Supporting Neurodiverse Children, featuring Dr Emily Midouhas

PROFESSOR PHILIP SCHOFIELD (INTRO)

Hello, and welcome to series two of The Greatest Good, a UCL Press podcast. 

Jeremy Bentham, the late 18^th and early 19^th century philosopher, was the intellectual inspiration for the founding of University College London and is credited with the maxim that actions should be judged by the amount of happiness that each produces.

I’m your host, Professor Philip Schofield, DireDirector of the Bentham Project here at UCL. Join me as I explore the ways in which Bentham’s thought is still relevant in the 21^st century.

In this series, we focus on the intersection of Bentham’s ideas with current research into how we understand the human mind, in conversation with leading UCL academics.  

PROFESSOR PHILIP SCHOFIELD 

Hello, and thanks very much for coming along today. And would you please introduce yourself and say a little bit about your research?

DR EMILY MIDOUHAS

Okay, so my name is Emily Midouhas, and I’m an Associate Professor of Developmental Psychology. And my research explores developmental processes of children’s emotional and behavioral problems across the life course. But I’m interested in understanding how parenting relates to children’s development. So for example, if you have parents who are, you know, shouting at their children, smacking their children, what kind of environment does that create in the home? So one that might feel more chaotic, filled with tension, etc., and then how that impacts on children’s behaviors and emotions. So I’m interested in understanding those processes as they play out as children get older. And so that’s the sort of developmental side of things.  And I have a very keen interest in understanding how these processes play out for children who are neurodivergent. So looking specifically at autism and ADHD. And we know that these two child onset developmental conditions do have some genetic overlap as well. So they’re often sort of explored together. 

PROFESSOR PHILIP SCHOFIELD 

Could you explain ADHD – I have to remind myself is – attention difficult hyperactivity disorder?

DR EMILY MIDOUHAS

Yeah, attention deficit hyperactivity disorder. Yeah. 

PROFESSOR PHILIP SCHOFIELD 

And what does that mean? And what does autism mean? 

DR EMILY MIDOUHAS

Okay, so ADHD is characterized by executive functioning challenges. Executive functioning has to do with planning and organization, and it’s sort of situated in the prefrontal cortex. It’s characterized by dysregulation of attendance to things. So children who have ADHD can be very hyper focused on something that they’re very interested in, or if it’s something that they find boring or sort of routine tasks, it may be hard to get them to do those things because of the sort of executive functioning challenges.  There are different presentations, but they can also have hyperactivity as well alongside. So you can have a combination of the kind of attentional challenges and the hyperactivity, or you can have just one or the other. 

PROFESSOR PHILIP SCHOFIELD 

Okay, so when we lump them together, it may not be particularly helpful in thinking that they both they both go along together, they can do but they may not. 

DR EMILY MIDOUHAS

They can do, but they may not – exactly. And it’s really important to understand that each child has a different sort of presentation and experience.  Autism is characterized by sort of social communication challenges and restrictive sort of repetitive behaviors as well. But the two kind of share some interesting things. So often you have what we call emotion dysregulation in both of these conditions. Often there’s sort of an experience of rejection sensitivity in these children because they get quite a lot of negative feedback in their daily life. And they can also have challenges with uncertainty and changes that happen. 

And I should say that if you have one of those conditions, you are more likely to also have the other condition. A lot of my research looks at sort of large scale longitudinal data. So looking at cohorts that track children from birth. The current one that we’ve been using quite a lot is called the Millennium Cohort Study. It’s a brilliant study and has a sample of children with autism, a sample of children with ADHD. And the children who have autism, 30% also have ADHD. There’s quite a lot of overlap there. If you have both conditions then there are different challenges that you have to manage because there are also sort of competing experiences that you will have. 

So, in our studies we see that children who are ADHD or autistic tend to have higher levels of what we call behavioral problems. Those are conduct difficulties like aggression or having meltdowns or tantrums. We see that they have much higher on average difficulties in those areas than children who we would call neurotypical. 

And we see that’s also the case with emotional symptoms as well. So emotional symptoms are things like anxiety or having a low mood, feeling sad, those things as well, are also elevated in children who have ADHD or autism. 

