Professor Rachel Hiller Hi, my name’s Rachel  Hiller. I’m a Professor in Child and Adolescent   Mental Health at UCL. I lead a Research Team  called the Child Trauma and Recovery Research   Group, and we specialise in research on the mental  health and wellbeing of young people who have   experienced complex trauma, particularly young  people with experience of our care system [pause]. So, this, I think, is a really important  question, because some of these terms are newer,   some have been around for a long time, but what  we see in practice is that these teams – terms   are increasingly getting, kind of, merged  and confused in terms of what they mean.   And I think understanding the differences  between them are really key to how   we understand and address the mental  health of trauma exposed young people. So, obviously, trauma, as I’m sure many of  you will know, trauma is the experience. So,   our diagnostic manual actually  defines trauma quite specifically,   but essentially, it is an experience where the  young person may have felt very threatened,   like their life was in danger  or even that they might die,   or where they felt very worried for the safety  of someone else. So, that is what a trauma is. It can include many, many different  things, and partly, that’s why we now   see these different terms popping up, like  complex trauma or developmental trauma,   because what is a potentially traumatic event can  be such a wide, different range of experiences. So, sometimes you hear people talking about  acute or one-off traumas, like a car accident   or a one-off assault, or a very serious  sporting accident. And complex trauma usually   is trying to describe, as the name  suggests, traumatic experiences   that may have been more complex, and  that could be in different ways. So,   it might have been that there have been multiple  traumatic exposures. Often, it means that   there might have been an interpersonal  aspect to the trauma, so, for example,   abuse or maltreatment. But it might also mean that  the trauma has occurred in a very complex context,   either that the young person has more complex  needs, or perhaps the – their environment around   them is more complex. So, perhaps there’s lots  more adversities in that young person’s life. Developmental trauma, again, is a little bit  newer, and developmental trauma is usually   used interchangeably with complex trauma, but  usually, what it’s trying to capture is that   the trauma happened over a really important  or sensitive developmental period. Mostly,   and people will have different views on  this, but mostly when people talk about   developmental trauma, they are talking about child  maltreatment, where there might’ve been ongoing   traumas that were interpersonal in nature.  But the key here is that all of those terms,   “trauma, complex trauma, developmental  trauma,” are talking about the experience   that that young person has had. That’s not a  mental health outcome, that’s their experience. PTSD or complex PTSD, whichever you’re using, that  is one possible mental health outcome from trauma.   It’s a trauma-specific mental health outcome.  So, that’s the key, really, in this terminology,   that the ones that are talking about trauma are  the experience and then, PTSD or complex PTSD,   is one possible mental health outcome. But, of  course, trauma is related to lots of different   mental health outcomes and that will be different  for different individuals, or indeed, resilience,   as well, is also very, very possible after  trauma. So, that’s just a bit about those terms. I think one thing to keep in mind is that  developmental trauma as a term, in particular, is   often now used to discuss a mental health outcome,  that the young person has developmental trauma,   that young person is experiencing developmental  trauma. But actually, there is a very, very poor   research evidence base that developmental  trauma, or developmental trauma disorder,   should be used in practice. So, when we look at  the research on this, we would really caution   using the term ‘developmental trauma’ to talk  about a mental health outcome. It is an experience   and that could lead to a range of different  outcomes, which is why we need to be screening   for different types of mental health outcomes  after those kinds of early adversities [pause]. So, PTSD, post-traumatic stress disorder, has  been around for quite a long time now. It’s   very well established in our diagnostic manuals.  It has been very, very well researched in lots   of different groups, including with young  people that have experienced very complex   or developmental traumas. So, PTSD has  a set definition of symptom clusters. One is re – known as re-experiencing, so this  might be flashbacks, memories that flood into   their mind to make them feel like they’re back  at the time, feel really unsafe, or it could be,   for example, nightmares. Another core system  cluster is avoidance, so avoiding talking about,   thinking about, not wanting any reminders about  what’s happened, and then we have altered arousal.   So, for example, difficulty concentrating, perhaps  in the school environment, or difficulty sleeping.   So, they’re three core symptom clusters that  sit across both of our major diagnostic manuals. And then in 2018, I believe it was, one of our  diagnostic manuals, called the ICD, introduced the   term ‘complex PTSD’. So, complex PTSD, there’s  a few things to know about it. It’s only – it   was only introduced, as I said, in 2018, so we’re  only just starting to see some really interesting   research coming out on complex PTSD. But we  often think about complex PTSD as a potential   outcome where there has been very complex or early  developmental trauma, that complex PTSD might be a   particular outcome from that. But I think probably  core to remember about it is that the fundamentals   of complex PTSD are the same as ‘standard’ PTSD.  So, to have complex PTSD, you have to have PTSD. And then there are some other symptoms.  