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May 17, 2022

In episode 5 of the Generation Pandemic podcast we discuss the mental health and wellbeing of children before, during and after the pandemic. Joining host, Catherine McDonald, are Professor Cathy Cresswell and Dr Jennifer McMahon from the Co-SPACE study, Professor Birgitta Rabe from the Institute of Social and Economic Research, and Laura, a mother of two primary school aged children. Laura explains how the isolation and anxiety caused by the pandemic has manifested in her children's behaviour, and the panel discuss how they have tracked children's mental health changes and the urgent need to address the effects they have evidenced. 



Catherine McDonald  0:04 

Hello, and welcome to Generation Pandemic, a podcast from the Interdisciplinary Child Wellbeing Network, looking at the impact of the COVID-19 crisis on children in the UK and Ireland. I'm Catherine McDonald and today we're focusing on how the pandemic has affected the mental health and wellbeing of children. In a moment we'll be hearing about the work of Professor Cathy Cresswell and Dr. Jennifer McMahon from the Co-SPACE study, and a Professor Birgitta Rabe from the Institute for Social and Economic Research. But first we're going to hear from Laura, a mother of two primary school aged children. I began by asking her what effects the pandemic has had on her son and daughter?

Laura  0:45 

I had a seven-year-old girl and a just turned five year old boy. And I've noticed a significant change in their mental health through the pandemic and through the lock downs that we had. Most noticeably, during the pandemic, my daughter developed a very strong anxiety and separation anxiety. She has always been a very confident little girl. And she's always been very independent. And from being at home during the pandemic, she started to want us to sleep in the same bed as her or in the same room as her and want lots of cuddles and reassurance that we were there and that we weren't going to go away anywhere. If I was to change room putting the laundry away for say she would follow me I can no longer visit the bathroom without having a little visitor with me at the same time. Because she feels me being in another room from her is quite anxiety provoking. And equally, we've had issues at school with her wanting to be close to other students almost sitting on top of them and needing that close bonds, and not necessarily respecting their personal space because she feels that they're going to not be there, or she might lose them. With my son, I felt he was a young enough age not to be affected by the pandemic. But I feel as though I may have underestimated that. And having started school, he's had issues with settling in. And he's got a big issue around personal space. So, with other children coming too close to him, he reacts and that isn't necessarily an appropriate way either. He will either push another child to get them out of his personal space, because he finds it too difficult to verbalise his feelings. And I think that's due to the lack of stimulation during the pandemic with children of his age and developing those relationships and those bonds and behavioural attitudes that he would have normally learned in his preschool years which he just missed because he was at home with us as a family.

Catherine McDonald  2:46 

And when COVID had hit and we were then in the various lockdowns, his age combined with that meant that he had not had a birthday party had he So has he had one now?

Laura  2:55 

 He has just had his fifth birthday, and has had his first birthday party, which he really enjoyed. But again, he struggled with being in a room full of 30 children that halfway through he kind of switched off and was playing with the balloon and hitting it himself and needed some time on his own. Because he was being overstimulated by all the excitement that was going on. Because he not only had he not had a birthday party up until that point, he's not had the normal playdates. Normally you go around to other people's homes and have a playdate. Or you might go to a toddler and baby group and socialise with other children. He's had none of that he's had no experience of forming relationships with children of his own age. So he doesn't know how to interact with them how to share toys, how to take turns. So he sometimes then retreats into his own little world until he feels comfortable and ready to talk to another child or interact with them.

Catherine McDonald  3:55 

And as we all tried to get back to normal, do you have long term concerns around the effects that COVID and the lockdowns have had on your children?

Laura  4:04 

I do. I think it's a bit of an unknown. I don't quite know what the long term effects will be. But it's certainly a huge learning curve for them. They're having to learn the skills that ordinarily would have come naturally to them through hitting various different milestones of playdates, birthdays, preschool transitioning into reception. And they've lost that natural progression. So we've almost got to go back a couple of years and start that from the beginning. And be respectful that actually these children don't have those life skills that would have normally been built and how long that will take I don't know, because they're suddenly thrown into reception or my daughter's now in year two. And there's a level of expectation of right this is what a reception child should do. Or this is what a year two child should do, but actually forgetting that they haven't had the foundation leading up to that.

Catherine McDonald  4:32 

And to what extent have you found that they're able to articulate how they're feeling and what's going on for them?

