Kate Steinbeck [00:00:01] Hello, everyone, and welcome to WH&Y's monthly webinar. I'm Kate Steinbeck and it's my pleasure to be here. I'm just acknowledging all the people that we work with in research as part of our Centre of Research Excellence. And I would like to acknowledge the traditional owners of the country throughout Australia and recognise their continuing connection to land, waters and culture. We pay our respects to their elders past, present and emerging. And I know that we have people from many different lands. 
 
Kate Steinbeck [00:00:47] I just want to remind you that we have now gone live with our community of research practice. We do want to expand this and to include all the researchers and affiliates who are part of the CRE in developing what we think is a very important initiative. So, keep your eyes open for more on that. 
 
Kate Steinbeck [00:01:13] I've got just a little bit of housekeeping to let you know that during the webinar your microphone will be muted, and your video switched off. If you have anything to say or comment on and, importantly, if you have a question, please put it in the chat and we'll answer these at the end of the webinar. And you can see where you need to type your comments at the bottom on the right-hand of the screen. 
 
Kate Steinbeck [00:01:43] So, it is my pleasure today to introduce Professor Maree Teeson. Maree is the Director of the Matilda Centre, Director of the NHMRC Centre of Research Excellence in Prevention and Early Intervention in Mental Illness and Substance Use, and an NHMRC Principal Research Fellow at the University of Sydney. Maree has made a major contribution to Australia's health and medical research effort in the field of mental health and substance use. And I'm delighted to welcome Maree here today. 
 
Maree Teesson [00:02:23] Thank you so much, Kate, and it's an absolute pleasure to be here as well. And I will just click onto the next slide. So, I get to talk to you today about the mental health of adolescents in the community, trends, and lessons. I'm going to talk to you first about some of the work that is probably the most shocking and confronting work that I have been involved in. And then towards the end of the talk, I'll talk to you about some of the most fun and exciting research. So, the yin and yang of the mental health research with adolescents that I've been so privileged to do. 
 
Maree Teesson [00:03:06] And I would just like to start by acknowledging and paying respects to the traditional owners of the land on which I'm presenting. I’m on the land of the Cammeraygal people and it's upon their ancestral lands, the lands of the Gadigal people that the University of Sydney, where I work, is built. So just acknowledging that as we share our own knowledge, teaching, learning, research practices within this university in the many places that we're joining each other from today, that we pay respect to the knowledge that is embedded forever within the Aboriginal custodianship of country. The Matilda Centre is also committed to embracing diversity and eliminating all forms of discrimination, and we welcome all people, irrespective of ethnicity, lifestyle, faith, sexual orientation, or gender identity. And here is a portion of the Matilda Centre staff at the University of Sydney. And the work that I'm going to present to you today represents so much of the work of this incredible group of people I have the pleasure of working with. 
 
Maree Teesson [00:04:23] So, the mental health of adolescents in the community: what are the trends? And I think it's incredibly topical that we're discussing this today, particularly in light of COVID and the physical distancing that we're all experiencing, particularly those of us in Sydney. I know potentially we’ve people from across the country here, but those in Sydney and those in Melbourne, the physical distancing that we're experiencing, the impact of that on the mental health of adolescents in the community is significant. 
 
Maree Teesson [00:04:56] Young people are facing a crisis. These are the rates over the last 30 years of depression among high-school students in the US. This is a very large study completed by my colleague Kerry Keyes at Columbia University. Kerry has been modelling over the last 30 years rates of depression in high-school students, and you'll see there between the years 1991 and 2006-2009 the rates of depression, mean depression scores, in cohorts of young girls and boys, were stable, were starting to go down from the 1991 through to 2009. But then, in 2009, something started to happen within the population and the top line are the girls and the next line underneath are the boys in this cohort. And early 2008/2009 Kerry started to see a significant climb in mean depression scores in these successive cohorts of US adolescents interviewed. Slightly later, she started to see an increase in the young boys in the sample. We worked quite closely with Kerry, and we'd seen this data and we were wanting to know whether the same thing was starting to happen in Australian students. 
 