So, PTSD symptoms, when they come with   significant emotional dysregulation, relationship  difficulties or negative self affects, like,   “I’m not worth anything,” they – those clusters,  alongside PTSD, would be called complex PTSD. So,   it’s a relatively new diagnosis compared to  standard or just PTSD, but the symptoms are   very similar. PTSD is core of complex PTSD and  the treatments are also still the same. So,   it doesn’t need to be treated as a completely  separate mental health outcome and that’s really,   really important when we’re considering it as  a possible outcome for young people [pause]. So, we know a lot about factors that contribute  to the development of PTSD in young people. So,   there’s been a lot of, kind of, longitudinal  mechasit – mechanism studies, for example.   We have some really solid theories  on what drives PTSD symptoms. So,   in the UK we often use the cognitive  model of PTSD and that has been shown   to be really applicable to even young people  that have experienced very complex trauma. So, for example, my group a few years ago now  looked at whether those models were applicable   to young people in the care system and  found they were highly applicable. So,   what drives PTSD in other young people  are the same as what drives PTSD in,   for example, young people in the care system. But this has been looked at in many other  groups, as well, young people that have   been in car accidents, young people that  have perhaps experienced war trauma. So,   lots of different types of traumas, we see  really similar mechanisms driving PTSD. And   our work that looked at that in children in  care found that those mechanisms were also   important for complex PTSD. So, again,  when we’re talking about complex PTSD,   it’s potentially a really important diagnosis, but  the drivers will be very similar to what drives   PTSD and the treatments at the moment are the same  treatment that is more effective for both of them. So, taking a step back and thinking about  what it is that drives the development of   PTSD and the maintenance of PTSD, what we found  in our work with young people in care was that   the key driver of PTSD and complex PTSD  symptoms was something that we might call   ‘maladaptive appraisals’ or ‘maladaptive  cognitions’. And these are thoughts like,   “I’ll never get over what happened to me. It  was all my fault. I can’t trust anyone. The   world is not safe for me.” And these are the  kinds of thoughts that actually make complete   sense when you have come from a context where  the world might not have been safe for you,   where people might not have been trustworthy  or been safe. But once you’re in a environment   of relative safety, the continuation of those  thoughts, or the really entrenching of those   maladaptive cognitions, can drive the maintenance  or worsening of PTSD or complex PTSD symptoms. The other, kind of, key driver that we found  in our work was the use of avoidant coping. So,   young people that are saying, “I push thoughts  away when they come into my head. I don’t   want to talk about what’s happened.”  These kinds of coping strategies are   associated with poorer outcomes in terms  of PTSD and complex PTSD. And as I said,   that has been found in lots of different studies.  There’s even meta-analytic reviews on this that   bring together the whole literature, that  show that these things are important. Other things that might be important, of course,   are the social support that young person has, so  how they’re supported to overcome those symptoms,   the types of coping behaviours that are  modelled to them, for example. And also,   memory processes are considered to be really  important maintainers of PTSD or complex PTSD. So,   having more disorganised or fragmented,  confused memories can maintain that, kind of,   sense of ongoing threat that is inherent  to both PTSD and complex PTSD [pause]. So, complex trauma could mean a range of  different traumas, as we’ve already talked   about. But usually, when people say complex  trauma, they mean that there have been multiple   different traumas and adversities in that young  person’s life. And, of course, that can have a   really profound effect on all aspects of  their life, including mental health. So,   in the UK we have some really nice epidemiological  work, done by people like Andrea Danese at King’s   College London and his colleagues, that have  looked at the experience of these more complex,   often interpersonal, traumas on mental health  outcomes for young people living in the UK. And here, what we find, consistent  with a really broad literature,   a broad international literature, is that young  people that have experienced complex trauma are   at particularly elevated risk of a range of  mental health outcomes. PTSD is one, that’s a   trauma-specific mental health outcome, but it –  all – they are also at high-risk of depression,   anxiety-based disorders, conduct difficulties,  potentially substance abuse in later adolescence,   concerns like self-harm behaviour. So, all  of these outcomes are elevated in young   people that have experienced complex trauma.  So, it’s incredibly important that when we   know a young person has experienced these early  complexities, or complex traumas and adversities,   that we’re making sure we’re keeping  an eye on their mental health.  And, of course, those experiences, if they lead  to the development of poor mental health outcomes,   can have a major effect on all aspects of their  life. It makes school incredibly difficult,   a really difficult environment to  navigate. It can make relationships very   difficult in terms of forming new relationships,  or perhaps challenges that it might present in the   existing family unit. So, again, it’s really  important that we recognise when young people   have experienced complex trauma, that it can lead  to a range of different mental health outcomes.   