Laura  5:02 

I think that is something that is still evolving. We used an emotions diary for my daughter when we were at home so she could log the positive and negative things that happened throughout the day and trying to get her to focus on the positives. And that is still ongoing. With my son he is only now just starting to verbalise his feelings. And that has been a significant challenge because up until now, he would verbalise his emotions through a tantrum, or through crying or having a really big meltdown, because he didn't know how to say, actually, mummy, I'm scared, or I'm a little bit worried about things.

Catherine McDonald  5:43 

And what do you think we need to be prioritising in the recovery process to help our children through this and move into the new normal?

Laura  5:53 

I think it needs to be focusing on their relationships through play, and emotions around that, and allowing them to explore it in a nice, safe environment and in a fun environment. Because realistically, over the last few years, the fun has been lost in their lives, you know, they got up, they've stayed in their homes, yes, they've had access to their toys at home. But, you know, multiply that over the past two years, that then becomes quite boring. So actually allowing them to explore life and life skills. And around those activities, I think around forming relationships and by forming the relationships, other things will then come into play from that naturally.

Catherine McDonald  6:35 

Sure. So Cathy, Jennifer, you're joining us today from the Co-SPACE study, which has tracked the mental health of children and young people during the pandemic. Can you talk us through your main findings, and Cathy, if I could start with you.

Cathy Cresswell  6:48 

So the Co-SPACE study is a longitudinal study where we invited parents of school aged children to report on their children and young people's mental health on a monthly basis throughout the pandemic. And we have data from over 8000 families. And we started in March of 2020. So a week after the first lockdown started in the UK. And we continued until a summer of last year, so collecting data on a monthly basis. And we're actually now we've just done the two year follow up. So two years from our very first lockdown. And we'll be following up families now in six months, and then again this time next year. So that will give us a better sense of the longer term impacts. But the data that we've really had a good look at so far has focused much more on what was happening during those times when we were at peak restrictions. And essentially, what we saw from our UK sample was that if we focus on the parent report, because that we can look at that across all ages, the pattern that we saw was that as restrictions increased, unsurprisingly, we saw parents report higher levels of difficulties, both in terms of emotional, but particularly in terms of behavioural difficulties, including kind of attention hyperactivity type difficulties. Ours isn't a representative sample. So we can't draw conclusions about what things were like for people as a whole. But what we are able to do within our sample is look at how patterns may have differed for people in different circumstances. And some of the things that were really clear were that families who we already know are more vulnerable to mental health problems. So those living on very low incomes, or where children have special educational needs. For those groups, we saw consistently elevated levels of emotional behavioural difficulties throughout the pandemic. And one of the most concerning things was that when we were looking last summer at the patterns and how symptoms seem to generally show some improvement as restrictions had eased among those groups, that we actually weren't seeing that evidence of kind of bounce back after restrictions ease. So it really raised concerns about ongoing challenges for some young people, and particularly those that we could see that that was the case where people had those sorts of vulnerabilities. Among our sample, we saw particular, more dramatic changes in symptoms among the primary school age group among our samples. And so particularly the sort of behavioural disturbance at times when schools were closed, which I guess is not necessarily surprising when children, you know, didn't have many opportunities, and were often cooped up at home. And certainly among our sample, the secondary school age group were much more connected with their peers. And also parents of younger children reported having a much more challenging time. You know, obviously, the childcare commitments are higher. And often parents were struggling juggling that with work commitments as well, which often made things quite difficult within the home. So as I said, we're now coming up to our two year follow up. So that's going to be really important and useful to help us see how things have continued over time as restrictions have continued to ease and critically be able to really pay more attention to question about who's been able to kind of bounce back after such an unusual period, and who has seen ongoing, persistent difficulties, as restrictions have eased?

Catherine McDonald  10:11 

And from the data that you've analysed so far, did you notice any differences between boys and girls?

Cathy Cresswell  10:17 

We haven't actually seeing clear differences in terms of the trajectories and how things have changed over time. So there obviously are at any point in time differences between boys and girls and the sorts of symptoms that we measure. So typically, you see higher levels of the more behavioural difficulties reported on boys, you see higher levels of emotional symptoms reported among girls, particularly as you move into adolescence. And we saw that typical pattern throughout the pandemic as well. But we didn't see that boys and girls differed in response to the changing restrictions particularly.

