Susie Chandler

Purpose: Compared to neurotypical peers, neurodivergent students experience increased exposure and more intense responses to commonly upsetting events (emotional burden), contributing to poor mental health. Student and staff perspectives offer insights into sources of emotional burden in school and how they can be managed and reduced. However, student and staff perspectives are rarely explored together. Methods: Focus groups with students (11–16 years, n = 11) with autism or ADHD diagnoses, and school staff (n = 12) were used to explore the impact of the school environment on students’ emotions. Multimedia methodologies supported communication and participation. Results: Reflexive thematic analysis generated three themes: Theme 1 “Upsetting experiences in school that trigger negative emotions” with subthemes: (i) an overwhelming and uncertain physical environment; (ii) a lack of belonging and understanding; (iii) inflexible school policies; (iv) an overemphasis on academic achievement; Theme 2 “Staff-specific barriers to supporting neurodivergent students” with subthemes (i) staff wellbeing; (ii) inconsistent understandings of, and support for, neurodivergent students; and Theme 3 “Promoting emotionally healthy school environments” with subthemes: (i) whole school collaboration and action; (ii) positive approaches and agency; (iii) building trust, understanding and belonging; (iv) close staff relationships, training and supervision. Conclusion: Staff and students had shared understandings of stressors, staff through observing behaviour, students through internal experience. Both reported helpful practices, primarily environmental adaptations to accommodate students’ needs. Staff also reflected on their own wellbeing, training and supervision. These insights offer a nuanced understanding of student and staff knowledge to inform policy, practice, and research in school settings.

BackgroundADHD and autistic adolescents experience elevated rates of anxiety, depression, burnout and school distress. Emerging evidence suggests that mainstream school environments can create an “emotional burden” for neurodivergent students, through sensory overwhelm, social exclusion, and pressures to conform to neurotypical expectations, potentially contributing to poor mental health. However, little is known about how neurodivergent young people themselves who face low mood, understand these experiences.ObjectiveTo qualitatively explore the experiences of autistic and ADHD adolescents with low mood, depression and burnout and how school environments may contribute to them.MethodsOnline semi-structured interviews were conducted with 22 ADHD and/or autistic adolescents aged 11-16 years (Mage= 13.82, SD=1.44) attending or previously attending mainstream secondary schools in the United Kingdom (UK). Interviews explored experiences of school, low mood, depression, anxiety, emotional burden and wellbeing, and were analysed using reflexive thematic analysis. Using a deep participatory model of qualitative research, interviews were co-designed, co-delivered and co-analysed with neurodivergent youth co-researchers.FindingsFive themes were generated: (1) School culture prioritises discipline over wellbeing; (2) Lack of neurodivergence-informed practice; (3) No choice but hiding self to survive; (4) Chronic exhaustion, hypervigilance, and burnout; and (5) Depression and low mood. Participants described school environments characterised by academic pressure, punitive systems, sensory and social overwhelm and limited psychological safety, contributing to mental health problems. Masking and self-suppression were commonly described as necessary for survival and linked to chronic exhaustion, burnout, cognitive shutdown, withdrawal, anxiety, and low mood. Participants’ accounts suggested that distress was closely associated with ongoing environmental mismatch and pressures to adapt to neurotypical expectations.ConclusionsSchool environments characterised by repeated demands for adaptation can create chronic emotional burden. Hypervigilance and masking become adaptive responses. These responses accumulate into exhaustion and burnout, alongside which low mood and depression develop.Clinical implicationsThese findings highlight the need for more neurodivergent-informed, context-adaptive and preventative approaches within educational and mental health settings to help reduce the risk of low mood and prevent the escalation of these experiences. Neurodivergent students’ perspectives should be at the forefront of these mental health approaches.