What me and my colleagues are interested in are looking at how can the environment better support those children and reduce those sorts of experiences and try to understand where we can target supports for those children in the environment. 

And there are a few different reasons why they’ll have higher levels of problems. So one is that these children are more sensitive to their environmental contexts. There are lots of different features of, let’s say autism or ADHD that can make them more sensitive to the environment. For example, sensory issues are sort of prevalent. So they might be very sensitive to noise, let’s say. 

PROFESSOR PHILIP SCHOFIELD 

Are there other sensory issues apart from noise? Cause, in a sense, that can irritate all of us. 

DR EMILY MIDOUHAS

Yeah, I mean, there could be also sort of bright lights or maybe just overwhelmed from, you know, too much interaction with other individuals or things. 

PROFESSOR PHILIP SCHOFIELD 

Too much going on around them?

DR EMILY MIDOUHAS

Yeah, too much going on around them, so there can be an overwhelm with that. Also, these children tend to have lots of negative feedback because they’re more likely to have conduct problems. Teachers and parents can find that very challenging and they might use more harsher discipline tactics or punitive measures in schools and that can be difficult for those children to take on and can affect their behaviors and their emotions even more. And then they’re also more likely to be rejected by their peers. So over many years, you can imagine children developing a sort of sensitivity to their environment.  So we’re interested in the role of the environment and then these children also can be more sensitive to the environment. Also, children who have behavioral difficulties can have an impact on their parents. So I’m really, really interested in family dynamics and I look at the idea that children and their parents mutually influence each other. So there’s a lot of research showing that children with neurodivergent conditions, you know, their parents are more stressed than children who are neurotypical. So there’s a lot of parenting stress that’s reported and parenting stress and overwhelm can potentially make parents more negative about their children or more critical and then those things feed into the children then later on right into their behaviors again.  So they’re sort of like a two-way straight when it comes to families and family dynamics. A project that I’m currently leading is looking at how parents and children mutually influence each other day to day whilst their parents are receiving support for their behavioral problems.

PROFESSOR PHILIP SCHOFIELD 

For the behavioural problems of the children?

DR EMILY MIDOUHAS

Yeah, of the children, yeah. So when children have behavioral problems, the sort of gold standard of, I guess, intervening is for them to attend maybe a parent training program and they get support in parent training. They get support in using positive techniques to support their children, labeled praise and positive reinforcement and special time, etc. And then they’ve learned to then reduce their negative or critical approaches to parenting through that process. And it’s really effective for many parents.  And many of those parents, their children have neuro divergent conditions. So we’re recruiting from these different parenting groups and we’re asking parents to track their behaviors every day and their children’s behaviors every day, to try to understand how does the family dynamic actually change whilst they’re receiving support and testing out these different techniques. And that’s a way to sort of zoom in on what’s happening in the home and understand those processes. And we think that will be really interesting to look at alongside what actually happens over many years in terms of parents and children influencing each other.

PROFESSOR PHILIP SCHOFIELD 

I was thinking about what Bentham says because he wrote a lot about punishment, but he also wrote about reward and saying, you know, we don’t necessarily use reward as much as we should. And, you know, both reward and punishment can motivate behavior.  And so do you find that in these instances, it’s sort of the direction of reward that works better than punishment?

DR EMILY MIDOUHAS

Yeah, so I would say definitely, yeah, I’m definitely a proponent of more positive reinforcement. So, my daughter has ADHD, so that has sort of also motivated me even more in terms of my research, and for her, positive reinforcement works really, really well in the sense that… So, I was listening to something the other day, someone, an ADHD expert, who was saying that ADHD children have two sort of timings: now and not now. So when you’re trying to think about motivating a child with ADHD, you have to make sure that you are thinking about that because the task that they’re going to do, if you want them to be motivated, having a little carrot or a little reward right after the thing that you want them to do can really motivate them. And I’ve used a lot of different techniques with my daughter. I think, though, that we have to remember that it’s important to set boundaries as parents. And that’s a little bit different than sort of negative discipline tactics. So setting boundaries is crucial alongside saying, hey, I understand what you’re going through and validating that emotion that they have. But I do think that positive reinforcement can work really well for children with behavioral problems. 

