Access to best-evidenced mental health support for care-experienced young people: Learnings from the implementation of cognitive therapy for PTSD.

OBJECTIVES: Rates of PTSD are up to 12 times higher in care-experienced young people (CEYP) compared to their peers. Trauma-focused CBTs (tf-CBT) are the best-evidenced treatment for youth with PTSD, yet, in practice, CEYP often struggle to access this treatment. We worked alongside services to understand barriers and facilitators of the implementation of cognitive therapy for PTSD (a type of tf-CBT) to CEYP. DESIGN: This was an active, open implementation trial. METHODS: We recruited 28 mental health teams across England, including general CAMHS, targeted CAMHS for CEYP and social care-based teams. From these teams, participants were 243 mental health professionals, from a wide variety of professional backgrounds. Following recruitment/intervention training, teams participated in rolling three monthly focus groups and individual interviews, to understand what helped and hindered implementation. Data were analysed using a framework analysis conducted using CFIR 2.0. RESULTS: Almost half of the teams were able to implement, but only approximately one quarter with CEYP, specifically. Universal barriers that were discussed by almost all teams particularly highlighted service structures and poor resourcing as major barriers to delivery to CEYP, as well as the complexities of the young person and their network. Unique factors that differentiated teams who did and did not implement included commissioning practices, the culture of the team, leadership engagement and style, and the development of supervision structures. CONCLUSIONS: Findings offer key considerations for mental health teams, service leads, commissioners and policy-makers to enhance delivery of best-evidenced mental health treatments like CT-PTSD, for CEYP.

Cognitive and affective control for adolescents in care versus their peers: implications for mental health.

BACKGROUND: Many adolescents who have been removed from the care of their biological parent(s) and placed in State or Local Authority care have experienced significant adversity, including high rates of maltreatment and other trauma(s). As a group, these young people experience far higher rates of mental health difficulties compared to their peers. While their mental health outcomes are well-documented, little is known about mechanisms that may drive this. One potential mechanism, linked to both trauma and adversity exposure and mental health, is affective control (the application of cognitive control in affective contexts). METHODS: We compared cognitive and affective control in 71 adolescents (65% girls) in care aged 11-18 (M = 14.82, SD = 2.10) and 71 age and gender-matched peers aged 11-19 years (M = 14.75, SD = 1.95). We measured cognitive and affective control using standard experimental tasks, and for those in care, we also examined associations with self-reported emotion regulation, mental health, and school well-being. RESULTS: After controlling for IQ, there was a significant group difference in affective control performance, with those in care on average performing worse across all tasks. However, further analyses showed this was driven by deficits in overall cognitive control ability, and was not specific to, or worsened by, affective stimuli. Further, we found no evidence that either cognitive or affective control was associated with emotion regulation abilities or the mental health and well-being of young people in care. CONCLUSIONS: Results suggest that cognitive and affective control may not underlie mental health for young people in care, though limitations should be considered. We discuss implications for theory and intervention development, and avenues for further research. TRIAL REGISTRATION: https://doi.org/10.17605/OSF.IO/QJVDA.

The journey back to normality: Support systems and posttrauma needs following exposure to single-incident trauma among children and adolescents.

Social support has been linked to posttrauma adjustment in children and adolescents, but the components of good support remain poorly defined. We conducted qualitative interviews with 30 youths aged 7-16 years after being admitted to a hospital following a single-incident trauma, predominantly injury or illness. The aim was to identify youths' support needs and examine the support they received across different recovery stages. Thematic analysis revealed that although participants appreciated increased attention and warm support during their hospital stay, most wanted their lives to return to normal soon afterward and were frustrated by barriers to achieving this. Participants received support from different sources, but parents and peers were the most important providers of emotional support and the people with whom these individuals most frequently engaged in trauma-related conversations. Furthermore, although it was important that schools were sensitive to the youths' potential limitations regarding their ability to engage with lessons, emotional support from teachers was less valued. Overall, this study implies that ecological models incorporating multiple interacting layers capture the structure of youths' posttrauma support systems well. These findings may be used to tailor posttrauma interventions more closely to child and adolescent needs at different recovery stages and highlight the importance of having parents and, where possible, peers involved in posttrauma interventions or prevention programs.