Catherine McDonald  10:51 

And Jennifer, was it a similar picture in Ireland?

Jennifer McMahon  10:53 

Yes, we found similar findings to the Co-SPACE UK team. And I suppose just to say, we didn't track our young people monthly, we tracked them at certain time intervals throughout. But like the Co-SPACE UK findings, we found that at particular time points young people did better than others. So like in the restrictions, when schools were closed, young people tended to have more difficulty around their emotional symptoms. And these alleviated somewhat as we moved into periods of, say, the summer or periods around the Christmas break. So young people were finding it more difficult to manage when they were out of their normal environment and their traditional supports. And so overall, I think one takeaway from our research is that it really highlighted how inequalities that already existed in the child and young person's environment, were amplified during the pandemic, as those aspects that normally work to offset the inequality were inaccessible, such as school closures, or for children with special education needs, the loss of their support services, which was very widespread throughout the pandemic. And even very simple things that we found. So for one piece we included was a qualitative question around stressors and issues for young people. And parents told us that those young people who had access to outdoor space, for example, they tended to report that their young people were doing well and that they felt that they had time to spend outdoors in nature. Now, again, not everybody would have had that access to outdoor space. So there was various different aspects of the environment that fed into the issues around who did better and who struggled more during the pandemic.

Catherine McDonald  12:21 

It does all make sense, doesn't it? You know, we know as adults, what makes us feel better, and it's no surprise, is it our children react in similar ways? But I guess much as I said to Laura, it's very difficult, isn't it when we're dealing with one so young to kind of get inside how they're feeling? How is the study managed to do that?

Cathy Cresswell  12:40 

Certainly, from the UK point of view, there are two main ways that we've tried to understand how things have been going. One is based on parent report for young children and parent reports have been found to be reliable and valid. But of course, you know, parents can only report on what they can see. And as Laura highlighted, obviously, children's emotions can be expressed in a range of different ways. But certainly the standard measures that we use to try to capture both those sort of behavioural and more obviously, emotional symptoms. So that's one way that we do it. But the other way that we've been doing it is through qualitative interviews. So within Co-SPACE my colleague Polly Wade has been leading a couple of qualitative studies that have tried to really understand and get a more in depth understanding of how children and young people have been getting on. And that's by both working with families directly, but also by having interviews with people that work with families so that we can get a broader sense of the things that they've been seeing in the families they're working with, as well.

Catherine McDonald  13:38 

And I wonder, actually, if this generation that have been children during this time, where they're actually they will grow up being far more aware. And, you know, with the ability to be far more articulate about their mental health.

Cathy Cresswell  13:52 

I mean, I think we were definitely moving into that situation already. Prior to the pandemic. I'm constantly, you know, surprised and impressed by how articulate young people today are about talking about mental health and also much more accepting and aware of mental health challenges that people experience, you know, whether the pandemic has added to that, but it's a really interesting question. And certainly, I think, obviously, it has raised lots of conversations about wellbeing and mental health, which I hope will contribute to that wider awareness and acceptance.

Jennifer McMahon  14:24 

I think I think that could be one of the really positive aspects that might come out of the pandemic is a focus on young people and children's emotional well being now might provide them with the emotional literacy tools to really reflect on the pandemic and the impact that it had on them. And I suppose there is a piece around encouraging that and building opportunities for that to happen, because the two years that the pandemic went on for indeed for some families the impacts are still persisting in terms of like, you may still be out of school if you have COVID or so on or a lot of work. We have started a qualitative study exploring young people's perspectives on the pandemic, retrospectively. And we had our first meeting yesterday. So the data is not ready. But we did have a meeting, I was really impressed with the young people's perspectives on the pandemic. And one interesting thing that young people said to us was that it was as though there was multiple pandemics. And I thought that was interesting because young people can reflect that sometimes it was good. And that initial lockdown, for example, some young people found that really rewarding and exciting, and they had time to do things that they didn't normally do. But as the pandemic went on, and the uncertainty around how long it would persist, for things started to change, and young people could start to sense that in their own emotional well being that they were actually on a different trajectory. And I think now is a really good time for young people to really think back and reflect on how they actually need to move forward to offset some of maybe the harm that that caused, or how they can actually deal with some of the issues and key time points that they missed out on. So for example, one of our young people said that they missed those key milestones around their graduation around their Debs, around that first year of college. And I suppose, as young people emerging from that they really need to consider how might this impact them moving forward? And is there anything that they can do right now to actually enhance their experience in the aftermath of the pandemic.