Rates of depression are elevated in autistic and/or ADHD adolescents, but the reasons for this are unclear. We have previously shown that autistic and/or ADHD adolescents experience twice the school-related emotional burden of the non-ADHD/non-autistic control peers. Using a new self-report measure, the My Emotional Responses in School Inventory (MERSI), we now examine how autistic and/or ADHD students’ responses after being upset —often pathologised as “emotional dysregulation”—are associated with mental health. The 20-item MERSI was co-produced with neurodivergent young adults to measure adolescents’ responses after being made upset in school. It was administered to 732 secondary school students (ADHD [ n = 100]; autism [ n = 100]; ADHD+autism [ n = 79]; non-ADHD/non-autistic control [ n = 453]) alongside measures of depression, anxiety, emotion regulation difficulties, and emotional burden. The MERSI had three factors: (1 ) outward distress expressions, (2) inward distress expressions, and (3) solution-focused responses, and satisfactory reliability. Outward distress expressions were more likely for ADHD than non-ADHD, and for autistic than the control group. Autistic and/or ADHD students reported similarly higher inward distress expressions than controls. Solution-focused responses were less likely in ADHD. Inward distress expressions improved the prediction of depression and anxiety beyond emotional burden alone. Solution-focused responses were associated with lower anxiety in both ADHD groups relative to controls. Autistic and/or ADHD students respond differently after being upset at school than control peers. Our findings highlight the importance of monitoring students’ responses after being upset, especially in the cross-sectional prediction of anxiety and depression, to be further clarified through longitudinal data.

Systematic analysis of interview data can provide important insights into how young people experience and interpret their emotions. Both human-led qualitative (e.g., thematic analysis) and machine-driven quantitative (e.g., natural language processing [NLP]) analytical approaches are available, but their solutions are rarely compared. Interview responses by 57 neurodivergent adolescents to questions about their emotions, previously analysed using reflexive thematic analysis (RTA), were submitted to Topic Modelling (TM). Topic labels were developed in collaboration with neurodivergent co-researchers to ground their meaning in the lived experience of neurodivergent communities. Topics were mapped to RTA themes or subthemes to examine their proximities. Topic-based cluster analysis was used to identify participant groupings with similar topic distributions. TM revealed 10 interpretable and meaningful emotion-related topics – some closely overlapping with and others differing from the RTA themes. TM topics differentiated the young people’s emotional experiences at school from those in other settings. TM and RTA resulted in overlapping and different insights into the meaning of neurodivergent young people’s accounts of their emotions. Our findings demonstrate the potential use of TM in interview analysis and might suggest a potential complementarity between the TM topics and RTA themes, to be further explored using more advanced algorithms and a more sophisticated NLP implementation.

Background: Depression levels increase dramatically during adolescence in the general population. This effect is exacerbated in adolescents with a diagnosis of attention‐deficit/hyperactivity disorder (ADHD), autism, or both. Here we detail the protocol for the My Emotions and Me Over Time (MEMO) study, a 12‐month longitudinal study with the primary aim to compare two competing hypotheses for why this is the case. The first, established hypothesis is that depression risk associated with ADHD and/or autism is mediated by emotion regulation deficits (ERD). The second and new perspective is that it is mediated by the experience of elevated emotional burden (EB) created by (i) greater exposure to upsetting events and encounters, which are (ii) experienced more intensely. Cross‐lagged path models will test the relative importance of the ERD and EB pathways to the relationship between autism and ADHD traits and depression symptoms. Exploratory analyses examining secondary mediators (i.e., self‐esteem) and moderators (rumination, resilience and alexithymia) will also be conducted. Methods: A sample of 600 adolescents aged 11–16 years, enriched for the presence of autism and ADHD diagnosed cases, and their parent/guardian will be recruited via schools, local NHS (South London and Maudsley) and ADHD and autism charities. Measures of ADHD, autism and depression, ERD, EB, self‐esteem, rumination, resilience and alexithymia will be completed at baseline, 6 months and/or 12 months by parents and/or participants. Background factors such as age, sex, cognitive abilities and socioeconomic status as well as service use and medication status will also be collected. Results: The pathways between ADHD/autism and depression, along with their mediators and moderators, will be analysed using structural equation modelling. Conclusion: The findings from MEMO will feed into the other studies within the RE‐STAR programme to support the development of an intervention to reduce ADHD and/or autism‐related depression risk in adolescence.