An agenda for future research regarding the mental health of young people with care experience.

Young people who are currently or were previously in state care have consistently been found to have much higher rates of mental health and neurodevelopmental difficulties than the general youth population. While a number of high-quality reviews highlight what research has been undertaken in relation to the mental health of young people with care experience and the gaps in our knowledge and understanding, there is, until now, no consensus, so far as we aware, as to where our collective research efforts should be directed with this important group. Through a series of UK wide workshops, we undertook a consultative process to identify an agreed research agenda between those with lived experience of being in care (n = 15), practitioners, policy makers and researchers (n = 59), for future research regarding the mental health of young people with care experience, including those who are neurodiverse/have a neurodevelopmental difficulty. This consensus statement identified 21 foci within four broad categories: how we conceptualize mental health; under-studied populations; under-studied topics; and underused methodologies. We hope that those who commission, fund and undertake research will engage in this discussion about the future agenda for research regarding the mental health of young people with care experience.

Differences in the diagnosis and treatment decisions for children in care compared to their peers: An experimental study on post-traumatic stress disorder.

OBJECTIVES: Despite evidence of high rates of diagnosable mental health difficulties in children in care, there remains ongoing debate around the appropriateness of traditional diagnoses and treatments. The aim of this study was to quantitatively explore whether mental health diagnosis and treatment decision-making differed when a young person was identified as being in care, specifically focused on post-traumatic stress disorder (PTSD). PTSD is a trauma-specific mental health disorder with rates substantially higher in children in care versus their peers. METHODS: Participants were 270 UK mental health professionals who completed an online survey. Participants were randomized to receive one of two vignettes, which were identical in their description of a teenage boy experiencing PTSD symptoms, except in one he was in foster care and in the other he lived with his mother. Participants were asked to select a primary diagnosis, treatment approach, and potential secondary diagnosis. RESULTS: Professionals were twice as likely to choose a primary diagnosis of PTSD and a National Institute for Clinical Excellence (NICE)-recommended PTSD treatment when randomized to the mother vignette versus the foster carer vignette. Selecting PTSD as the primary diagnosis made clinicians three times more likely to select a NICE-recommended treatment for PTSD. Developmental trauma was the most common 'diagnosis' for both groups, although this led to different treatment decisions. CONCLUSIONS: In the context of PTSD, we found children in care face diagnosis and treatment decision-making biases. Practice implications are discussed.

A Longitudinal Investigation of Children's Trauma Memory Characteristics and Their Relationship with Posttraumatic Stress Disorder Symptoms.

While trauma memory characteristics are considered a core predictor of adult PTSD, the literature on child PTSD is limited and inconsistent. We investigated whether children's trauma memory characteristics predict their posttraumatic stress symptoms (PTSS) at 1 month and 6 months post-trauma. We recruited 126 6-13 year olds who experienced a single-incident trauma that led to attendance at an emergency department. We assessed trauma memory disorganisation and sensory-emotional qualities through both narrative recall and self-report questionnaire, and PTSS at 1-month post-trauma and at 6-month follow-up. We found that, after controlling for age, children's self-reported trauma memory characteristics were positively associated with their concurrent PTSS, and longitudinally predicted symptoms 6-months later. However, observable trauma memory characteristics coded from children's narratives were not related to PTSS at any time. This suggests that children's perceptions of their trauma memories are a more reliable predictor of the development and maintenance of PTSS than the nature of their trauma narrative, which has important implications for clinical practice.

A Systematic Review of Controlled-Trials for PTSD in Maltreated Children and Adolescents.

Child maltreatment is associated with elevated risk of post-traumatic stress disorder (PTSD), which can often present alongside comorbidities. While evidence-based treatments for PTSD in young people already exist, there remains ongoing clinical and academic debate about the suitability of these approaches, particularly cognitive-behavioral approaches, for young people who have been exposed to more complex traumatic experiences, such as maltreatment. We conducted an updated systematic review of the evidence-base for psychological treatments for PTSD, specifically for maltreated young people. Fifteen randomized controlled trials and five non-randomized controlled clinical trials satisfied the inclusion criteria. Trials included treatments ranging from trauma-focused CBT to creative-based therapies. Trauma-focused CBT remained the best supported treatment for children and adolescents following child maltreatment, with new evidence that symptom improvements are maintained at longer-term follow up. The evidence for other therapies remained limited, and there were concerns regarding methodological quality. Implications for treatment decision-making are discussed.