Maree Teesson [00:06:38] Since 2007, not quite 30 years, closer to 15 years, we have been lucky enough at the Matilda Centre to be working with cohorts of 13-year-olds. These have been involved in large trials that we've run in schools, and in total we have interviewed 14,000 young Australians from 2007 to 2019. So, this is the level of high psychological distress in the studies that we conducted in 2007, 2012, 2014, 2019. And this represents the psychological distress in kids who were 13 in 2007, kids or young people who were 13 in 2012, and then young people who were 13 in 2014 and young people who were 13 in 2019. So, they are different cohorts of 13-year-olds over that span of time. And you can see, as Kerry saw in her data in the US, in Australian young people, we are seeing significant increases in the proportion of young people who are reporting high psychological distress. When we split this down by males and females, we saw the same pattern that is happening in the US, that the rate of increase is slightly later for young males, but it is a significant increase in the high rates of distress between 2007 and 2009. For females, the rate is steeper, so that one in five females in 2019 in these cohorts using the same questions are reporting high levels of high psychological distress. 
 
Maree Teesson [00:09:02] So something happened in 2007, 2008, 2009 that really started to change the landscape of young people and their experience with psychological distress. We've also got, and Kerry has as well, measures of alcohol use in young people. And so in the way that we reported high psychological distress, we also plotted any alcohol use. So, this is a little bit of a good news story in that you can see that they crossed over, that young people in 2007 were reporting much higher rates of alcohol use than young people in 2019. 
 
Maree Teesson [00:09:49] But just before we get too excited about those changes and those trends, that's any alcohol use. Still, the rates of risky drinking are significant in young people and the rates are very high for risky binge drinking are significant and are highest among young people, and young people remain more likely to be victims of alcohol-related crime. So that really low-level use or any exposure to alcohol is significantly less in 2019 compared to 2007. But for the young people who are engaged in risky levels, that hasn't changed. And when I say risky levels, I'm talking about 11 or more drinks in a single sitting. 
 
Maree Teesson [00:10:40] When we look at the trends in suicide deaths in Australians 15 to 19-year-olds, again we saw, particularly amongst males, what looked to be a trend down. This is data from 1989 - 2018, but again, that data is shifting up again from 2014 to 2018 to slightly later. But again, an upward trend, whereas prior to 2014, the trend was certainly either flat or heading in the right way. 
 
Maree Teesson [00:11:24] And when we 2019 and 2020. And some of us will remember the 2019 big impact on young people that we were concerned about was with the bushfires. Little did we know that a couple of months later around the corner would come the impact of the coronavirus. And clearly the impacts of COVID-19 on use have been significant. There was data just presented out of the US yesterday showing the rates of emergency department visits for self-harm in young females in the US is increasing exponentially. In Australia in New South Wales, we've seen a 47 percent increase in emergency department visits for self-harm in young people, 12 to 17. So COVID-19 on top of these already increasing rates has seen high levels and spikes of psychological distress, particularly in young people. The recent Australian Institute of Health and Welfare data showed that if you're over 45, you're reported doing better now than pre-COVID. But if you were younger, particularly in the age ranges under 35, then you would be doing worse with your psychological distress now compared to pre-COVID. 
 
Maree Teesson [00:13:05] So, the reasons underlying these increases obviously require urgent attention and doubly so, given that we've compounded on top of this the impacts of COVID and the impacts of the bushfires. And it's true to say that the reason why we're seeing these population rates are just not fully explained. 
 
Maree Teesson [00:13:27] I'm going to go through some reasons, and I can see in the chat, exactly, what happened, in 2007, 2008, 2009? And the first thing everyone goes to in answering this question is smartphones, and it's actually true that in that period of time we did have saturation in terms of young people's access to smartphones and iPhones. But that's not the same as saying that smartphones destroyed a generation. And quite clearly, it's not going to be a very clear one on one relationship here, we've got to pull it apart. So, if you ask the person in the street what happened, the first thing they will say is the iPhone. The second thing they say, and thanks, that's prompted the chat too, is the global financial crisis and economic downturn. 
 