There’s no one mental health outcome for these  young people, so it really requires us to be   doing a thorough assessment of their individual  mental health needs as a young person [pause]. So, in terms of treatment approaches  for PTSD, or complex PTSD specifically,   by far the best evidence approach for  young people is a type of treatment we call   trauma-focused cognitive behaviour therapies,  or trauma-focused CBTs. These are manualised   programmes. They have different names. So, there’s  a manual called “Trauma-Focused CBT,” but there’s   also options called “Cognitive Therapy for PTSD,”  “Narrative Exposure Therapy,” “Prolonged Exposure   Therapy.” And these are all treatments that  fall under that umbrella of trauma-focused CBT. They are by far the best evidenced treatments  for young people who have PTSD and there’s also   growing evidence that they’re the best treatments  for young people that have complex PTSD. So,   they have been found that as an intervention,  trauma-focused CBTs have been shown to be as   effective at reducing symptoms for young people  with complex PTSD as they are as standard PTSD. It might mean, as is highlighted in the NICE  guidance, that young people with more complex   presentations require longer treatments. So, a  standard treatment of trauma-focused CBT might be,   for example, ten to 12 sessions. A young person  with complex PTSD, or a more complex presentation,   might require more like 20 sessions, for example.  But those manuals are by far our best chance of   helping young people to recover from their PTSD or  complex PTSD, regardless of what the trauma might   be, or the traumas might be, that have led to the  development of that PTSD or complex PTSD [pause]. So, in terms of some of the barriers for young  people in care specifically accessing mental   health support, there are many that they might  face. I think the first, which is incredibly   important to highlight, is that they are in  systems that are really chronically underfunded   and understaffed. So, one of the major barriers  is that we just don’t have services that are able   to hold the needs of those young people, and that  is so difficult for young people and their carers,   but it is also incredibly difficult for  the staff working in those systems. So,   that is one of the major barriers is that our  services actually just aren’t given the resources   they need to support young people in care,  often, not always, but certainly very often. But there are also barriers that are unique  for young people in care and one of them   is that we know from our research and we  know from research other groups have done,   that there are diagnostic and treatment biases  against young people in care. Sometimes that’s   called ‘diagnostic overshadowing’, which  is a term that came from the health field,   that we sometimes now use in the mental health  field. And that might mean, for example,   a young person is less likely to be assessed using  standardised instruments to look at their needs,   or they’re less likely to have things like PTSD  picked up on. And they might be over-diagnosed,   for example, with things like attachment  difficulties. And there, what we’re seeing is that   assumptions are made about their mental health  because they’re a young person in the care system,   without there being, really, a thorough assessment  of what their individual mental health needs are. And I think that’s really important because,  as we’ve talked about previously, young people   that have experienced very complex traumas,  like many young people in our care system,   and have also had to navigate the care system,  which is not an easy system to navigate in   itself. Their – placement breakdowns are common.  They might have been separated from siblings. So,   a lot of incredibly difficult experiences  that that – those experiences can lead   to a range of different mental health  outcomes. There’s not one mental health   outcome that categorises young people in  care. They’re still young people first,   they’re individual children, so we really  need to make sure we’re doing individual,   really comprehensive assessments, of  what their mental health needs are. So, in terms of other barriers that young  people in care might face with accessing   mental health services, certainly, a big one is  that their carer network might be quite unstable,   and that presents a lot of challenges for  mental health services. So, there might   not be a stable caregiver, or there might be  a risk of the foster placement, for example,   breaking down. There might be a risk of school  exclusion, whatever it might be that’s going   on. That they’re rarely – young people in care  are rarely presenting to mental health services   with just one issue. There’s often a lot of  complexities and a lot of things going on. So, a real challenge for services is how to  hold those complexities, hold, potentially,   safeguarding or risk concerns, and work  together across mental health and social   care and education settings to make sure all of  the professionals understand their roles and are   able to work together to provide the wraparound  support that that young person really needs. But interestingly, when we talk to mental  health professionals, many young people,   not just young people in care, but many young  people, presenting to mental health services,   have really complex lives, really complex needs.  So, there does seem to be something relatively   unique about being a young person in care that  means we do see some different decisions being   made, like, for example, not offering treatment  because the young person doesn’t live in a stable   home. Whereas we know that young people  that have lots of placement breakdowns,   that in the care system are often those that are  struggling the most with their mental health. So, we really need to be working together,  Researchers, professionals, young people,   carers, to think about how we can best work with  that complexity, rather than using it as a reason   not to be providing mental health support. But  it’s a really big challenge for our services to   know what to do, in the context of perhaps not  having the resources they need to offer longer   treatment programmes, and particularly to do  that one-on-one work with the young person.