Cathy Cresswell  16:08 

And we found very much the same that when people look back at the first lockdown some people, which was when it was quite warm, and certainly for those who could get outside, they could see some positives of that. Whereas the second national lockdown, which was in the winter, and obviously by then everything was feeling quite relentless, really felt quite difficult and quite different for people. And we certainly saw that in our data as well, where we saw greater elevations and symptoms in that second lockdown. So I think that variability of experience is really important to capture. And I think also, as Jennifer said, that there are studies that have highlighted that, you know, proportions of children, young people, have definitely seen some positives from the experience. And actually, often children who may have struggled in school prior to the pandemic, there were things that they found easier during lockdown when those demands of school were relieved from them. So that maybe children who had special educational needs who were struggling in school, children who have pre existing mental health difficulties where school was a challenge. And so I think it has also raised some really important questions and highlighted areas where we could think about why was life easier for those children, young people? And how can we think about how we do school in ways that are easier for children and young people where their experiences at school may contribute to the mental health difficulties that they experience?

Catherine McDonald  17:25 

Yeah, so it's so interesting, isn't it? And we have to take what we can from what we've all been through, don't we and as you said, if we can find the positives, and support the children to be more emotionally literate, or more in touch with their mental health, that would be a positive and massive positive to take from it. Birgitta, I'd like to bring you in here. So you also looked at the effects school closures had on the mental health of children during the pandemic, can you tell us what you were able to compare and what you found?

Birgitta Rabe  17:51 

Yeah, so it looks to me that Cathy and Jennifer with the Co-SPACE study, they followed the children over time, and we know when the schools were locked down, and when the lockdowns, eased and all of that, but we cannot really say to what extent it was the schools that were contributing to the mental health problems, or was it other things like anxieties in the family, and so on. So that's basically where our study comes in. We have used a little event in the June of 2020, where after the schools were closed for everyone during everyone remembers that fated day 23rd of March 2020, schools were then closed for everybody, as we know, and from June there was government guidance to reopen schools just for some children, but not for all of them. Because if you remember back, there was social distancing in the classroom, and so on. So they couldn't have all the children back. And this little episode enables us to look specifically at the role of school closures, as opposed to all the other things that might impact on mental health. So what we do is we look at children aged five to 12. And we compare those who had the opportunity to go back with those that didn't and the ones that were asked to come back were reception and year one and also year six in primary school. And this is because research shows that the youngest children, you know, it's a very formative period. It's very important to have them back. And then the year sixes were asked back, I think, because they were about to transition into secondary school, which is also quite a key moment in children's lives. So the children that were prioritised had the opportunity to have seven weeks of more schooling than the ones that weren't prioritised the other year groups. And we find that there was a massive difference in the mental health of those that were and weren't prioritised to go back. We use data from understanding society, which is a UK household Longitudinal Survey, which was running for years and years anyway and then had the opportunity to ask monthly questions including about mental health of children to our respondents that we have, and we use the strength and difficulty questionnaire, which measures the emotional behavioural difficulties of children. And we found that those who didn't have the opportunity to go back to school had behaviours that were quite worse and emotional symptoms, and those that did they have the opportunity. So for example, children who had no tantrum ever went up to having tantrums all of the time. Or another example would be fidgeting with stuff children who never fidgeted before going on to fidgeting all the time, or two of those behaviours going up by a bit. So that was kind of the size of the effect for those that didn't go compared to those that did go back to school. And comparing this with the learning loss, because as we know, there was a lot of focus on the learning loss, we find that the strength of this effect is larger, or most likely than that on learning loss.

Catherine McDonald  20:56

And were you able to get a sense of how long the negative effects on mental health might last?