Accounts of emotional dysregulation in autism and ADHD are typically based on external adult observations anchored in neurotypical notions of appropriate emotional responses1. These often fail to account for neurodivergent people’s efforts to regulate in the context of the upsetting experiences they face, and to explore how neurodivergent young people manage emotional burden or find effective strategies to reduce distress and increase resilience. We interviewed 57 adolescents (11-15 years; 19 females) with diagnoses of ADHD (n=24), autism (n=21) or both (n=12), about their experience of upsetting events using a codesigned semi-structured interview schedule. We analysed data using reflexive thematic analysis which generated shared themes with diagnostic nuances. Three themes were found: (1) What helps prevent experiences from becoming upsetting, (2) Managing emotional responses during periods of upset and (3) Leveraging own strengths. Participants highlighted the importance of consistent, neurodivergent-affirming environments, flexible supports, and being genuinely accepted. Autonomy in choosing self-regulation strategies, co-regulation and expressing distress without stigma were key to emotional wellbeing. These findings underscore the value of stable, trusting relationships and the need for predictable routines. Results offer actionable insights for educators, caregivers, and professionals aiming to foster inclusive, emotionally supportive environments for neurodivergent youth.

Background: Cannabis use is elevated in youth with depression and attention-deficit/hyperactivity disorder (ADHD), but drivers of this increase remain underexplored. The self-medication hypothesis suggests cannabis is used by patients for mood regulation, a common difficulty in ADHD and depression. This study aimed to examine associations between mood instability and cannabis use in a large, representative clinical cohort of adolescents diagnosed with ADHD and/or depression. Methods: Natural language processing (NLP) approaches were utilised to identify references to mood instability and cannabis use in the electronic health records of adolescents (aged 11–18 years) with primary diagnoses of ADHD (n = 7,985) or depression (n = 5,738). Logistic regression was used to examine mood instability as the main exposure for cannabis use in models stratified by ADHD and depression. Results: Mood instability was associated with a 25% higher probability of cannabis use in adolescents with ADHD compared to those with depression. Following adjustment for available sociodemographic and clinical covariates, mood instability was associated with increased cannabis use in both ADHD (aOR: 1.61 [95% CI: 1.41–1.84]) and depression (aOR: 1.38 [95% CI: 1.21–1.57]) groups. Conclusions: This was the first study to explore the differential impact of mood instability on adolescent cannabis use across distinct diagnostic profiles. NLP analysis proved an efficient tool for examining large populations of adolescents accessing psychiatric services and provided preliminary evidence of a link between mood instability and cannabis use in ADHD and depression. Longitudinal studies using direct measures or tailored NLP techniques can further establish the directionality of these associations.

Background: Accounts of emotional dysregulation in autism and attention‐deficit/hyperactivity disorder (ADHD) are typically based on external adult observations anchored in neurotypical notions of emotional responding. These often fail to place neurodivergent people's emotional responses in the context of the upsetting experiences they face; information best provided by the young people themselves. Methods: We interviewed 57 adolescents (11–15 years; 19 females) with diagnoses of ADHD ( n = 24), autism ( n = 21) or both ( n = 12), about their experience of upsetting events using a co‐designed semi‐structured interview schedule. Reflexive thematic analysis generated shared themes with diagnosis‐specific nuances. Results: Four themes were extracted: social dislocation, alienation and conflict; need to mask; self‐doubt, loathing, embarrassment; and over stimulation/sensory mismatch. Upsetting experiences, for ADHD participants, were typically perceived as instigated by external agents trying to impose control, and/or a sense of injustice; for autistic participants they often related to feelings of ‘not belonging’ and alienation. Masking, for autistic participants, included ‘hiding’ negative emotions to protect others from their intensity; whereas in ADHD, masking usually involved supressing emotional upset to protect oneself from conflict or consequences. Those with a joint diagnosis reported a combination of these experiences, often felt more intensely. Conclusions: First‐person accounts of emotional responding could provide new insights with potential to refine current dysregulation‐based accounts of ADHD or autism.

