strategies.”

Failing our children

As with so many areas of science, finding sufficient funding is a challenge. The UCL Developmental Risk and Resilience Unit has attracted grants not only from the Anna Freud Centre, but also the Economic and Social Research Council, the British Academy, the Medical Research Council and the Royal Society.

However, as Professor Fearon points out, the children that he and his colleagues are trying to help often face a growing number of challenges — with a consequent need for greater support.

“We know that children in the care system can be subjected to many repeated difficult experiences, even after the maltreatment they’ve already received. They may go back to their families and be removed again; they may be repeatedly moved from foster placement to foster placement; they may move into residential care and then out again — and it can be a very difficult and potentially damaging experience.

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We know it is really problematic for children to have their attachments made and broken repeatedly during childhood.

“So prevention has to be a two-pronged thing: preventing the maltreatment, but also helping the whole system of social carers, foster carers and birth parents in stabilising the whole experience, so that the child’s experience is as consistent and supportive as it possibly can be through that very difficult time.”

Government support for such measures is piecemeal and, argues Professor Peter Fonagy, far from adequate.

“As Nelson Mandela pointed out, a society should be judged by the way that they treat sick children,” he says.

“There is no doubt that we in England, by being at the bottom of the UNICEF ratings, are not doing as well as other western countries.

“I have a Swiss colleague who asked me once, ‘Do you English people hate children?’ because no more than six per cent of what we invest in mental health goes on children. I think UCL should be at the forefront of making the claim — and shouting it from the rooftops — that it is with young children that we can, and should, intervene if we’re going to alleviate the burden of mental disorder, which is crippling not just our society, but most societies out there.”


Ben Stevens is Editorial Manager for UCL Communications.

Find out more about the UCL Developmental Risk and Resilience Unit.