PROFESSOR PHILIP SCHOFIELD 

I mean, from the point of view of the parent, there’s nothing gets you quite as much as your child. So I mean, from what you say, it’s sort of what you’re looking for is strategies to help and educate parents as to how to deal with the situation. And if they are stressed, then they are much less likely to be able to think rationally, if you like, in the moment about what do I need to do?  And I suppose the other thing is, you know, with thinking about these conditions, well, who’s harmed by them, I suppose if the behaviour is disruptive, then that could be problematic for siblings or in the school situation for teachers and other members of the class, and therefore leads to animosity on the part of… So you get into a vicious circle. Yeah. And what advice do you have for teachers or, you know, for instance, do they need special training?

DR EMILY MIDOUHAS

Yeah, definitely, and there are trainings now that are being developed and that some schools have adopted in terms of how to best support children with neurodivergent conditions. But absolutely, I think part of it is sheer understanding about what the challenges might be for individual children as well. And trying to, and it’s hard, you know, in primary school in a class of 30 children, right, to be able to know each child and know what their needs are is a really big challenge. So it’s not easy, but I think being more educated on – and many teachers are very educated on these things – but I think more education on and understanding can help just with the day-to-day of interacting with children and really taking more relational approaches.  And I think that that is a simple thing, but I think it can be very effective for children. And so the teacher-child relationship, I think, is absolutely crucial. 

PROFESSOR PHILIP SCHOFIELD 

And there’s a difference between boys and girls? In that, I think part of your research suggests that boys are diagnosed earlier?

DR EMILY MIDOUHAS

Right, so, some of our research has focused on autism diagnosis. So we found that boys are diagnosed earlier, girls and those with a higher IQ and with more educated parents tend to be diagnosed later.  But interestingly, so if you’re a boy and you have an elevated level of conduct difficulties, you’re more likely to be diagnosed before the age of seven, according to our research from the Millennium Cohort Study. But yeah, if you’re a girl, you’re more likely to be diagnosed later. But those children who were diagnosed later also showed elevated levels of problems. It’s just that they weren’t picked up.

PROFESSOR PHILIP SCHOFIELD

So it’s not that it’s better or worse for a boy or a girl, it’s just about the way in which people recognise the condition?

DR EMILY MIDOUHAS

It’s the recognition. And also, I think there’s some evidence that girls are better at masking in a classroom setting, so they might be better at figuring out what behaviors they need to engage in to sort of fit with the social norms, and that might be a reason. But those girls that were diagnosed later, they actually had a sharp incline in their problems, especially their emotional problems and their peer relationships as they reached adolescence.  The question is, where is that coming from? Why is there this sort of sharp incline? What’s happening between primary and secondary that’s resulting in that? We do know that neurotypical girls do have increases in emotional problems when they go into the teen years, just in general, but it seems like it’s much more sort of marked for autistic girls. 

PROFESSOR PHILIP SCHOFIELD

Right, so the evidence is there, but nobody’s figured out the causes?

DR EMILY MIDOUHAS

No, but, you know, focusing on each child’s unique presentation, makeup, experience, all that, I think, is really important to understand that there are individual differences between children in this experience, but yeah. 

PROFESSOR PHILIP SCHOFIELD

I mean, in the past, would it have just been written off as bad behaviour or bad parenting? 

DR EMILY MIDOUHAS

Yes, yeah, yeah, definitely. And now there is an increased understanding, which is what we’d like to see. And I’m always really surprised that people don’t know more about neurodivergent conditions just in general, and don’t want to sort of understand it further and sort of have a label of like, Oh, there’s something wrong with that child. That is still surprising, even in the communities where my children go to school.  But then I have to remember that I live and breathe this stuff all the time, because I work in this field. So it’s very different. But it does drive me a little bit mad that there’s, and I can’t give examples right now off the top of my head, but of things that people have said, where I’ve been like, Oh, wow, they really just don’t know anything about it. And I would say my daughter doesn’t want her, she hasn’t told her friends about this diagnosis that she’s received. But she has other friends who have received other diagnoses of things like dyslexia and things, you know, and, and we talk about those, and they’re very much aware of it, because they have Mental Health Awareness Week at school, and they have Neurodivergent Awareness Week, you know, the next week. And so they they know about these things very much.  So I would say the parents are less educated on it, they’re not as exposed as the children are. And the children are, I mean, the worry is that children will over identify with something that they will grow up thinking I have this thing, and this is defines who I am. 