Birgitta Rabe  21:02

So the effect I just spoke about was at the end of July. So this was already in the summer holiday, when everyone was in the holiday, we could still see those differences between children who had seven weeks of school and those that didn't, then we looked again, at the end of September when everyone was back at school. And we still saw those differences between children lingering. So this is now two, three months down the line, some children had the opportunity to have seven weeks of school, and we still see that this was benefiting them compared to those who didn't. So this is suggesting that the effects were quite not only large, but relatively long lasting in total children missed about 18-19 weeks of school, not just the seven that we were able to look at. And we don't know whether this just accumulates the negative effects or they exacerbate over time. These are questions we cannot answer in our research, but it sort of indicates that they might be quite long lasting, and strong, which I think tells us I mean, going back to what Laura was saying that she was seeing, it was so important for children to have interactions with other children and forming relationships. That's exactly what we would expect to happen in school. Girls actually had one positive effect during this first lockdown. And this was a reduction in their peer problems. So this is quite interesting, I find thinking about the positive that for some children, it might have been a relief to be away from their peers for some of the time,

Catherine McDonald  22:31 

Which is very interesting, but it's also very depressing isn't it?

Birgitta Rabe  22:35 

It is yeah, if you think about I suppose it's about things like bullying and peer pressures and, and things like those.

Catherine McDonald  22:42 

Cathy, Jennifer, I mean, obviously, what Birgitta is saying is going to resonate with you. What would you say about it?

Cathy Cresswell  22:48 

I mean, I Well, I think it did resonate very much. And it's such useful data to be able to have and, and actually, within our Co-SPACE sample, there's certainly a lot more we want to do of digging in and looking at those who were able to be at school and those who weren't. But certainly the variety of experiences that's highlighted there and the particular vulnerabilities are very consistent with the findings that we've been getting.

Catherine McDonald  23:08 

Sure, which again, is a good thing when we have to learn from this, don't we and we have to take these messages forward. On that, Birgitta, who has listened to your research so far, and sort of taken it forward?

Birgitta Rabe  23:22 

But we were quite amazed actually at the impact this has had because if you remember back the vaccinations for 12 to 15 year olds, the JCVI, the Joint Committee for Vaccinations, didn't recommend vaccinations for this age group on health grounds. But they did ask the chief medical officer to look at it a little bit more broadly. So what they did was to look at the effect of school closures on mental health because this is obviously another, you know, area of health other than the physical health. And looking at that evidence, the chief medical officer then recommended vaccinations for 12 to 15 year olds to avoid school closures and to avoid the negative impact on children's mental health. And this was, you know, with citing various studies, they also referred to our work because we had looked specifically at the effect of school closures, which is quite amazing, because then around 2 million children subsequently had the opportunity to go for the vaccine if they opted to do so.

Catherine McDonald  24:23 

And Jennifer , how has the CO-SPACE findings resonated in the wider world? Who's picked that up and who's been listening?

Jennifer McMahon  24:29 

A lot of key stakeholders have been really interested in the findings of the Co-SPACE study, particularly because there was very little information in the early days of the pandemic. And we were one of the only studies in Ireland that had any information. So we were picked up by an agency such as the ESRI in Ireland who kind of set the kind of policy and advise government and so on and we also presented to the offices within the government, within government agencies. So the Department of Children and Youth Affairs we presented to those and they actually fed into some of the development of the questionnaire over time. So the findings have been picked up by lots of different agencies and stakeholders that have a keen interest in understanding how the pandemic has affected young people.

Catherine McDonald  25:07 

Which is great. And Cathy, would you say the same about the UK? Who's been listening over here?

Cathy Cresswell  25:12 

Yes, absolutely. So we were obviously, for exactly the reasons Jennifer mentioned that there was very little data, particularly early on, we were really keen that we were feeding it into decision making all the way through. So we were trying to produce very rapid reports, which we would send off to lots of key stakeholders, policymakers and practitioners, voluntary community sector organisations, they were Public Health England at that time, and also the Department for Education, who used a lot of Co-SPACE based data, for example, in the State of the Nation report for the last couple of years. So we've been really trying to make sure that policymakers have had the data at their fingertips and been able to use it throughout, it's sometimes hard to know exactly how that translates into practice and how it changes things. But we have also tried to pick up on the findings ourselves and take forward other research that's able to have a more direct impact. So we launched a couple of quite large randomised control trials to try and address some of the things parents were telling us early on in the pandemic. So one of those is the SPARKLE trial, which is led by Edmund Sonuga-Barke and colleagues at King's College London, where they rapidly developed an app to support parents with everyday sort of parenting challenges, and randomised a large group of families to evaluate that very rapidly, because parents were telling us they would really welcome that sort of support when we were in the full restriction period. And we also launched a large randomised controlled trial, which we've been conducting in NHS and local authority, child adolescent mental health services to evaluate an online parent led cognitive behaviour therapy intervention for child anxiety problems, to enable families to access support remotely, but for services to be able to deliver efficient support that's also effective. So that's actually continuing, we're coming into the final phases of that now. But we hope that as well as being able to communicate the results to policymakers, we've also taken the opportunity to sort of innovate and carry out rapid evaluations, which we hope will provide some useful solutions for practice going forwards you know, but in pandemic context, but also beyond just as ways of increasing access to evidence based support for families.