Maree Teesson [00:14:37] So let's have a look at what the epi tells us about pulling these issues apart. The first one I want to pull apart is around screen time. So, screen time and phone use, pulling apart phone use down to screen time, is just the incredible amount of time that young people are spending on screen time. This is a study of just under 4,000 adolescents that Nicola Newton, who is at the Matilda Centre, and colleagues in Canada completed and they looked at the relationship between screen time and depression between 2014 and 2018. And what they found was that the high mean levels of social media and high mean levels of computer use were strongly associated in this longitudinal study with depression. Equally, or on the counter, they found that high mean levels of television use over four years was associated with less depression. And they found that video gaming was not associated with depression, so all my gaming friends and gaming young people who work within our groups are very excited about that result. But the clear message is it's not just a simple one on one relationship between screen time and depression, and it's not a simple one on one relationship between phone use and these rates of depression. 
 
Maree Teesson [00:16:18] So, what about changes in alcohol use and exposure? I talked about those changes in young people. Sorry, I just got distracted by someone saying the high levels of TV watching makes me feel much better about my children's screen time in lockdown. About the changes in alcohol use in young people that I talked about,we're also seeing global population level changes in our relationship with alcohol. So, one of the pieces of work that we've been undertaking in terms of looking at global cohort trends in alcohol, is birth cohort trends in the amount of alcohol use and alcohol related harms in men and women. Traditionally, alcohol use and alcohol related harm has been an issue which is most predominantly experienced amongst men. We were sort of curious by anecdotal evidence that this had been changing and particularly for women, that alcohol use and alcohol related harms were starting to change population level. 
 
Maree Teesson [00:17:32] I've just popped this here because this study was so popular, it was even mentioned by Theresa May, who was then Prime Minister of the UK. OK, so what did we find? This is mapping, we pulled together the literature of over four million data points from the years 1891 through to the year 2000. And we looked at the male to female ratio of alcohol and harms by birth cohort. And at the turn of the century, 1900, the ratio of male to female for alcohol use and alcohol related harms was about two to four. As we scoot across the years, you can see the decline slowly in that ratio to when you get to those born in 1991 and 2000, the ratio of male to female is 1 to 2, but not significantly different from one. So, we have now completely closed the alcohol gender gap in terms of harms from alcohol for males and females, the ratio is 1:1. And what is significant is that people who were born in 1991 to 2000 are now at the age where they are having children themselves. So, have there been changes, is prenatal alcohol exposure a risk factor? We know one in two Australian women drink at some stage during pregnancy, and for the majority of them, that's really low levels. So, one of the studies we were curious about in terms of population changes and population effects on mental health was asking whether prenatal alcohol exposure was associated with psychological, behavioural and developmental outcomes in children. Given that we potentially at a population level are starting to see much higher rates of exposure and we know very heavy levels of alcohol use are associated with psychological, behavioural and neurodevelopmental outcomes, but what about lower levels? 
 
Maree Teesson [00:20:15] So this is a study, the ABCD Study, which is the largest longitudinal study of brain development in the US. There are just under 9,000, nine-year-olds currently in this study and each child is examined with high-quality imaging data. The imaging data is collected across multiple sites and there are psychological, behavioural and cognitive data as well. And 25 percent reported exposure to alcohol in utero through parental interviews. The data is collected at baseline and then all the way through to the current cohort, which are nine to 10 years of age. So, we worked with our US colleagues who gathered the data, to examine the data and to look at the impact of alcohol exposure. We looked at total alcohol exposure, we looked at the exposure pattern, and then we looked at cross-sectional mediation and longitudinal mediation. So, what did we find? Alcohol use during pregnancy is a risk factor for youth mental health problems, there are subtle yet significant differences. So one to two drinks during any week in pregnancy was a risk factor for anxiety, depression, attention problems and high impulsivity. It was also a risk factor for early alcohol experimentation, and we saw altered brain structure within young people at nine years of age where there was reported one to two drinks during any week in pregnancy. When there were three or more drinks per occasion, in addition to the above risk factors, we saw attention deficit hyperactivity disorder and oppositional defiant disorder. 
 