They’re called developmental conditions because they are lifelong. But there are also are different phases of your life where you can have different environments that you’re in where you’re showing fewer challenges. And I think that’s really important to note.  Also, the neurodivergent approach has changed now. So we’re moving away from the medical model, we’re moving towards a strengths based approach, where we say, let’s have a balanced approach, actually, it’s strengths based, but it’s also recognizing challenges. So children with ADHD, for example, you know, they’re known to be very creative, known to have lots of energy, and be a little bit risk taking, which could pay off for some children. And there are lots of things that we see with autistic children, there are also some strengths there as well. And I think that we need to remember that those are things that we should celebrate.  And then at the same time, we should not ignore the fact children have these challenges as well. I think that you just need to remember that it’s just one part of you and maybe not the whole of you. And also, there are many other things about you that characterize who you are. 

PROFESSOR PHILIP SCHOFIELD

You said that in terms of focusing on an activity, a child with ADHD might be able to focus on a particular activity for quite a long time, but then another activity only fleetingly. I mean, that makes it very difficult for them in a school context, where the bell goes, and you do this lesson for this length of time, and the bell goes again, and then you do something else.  

DR EMILY MIDOUHAS

Yes.

PROFESSOR PHILIP SCHOFIELD

It brings to my mind Bentham’s idea of, I don’t know whether it would have worked or not, but his Crestomathic school. 

DR EMILY MIDOUHAS

What was that? 

PROFESSOR PHILIP SCHOFIELD

Because resources were limited, there was one master and the elder pupils taught the younger pupils, so it was the monetorial system, but you did your lesson until you got it. So you had as much time or as little time as you needed to get that lesson. And because the other pupils were doing the teaching, the groups were much smaller and you then sort of moved on when you were ready. I mean, the other issue though is that it might have been quite a chaotic environment with all sorts of different teaching going on in the same space. But no, it was just interesting whether that sounds to me like it could be a real problem for teachers and how do you deal with that? I suppose that they have to think about strategies to differentiate the work and if a ADHD child is really stuck into something, just carry on with it. 

DR EMILY MIDOUHAS

Yeah, I think that would be the best case scenario. If a child, you know, I mean, not to bring up my daughter again, but this is an example, is that she’s great at creative writing, but she needs a lot of time. And she’s passionate about it, but she needs time to actually work it through. And you know, and they’re in the lesson for an hour. And then the hour ends, right? And then they can’t finish it off. And her teacher said, she would do the most amazing creative writing piece if she had the full week to really like, get into it and really, really do something really thorough. But I do think yeah, it’s just not feasible.  The timing and the time limits, I think make it really challenging. And I don’t know what the solution would be, to be honest. 

But I think within a family context, you know, you’re not going to be able to control all the things that your children do. And what I would say to parents of at least young children, because I don’t know that much about the sort of late teen emerging adulthood phase, I would say that it’s really important to focus on what is happening in your own family dynamic, to see, okay, when I feel stressed, that makes me fly off the handle with my kid, or when my kid will not stop talking, you know, and just keeps bombarding me with, you know, a lot of emotion or, you know, whatever it is, I feel really overwhelmed. Okay, what do I do in that situation? What’s the best way of staying calm? Because it’s very important to be calm and sturdy as a parent in general, right? And then when you have a child who might be sort of creating a lot of kind of chaos and stress in the home, it’s just helpful to be aware of how that can impact on the adult. Yeah, just to recognize your own dynamic that’s happening at home and try to keep yourself as regulated as possible. So yeah. 

PROFESSOR PHILIP SCHOFIELD

Thank you.