Catherine McDonald  27:20 

So Cathy, Jennifer, Brigitta, what has your research told you about what policymakers should be focusing on in terms of priorities for the recovery?

Cathy Cresswell  27:31 

So I mean, I absolutely agree with Laura about opportunities for children and young people to have fun and play and build connections, and also to make up for lost opportunities, you know, opportunities to kind of be inspired and discover, you know, what they enjoy doing what they want to be doing with their lives, I completely agree that that is really critical. As a clinical psychologist, I'm also quite focused on the end of those children, young people who are struggling and where families are struggling and thinking about their needs. So I think one thing that was obviously really important prior to the pandemic, and the pandemic has really highlighted the need is for, you know, rapid access to evidence base psychological support for families when they first need it. And it's something that families were telling us that they wanted prior to the pandemic, people don't want to have to wait until problems are really severe. They want to be able to get support, you know, it could be low level support, but support that has an evidence base behind it, you know, at an early stage when they first have concerns about their children and young people. And we really, you know, I think the pandemic has really highlighted how we need to find creative ways to make sure that families can access that evidence-based support when they first need it.

Catherine McDonald  28:43 

Sure. And Jennifer, would you say the same?

Jennifer McMahon  28:45 

And if I could just add to what Cathy said there, because I think that's really just very spot on in terms of what needs to happen post pandemic. But I think what it also highlighted was that we need to be quite creative also in the way that we provide supports to families so that they are protected against something like a pandemic happening again. So for example, one of the first things to go during the pandemic was face to face contact for people who are seeking counselling or support and or any kind of intervention. So we need to actually enhance and develop methods where we can actually engage with families with young people with children that are not all about face to face. So enhancing those online supports, providing more toolkits, enhancing the supports through schools, and schools are largely under resourced in this area around providing therapeutic or emotional support to families. So I think if we could just focus on maybe some of the aspects that didn't work well, during the pandemic, certainly we need to think about if something like this was to happen again, would we be back to square one? Or have we actually taken lessons from the pandemic, whereby that we actually develop a suite of programmes and methods where we can enhance and support families wellbeing post the pandemic.

Catherine McDonald  29:50 

Yes. Which brings us back doesn't it too, we must learn from this. And Birgitta, what would your policy recommendations be moving forward?

Birgitta Rabe  29:57 

So I guess I'm looking more at what the schools can do to help. And one area here is curriculum as far as I'm aware of. So there is a mental wellbeing curriculum in its own right. But it's also possible to integrate it in all subject areas. And then schools are trying to get back to having extracurricular and extra after school activities. And one quite interesting area as well are the holiday activity and food programmes that are being run. This is something that we want to evaluate and to see how that affects children's and also parents’ mental health over the summer holidays, when often poor children may be not able to access very stimulating activities. And finally, I guess the schools need to be trained and given the resources to link up children quickly to provision where it is available. And I think in that sense, it all comes down to resourcing. And the schools have had a huge role in the pandemic. It's been highlighted that you know, they have a role in feeding children and ensuring they're physically active and so on. And all of these things kind of work together. But schools are also under a lot of strain. And it's a lot to ask, but I do think they have a very important role to play because they are a point of contact for children and their families.

Catherine McDonald  31:13 

My thanks to Professor Cathy Cresswell, Dr. Jennifer McMahon, Professor Birgitta Rabe and Laura. You can find out more about the work of the Interdisciplinary Child Wellbeing Network via their website and Twitter @ICWBN. The work of the network is funded by the UK Research and Innovation Economic and Social Research Council and the Irish Research Council under the ESRC-IRC UK Ireland networking grants. This was a Research Podcasts production. Thank you for listening and remember to subscribe to receive all future episodes.