Maree Teesson [00:22:31] The prenatal alcohol exposure was also associated with greater cerebral and regional volume and regional surface area, and that was specific areas within the brain where we saw these greater cerebral regional volume and regional surface area changes. And in the mediation analysis, it was that the prenatal alcohol exposure seemed to have the impact on psychopathology and impulsivity through the impact on the changes in the brain structure, and also direct impacts. 
 
Maree Teesson [00:23:14] So, they are two and the third one I want to talk about today is sleep. Again, some fascinating work from colleagues in the US and Kerry Keyes. We know sleep and the relationship between sleep and mental health is strong, and sleep being a risk factor for poor mental health, depression and anxiety. We know that the use of mobile phones is significantly changing sleep patterns across time and Kerry has mapped over the last 30 years trends in sleep duration amongst US adolescents. The top line, the blue line, is how many hours of sleep do young people in the Monitoring the Future survey get on average. And you can see the percentage of young people who get seven or more hours of sleep, the percentage of them doing that has declined rapidly over the period 1990 to 2020. 
 
Maree Teesson [000:24:36] The other concurrent measures that she's got there were loneliness, high self-derogation, low self-esteem and depression. So, again, sort of in that late 2010 - 2020 time we're seeing increases in loneliness and increase in some of these others, but not as significant a change as is happening in the proportion who are reducing their sleep. So there's been significant changes in passive screen time, alcohol, and alcohol exposure and in sleep. And these are some, but not all the reasons why we think we're starting to see some of these changes occurring in the mental health of young people. But clearly, as I said at the beginning, this is really just early days in trying to understand a phenomenon that we're quite literally just trying to map now. 
 
Maree Teesson [00:25:42] So many, many answers still to be explored. And I can see in the chat people starting to put up some of the hypotheses that we really need to examine as to why this is happening. But passive screen time, alcohol and sleep as the epi data is starting to show us may be related to some of these changes. 
 
Maree Teesson [00:26:12] I want to change gears now to not so much the trends in what's going wrong, but are there ways that we can use some of our best tools to change things around so that we don't have a sense for young people that the increasing rates of depression and anxiety will continue to increase? Are there things that we can use? Are there ways that we can work in a co-design process with young people and think differently about adolescent mental health and prevention, and use digital successfully.
 
Maree Teesson [00:26:52] I'm just going to take you through some of the work that we've been doing in this space. Our work is focused really strongly on using cartoon storyboards, youth storylines that engage and work with young people, teachers, education to tell stories that allow young people to place themselves within the context and then to use psychological theories to influence some of these changes that we're seeing at a population level. 
 
Maree Teesson [00:27:30] So, over the past 10 or so years, as I said, we've been using storyboards and cartoons embedded within the PDHPE curriculum to deliver digital online interventions, and our work had focused pretty solidly just on trying to change some of the substance use, alcohol and cannabis use outcomes for young people. In the last five years, we've been working more closely in understanding the clustering of symptoms and problems in young people, and we shifted our work over to not only looking at substance use, but also looking at depression and anxiety. And this paper just recently published in Lancet Digital Health, looked at whether we could do a combined, in this case taking substances and depression and anxiety, so looking at the fact that the risk factors are clustering in young people, taking that clustering and see if we could get significant results from addressing both the anxiety, depression and the substance use in adolescents. And this is a cluster RCT that was undertaken with year eight and year nine-, 13- and 14-year-old students, in New South Wales, Queensland and Western Australia. And there are just under 6,500 young people in this trial across 70 schools. And we were able to show over a three-year period, that relative to control students, students who got these sort of combined interventions of having both the anxiety and the substance use and depression addressed did best. So that was the cap group, the group that got the combined intervention. So the odds ratio changed over time and the best outcomes happened in the groups that actually got the combined intervention. So that was our first step at trying to understand, could we actually respond to not just one problem amongst young people in a sort of digital prevention space, could we then take this and look at more than one? It was hopeful that we could so we then embarked on the Health4Life initiative.
 