A mixed-methods investigation of parent-child posttrauma discussion and the effects of encouraging engagement.

Recent developments in the child trauma field include preventative interventions that focus on augmenting parental support. However, we have limited knowledge of how parents experience trauma conversations with children. We examined how parents and children experienced both spontaneous trauma conversations and a structured task in which they generated a joint trauma narrative, following the child's experience of an acute trauma. Parent and child ratings of distress during the structured narrative were low for all 127 families that took part, with child ratings of distress being lower overall than parent ratings. Task-related distress was positively associated with parent and child PTSD symptoms. Thematic analysis of semi-structured interviews conducted with a subset of twenty parents identified both facilitators of (e.g. open and honest relationship with child) and barriers to (e.g. parent/child avoidance of discussion) spontaneous trauma-related conversations with their child. Additionally, parents described the structured trauma narrative task as an opportunity to start the conversation with their child, to understand their child's feelings, and for the child to process the trauma. However, the task was also uncomfortable or upsetting for some parents/children, and resulted in parents becoming more overprotective. The findings can inform development of low-dose interventions that encourage families to engage in trauma-related conversations following child experiences of trauma.

Los desarrollos recientes en el campo del trauma infantil incluyen intervenciones preventivas que se centran en aumentar el apoyo de los padres. Sin embargo, tenemos un conocimiento limitado de cómo los padres experimentan las conversaciones de trauma con los niños. Examinamos cómo los padres y los niños experimentaron las conversaciones espontáneas sobre traumas y una tarea estructurada en la que generaron una narrativa conjunta sobre el trauma, siguiendo la experiencia del niño sobre un trauma agudo. Las calificaciones del malestar de los padres y los hijos durante la narrativa estructurada fueron bajas para las 127 familias que participaron, y las calificaciones del malestar de los niños fueron más bajas que las calificaciones de los padres. El malestar relacionado con la tarea se asoció positivamente con los síntomas de TEPT de los padres y de los hijos. El análisis temático de las entrevistas semiestructuradas realizadas con un subconjunto de veinte padres identificó tanto a los facilitadores (por ejemplo, una relación abierta y honesta con el niño) como a las barreras (por ejemplo, evitar la discusión entre los padres y los hijos) de las conversaciones espontáneas relacionadas con el trauma con su hijo. Además, los padres describieron la tarea narrativa del trauma estructurado como una oportunidad para iniciar la conversación con su hijo, para comprender los sentimientos de su hijo, y para que el niño procese el trauma. Sin embargo, la tarea también fue incómoda o molesta para algunos padres/hijos, y resultó en que los padres se volvieran más sobreprotectores. Los hallazgos pueden informar el desarrollo de intervenciones de dosis bajas que alientan a las familias a participar en conversaciones relacionadas con el trauma después de las experiencias de trauma del niño.

Gesture Production in Language Impairment: It's Quality, Not Quantity, That Matters.

Purpose: The aim of this study was to determine whether children with language impairment (LI) use gesture to compensate for their language difficulties. Method: The present study investigated gesture accuracy and frequency in children with LI (n = 21) across gesture imitation, gesture elicitation, spontaneous narrative, and interactive problem-solving tasks, relative to typically developing (TD) peers (n = 18) and peers with low language and educational concerns (n = 21). Results: Children with LI showed weaknesses in gesture accuracy (imitation and gesture elicitation) in comparison to TD peers, but no differences in gesture rate. Children with low language only showed weaknesses in gesture imitation and used significantly more gestures than TD peers during parent-child interaction. Across the whole sample, motor abilities were significantly related to gesture accuracy but not gesture rate. In addition, children with LI produced proportionately more extending gestures, suggesting that they may use gesture to replace words that they are unable to articulate verbally. Conclusion: The results support the notion that gesture and language form a tightly linked communication system in which gesture deficits are seen alongside difficulties with spoken communication. Furthermore, it is the quality, not quantity of gestures that distinguish children with LI from typical peers.