Background: Mental health problems are elevated in adolescents with ADHD and/or autism. Emotion regulation deficits (ERD) have been hypothesised as a key driver of such difficulties. The Regulating Emotions – Strengthening Adolescent Resilience (RE‐STAR) programme is examining an alternative pathway from neurodivergence to mental health problems, mediated by elevated emotional burden (EB) resulting from the interplay of increased exposure and an unusually intense emotional reaction to commonly upsetting events (CUEs). We present the development and application of the My Emotions in School Inventory (MESI), a self‐report questionnaire co‐produced with neurodivergent young people, focusing on EB in schools – a setting thought to be of particular significance in this regard.Methods: The MESI, containing 25 school‐related CUEs rated on their frequency and the intensity of negative emotions they induce, was completed by secondary school students meeting symptom cut‐offs on clinically validated scales of ADHD (n = 100), autism (n = 104), ADHD + autism (n = 79) and neurotypical students (n = 452). Psychometric properties were examined. The ability of the MESI to discriminate adolescents with ADHD and/or autism from neurotypical adolescents, and to predict depression and anxiety, independently of ERD, was explored.Results: Adolescents in the ADHD and/or autism groups experienced higher CUE frequency and intensity of reaction than their neurotypical peers. Overall levels of EB, most robustly indexed by 24 MESI CUEs, were higher in the three neurodivergent groups, though they did not differ from each other. EB in the autism and ADHD groups was generated by distinctly different CUEs. EB and ERD each contributed independently to the prediction of higher depression or anxiety.Conclusions: Our findings illustrate the potential value of the MESI as an instrument to measure the contribution of EB alongside ERD in relation to adolescent mental health risks in ADHD and/or autism. Future studies need to investigate its role longitudinally.

Background: Depression levels increase dramatically during adolescence in the general population. This effect is exacerbated in adolescents with a diagnosis of attention-deficit/hyperactivity disorder (ADHD), autism, or both. Here we detail the protocol for the My Emotions and Me Over Time (MEMO) study, a 12-month longitudinal study with the primary aim to compare two competing hypotheses for why this is the case. The first, established hypothesis is that depression risk associated with ADHD and/or autism is mediated by emotion regulation deficits (ERD). The second and new perspective is that it is mediated by the experience of elevated emotional burden (EB) created by (i) greater exposure to upsetting events and encounters, which are (ii) experienced more intensely. Cross-lagged path models will test the relative importance of the ERD and EB pathways to the relationship between autism and ADHD traits and depression symptoms. Exploratory analyses examining secondary mediators (i.e., self-esteem) and moderators (rumination, resilience and alexithymia) will also be conducted. Methods: A sample of 600 adolescents aged 11 to 16 years, enriched for the presence of autism and ADHD diagnosed cases, and their parent/guardian will be recruited via schools, local NHS (South London and Maudsley) and ADHD and autism charities. Measures of ADHD, autism and depression, ERD, EB, self-esteem, rumination, resilience and alexithymia will be completed at baseline, 6 months and/or 12 months by parents and/or participants. Background factors such as age, sex, cognitive abilities and socioeconomic status as well as service use and medication status will also be collected as covariates. Results: The pathways between ADHD/autism and depression, along with their mediators and moderators, will be analysed using structural equation modelling.Conclusion: The findings from MEMO will feed into the other studies within the RE-STAR programme to support the development of an intervention to reduce ADHD and/or autism-related depression risk in adolescence.