Maree Teesson [000:30:11] This was an innovative digital approach to health and wellbeing for secondary school students, again, taking the idea of cartoon storyboards, and they're embedded within the PDHPE curriculum, and they are built and described and created with young people. So the cartoons that I've got up here are the cartoons of the young people who are in the storyboards that I'm talking about. So, they're built around relationships, young people going to sport, engaging with each other, talking to each other on the phone, this person likes that person, this person's not sure if this person likes that person or not, are they frightened to tell them? And the best feedback that we got, as we did our focus groups and as we did our work with school kids over the period of developing these cartoons, is when we took them out to groups of young people who hadn't seen them, who hadn't written them, they wanted to have the whole series because they wanted to know what happened at the end. And the piece of feedback that we got here on this one with the characters Anna and Sebe who have a romantic relationship through the cartoons, was that young people were really, really disappointed that at the end of the six lessons of cartoons, Sebe and Anna didn't hook up. I'm very pleased to hear that young people still talk about people hooking up. So we actually had to produce a sequel to go out to the schools so that they could hear the end of the story, a bit like Harry Potter 19 years later. 
 
Maree Teesson [00:32:15] Just to acknowledge all of the people who are involved in the work that we do, a very big team across Western Australia, Queensland and New South Wales and all of our funding partners. We worked in this study on the big six risk factors that typically emerge in adolescence and, of course, track through into adulthood. And we wanted to capture some of the risk factors that we thought were related to the poorer outcomes in mental health and young people. So we included alcohol, we included screen time, we included sleep, we included physical activity, we included sweetened sugar beverages and smoking. Among Australians aged 12 to 17 years of age, this is in our baseline survey, we found that 66 per cent had consumed alcohol, 86 per cent had exceeded guidelines of screen time, 70 per cent had a sleep problem, 82 per cent didn't meet guidelines for physical activity, and 95 percent didn't eat enough fruit and veggies, and 18 per cent had used tobacco. So plenty of options and plenty of opportunity for being able to improve this. 
 
Maree Teesson [00:33:51] Our programme is six, 20-minute modules delivered during year seven health education, and they're delivered by web-based cartoons like I described, built on our previous models that had worked within school environments. And they aim to provide students with evidenced-based information about the big six, also improve resistance skills, modify existing norms, increase autonomous motivation and around alcohol and drugs use social influence models. Just to give you a bit of a sense about what's in the cartoons. This is just a small snippet; it was incredibly difficult to find negative impacts of alcohol for young males. And so, I'm just going to scoot through them so you can see what we came up with after much work with schools and young people themselves to come up with what could be a negative impact. In this set of cartoons, Claire is the brunette here on the steps, and Michael, he's the blonde drinking out of the can there. And that's the love interest in this set of cartoons. So, Michael's just popped into a car. 
Michael: " Hey, Claire, jump in. Come on”. 
Claire: “You know, seriously Michael, alcohol slows your brain down”. 
Now Claire is a bit geeky, she's also very sensible. And I’ll let you in on a secret, we did a little bit of autobiographical insertion in some of these. So, I like to think of Claire as being a little bit like me. 
Michael: “Fine, your loss.”
And then the day after. Knock, knock. And...
Michael: “I want to say I'm really sorry about last night.” 
Claire: “Why do you always have to do stupid things?” 
Michael: “I suppose I get carried away when I have a few drinks. At the time it seemed like a good idea, that was until I threw up in an older girl's lap”
Maree Teesson [00:36:00] Apparently, that's social death to 15, 16, 17, 18-year-olds. Lots of vomit in our cartoons, never get over the vomit. So goodbye, Michael. And that's just a really small snippet and the cartoons are embedded in the curriculum. I was incredibly fortunate that my PhD student at the time, Laura Vogel, was best friends with the cartoonists who did the Disney cartoons when Disney was based in Sydney. So we were lucky enough to have the cartoonists who worked for Happy Feet drawing our cartoons. We've just had a whole creation of cartoons with a group in Hong Kong, and they're taking our cartoons and making them into manga-style cartoons, that’s just cool. So, the cartoons are engaging and high quality, and on top of the cartoons, there's the web-based tailored feedback that's based on self-report assessments. It’s colour coded and gives immediate traffic-light feedback to people, for example: red, you need to do something; yellow, you might need a little bit of work; green, you're going strong, going OK. And at the end I’m going to tell people how to get involved.
 
Maree Teesson [00:37:41]. Also, in working with schools, we wanted to see if we could integrate in some extra technology, so that it wasn't just within the PDHPE curriculum, so It's embedded in the cartoons are, so it happens within PDHPE, but we also wanted to see if we could do some work with a smartphone app, which is like a companion tool to the school-based programme just to do some self-monitoring and goal setting, particularly because we knew what we were trying to do was to change behaviour and to change physical activity. And that's hard to do, just within six lessons in PDHPE. And then finally, we've got a helpful smart phone app, which is like a booster, and that uses CBT and motivational and enhancement principles to teach students skills to put some of that knowledge into practice. And it's built with the same cartoon characters, so there's consistency in storylines. And as they unlock and complete different modules, they can then unlock more aspects of the story and actually learn whether Sebe and Anna did hook up or not. 
 
Maree Teesson [00:39:14] So currently we're running this multiple health behaviour change trial in 6,716 students in schools across New South Wales, Western Australia and Queensland. In New South Wales there’s 37 schools, 24 are government turned independent and three Catholic, and we have schools both in rural and regional areas and in urban areas because we really wanted to make sure that the storylines could make sense outside of just urban areas. And in WA, similarly, we've got regional as well as urban areas, and in Queensland, 16 independent and two Catholic. So we're just starting to get our first lot of outcome data and we are seeing changes. I haven't analysed it to the point that I can tell you all about where the changes are happening, but we are starting to see some of the changes in at least some of the big six risk factors. 
 
Maree Teesson [00:40:41] In summary, adolescent mental health is clearly undergoing a rapid change. And I really think we need to be responding with broad population-based frameworks for prevention and intervention. Just picking off one area with adolescents isn't going to make the types of population changes that we need to see if we are going to bend that curve of mental health and substance use, particularly mental health problems in young people. 
 
Maree Teesson [00:41:13] So, if you want to get hold of any of the resources, there's my email, you can also visit the Matilda Centre page and the Climate Schools programmes, and the programmes that I'm talking about where the cartoons are, is called Climate Schools, and there’s a website. And we currently have made all of the cartoons free for schools, there was previously an administrative charge in order to make sure that we could cover availability of the website for people, but through COVID we've made the resources free for schools and over a thousand schools are now using the cartoon resources. So you can go to www.climateschool.com.au, and that will give you access to the resources. Or you can send me an email and I can send it to you. Thank you very much. 
 
Kate Steinbeck [00:42:23] Thank you Maree for a fantastic presentation. We've got questions coming through, as you've probably noticed in the chat, and we've got some time to answer them. So I'm going to try and get them answered in chronological order if I can, but I think I'm actually going to begin the first one. Oh, they're coming so thick and fast, I can't keep up with them. Look, I'm going to get you to go back to the US data for a second, and that is "early in the presentation, you mentioned there being new data released yesterday from the US indicating an increase in self harm presentation in girls. Where can I get this?". 
 
Maree Teesson [00:44:13] Yes, this is hot of the press this is, someone texted it to me this morning. So I am just wondering how I can get that to you. If [webinar attendee] Jackson sends me a message or email, I can email them the data. It comes from the National Syndromic Surveillance Programme, if you look up the National Syndromic Surveillance Programme in the United States. 
 
Kate Steinbeck [00:45:04] OK, well, look, thank you for that one, I'm going to take you to the next one, which is from Rachel who is asking about that amazing ABCD Study which we'll all be following for the next 20 years or so, asking whether the study was controlled for the confounders of alcohol use.
 
Maree Teesson [00:45:37] Yes, it is an extraordinary study where just about every possible confounder that we could think of, socioeconomic status, family history of alcohol use, we were able to add into the model and control. And because the study is so large, you're able to add that in and still have enough power to detect changes. So very happy to send that to you. That paper was published in the American Journal of Psychiatry earlier in the year, and it is quite extraordinary in terms of the confounders. You know, what other reasons might we have seen those changes other than the alcohol use is quite extraordinary. But all of those things, even when we put them all into the model, even low doses of alcohol still had an impact on brain development. It's modest, though. 
 
Kate Steinbeck [00:46:41] But that says you don't just have to be binge drinking in pregnancy, you can't pick a safe trimester. And that's pretty powerful stuff that probably isn't covered by what's generally written on alcohol bottles. So the big picture is bad, in other words. 
 
Maree Teesson [00:47:03] Yep and I know Kate sometimes there's a level of, you know, people will say, but that causes so much distress to mothers. And I totally get that, but I think it's also really important we're very clear with our health messages. This isn't about blaming the mother, but that was defining in terms of the health implications of drinking. There are no safe levels. 
 
Kate Steinbeck [00:47:37] Now, I've had a few questions around diversity of the demographics in the trials, I think by that stage we got to that fantastic Health4Life trial. And I guess I was interested to see the diversity of representation as well in the cartoons. 
 
Maree Teesson [00:47:59] Yes, so originally the cartoons were not very diverse and they're very urban as well, we know that. We are working now in a very large NHMRC trial where we've actually designed a series of cartoons for Aboriginal and Torres Strait Islander young people, called Strong and Deadly Futures, and we're out in the field at the moment.’ We’ve worked with groups in Lake Cargelligo, Hay and rural Queensland. So there is a diversity not just in the ones that I've shown you, but in other cartoons that are there. In Health4Life there is much more diversity. The fantastic thing about the cartoons is we can increase that as we go along. We’ve now got Hong Kong, Germany, and Africa all now developing their base. But I could always be doing more. Oh, and can I just say we have some of the most disadvantaged schools in the states in our trials. We do not just have independent and wealthy schools. And it’s incredible to see the engagement of young people within some of those disadvantaged schools, because it’s not the writing, it's the storyline that the kids can engage with. 
 
Kate Steinbeck [00:49:49] And I was thinking as we mentioned schools, always the question that comes into your mind, you know, what about the young people who are not at school? How do we engage with them, because they, too, would really benefit from something like this. 
 
Maree Teesson [00:50:12] School is such a phenomenal vehicle for reaching so many. And I absolutely agree we have to think about how to engage with young people who are school refusers or disengaged from school and education. We have done work with Juvenile Justice, we've developed these programmes within a juvenile justice setting. So that is one avenue in. And their storylines will be very different. And it's important to be respectful of that and reflected in the cartoons. 
 
Kate Steinbeck [00:50:53] And their burden of the big six risks are going to be so significant. 
 
Maree Teesson [00:51:02] But that data I put up, it probably doesn't shock you because you've been in this space for so long. But the rates of not having sufficient exercise are just frightening.
 
Kate Steinbeck [00:51:21] They are terrifying because when you look on the screen, what you see are the predictors of so-called adult non-communicable disease, I mean, they are all there from the second decade onwards, and this is why this sort of intervention in this adolescent age group, which is so very challenging, as you point out, is so important. So, yes, it is very difficult to know where to go next. So we'll look forward to seeing a programme coming through, hopefully for those who need to read the cartoons but who are not in school. Now, look, there are a few I'm just checking. I haven't got any major questions that I have missed. 
 
Maree Teesson [00:52:16] I didn't put up the website links. I'm sorry about that. I meant to have them on the final slide. But really, I think there are a hundred people online or so, so. 
 
Kate Steinbeck [00:52:26] You can send them to us. We can do something about that. 
 
Maree Teesson [00:52:31] Awesome. 
 
Kate Steinbeck [00:52:32] Now, this question comes from Carmen and it says: “Do you have a sense of how the big six are causally linked? Do you suspect that one of the particular factors you mentioned underlie these issues of self-control and motivation? Or does it not matter in terms of creating your intervention that seems to work?” 
 
Maree Teesson [00:52:58] Such a good question. So, they cluster, and they don’t cluster equally. The first way we've been approaching this is to think about, where are they clustering, and then what are some of the underlying factors relating to those clusters. Sugar sweetened beverages clustering with physical, alcohol and screen types. So that's like another whole talk as to whether they cluster. Do I suspect there are factors that underlie them like self-control? Well, actually, what we've tested so far is whether that clustering relates to internalising self-control, motivation factors. At the moment, I haven't been looking at whether self-control predicts the big six, but we've been having a look at whether the clusters of big six relate to self-control later, and internalising, externalising poor mental health later. The question about does it not matter in terms of creating your interventions, the model that we came from was that they would cluster and an impact in one could impact the other. That sort of does imply that there might be an underlying common cause of all of them. But I've given up on finding the Holy Grail biological common cause of everything because it’s just going to be so complicated. I'm a behaviorist at heart and I like to go in and see if I can change the behaviour. So it's a really good question and it would be really nice to have all the answers, but I think that final point is that if we can create something that changes them, we change the life trajectory of these people. 
 
Kate Steinbeck [00:55:03] Thank you. Look, I think we’ve probably got time for one more question. I'm going backwards and forwards because there are so many. 
 
Maree Teesson [00:55:14] There were so many that were awesome. 
 
Kate Steinbeck [00:55:29] I think you've answered most of the questions as to how people get access to the Health4Life. Now, somebody asked, is it only on a smartphone or is it available on Android? I presume it's on both. 
 
Maree Teesson [00:55:46] . We've also got web-enabled so you don't have to even have a phone to do it. But the Health4Life one you've got to let us run the trial first before I can make it available to everyone. With our other cartoons and other programmes which have been through RCT. So far we've run eight cluster randomised control trials with 14,000 young people, so when they've gone through those trials, that's when we can make them available. But they are there and they're for free during COVID. 
 
Kate Steinbeck [00:56:23] And you've got a whole website there where people go as well. 
 
Kate Steinbeck [00:56:26] And you don't have to be a teacher. I think someone asked me about that. You don't have to be a teacher anyone can get access.
 
Kate Steinbeck [00:56:32] I'd like to ask just one last question. How are you adjusting for vaping? 
 
Maree Teesson [00:56:43] Whoa, vaping is such a new challenge. Smoking in this intervention, it’s in there, but I have to hand on heart got say to you that vaping is the new thing we really, really need to address, and we're right at the moment thinking do we need a module that specifically addresses that. Schools are crying out for it. We had 800 people to a webinar we ran on vaping and with no advertising. Any one of the hundred or so people who are here today will know as well. So I think the principles will be the same Kate. I think the storylines just really need to embed it in and engage with it. And that takes development work. But 100 percent. You busy? We could do it together.
 
Kate Steinbeck [00:57:54] Well, we've certainly got a few things on the table, we should talk, but I think we should let you go, Maree. OK. Thank you for a wonderful presentation and thank you to everyone who joined. It was great to see the numbers today. Bye bye.