Rosie McGuire Hello, I’m Rosie McGuire, and I’m going to be talking to you today about a piece of research from my PhD, which I did at the University of Bath, and was funded by the Economic and Social Research Council. Rachel Hiller and Sarah Halligan were my supervisors and we worked on this with Richard Meiser-Stedman and Lucy Durbin. So, to give you a bit of context on young people in care, the numbers of young people in care are increasing. Over the last five years it’s increased by around 10%, and there’s now over 90,000 young people in care in the UK. And, quite often, these young people have had difficult early life experiences, many have experienced maltreatment or other adversity within their homes. So they’re removed from their homes and placed usually in a foster care placement, with someone that’s a stranger to them. But sometimes the setup can be slightly different, they could be placed with other family members or in residential care. But because of this upheaval and change and difficult early life experiences, it’s perhaps unsurprising that these young people have high rates of mental health difficulties. And, in particular, post-traumatic stress disorder, or PTSD, is 12 times higher for these young people than their peers. And, quite often, the mental health needs of these young people goes unmet. So, often they report difficulty accessing CAMHS, which is Child and Adolescent Mental Health Services, and once they do access these services, they’re often unsatisfied with the support that they receive. But I guess the question is whether this is unique to children in care, because we know that these services are under resourced. Many Clinicians don’t have the capacity to provide the support that perhaps they know that these young people they’re seeing need. So, maybe this is happening for all young people, not just those in care. So, focusing in on PTSD specifically, we know that this is poorly detected for young people in care, despite the fact that in these big cohort studies, like this one by Ford, done almost 20 years ago now, we – this showed us that rates of PTSD were much higher for young people in care. But there is ongoing debate around whether diagnostic frameworks generally are applicable to children in care, and perhaps this applies to PTSD specifically, as well, because of the types of trauma that these young people have experienced. But, again, we don’t know if this is unique to children in care, or if perhaps across the board PTSD is not always picked up in young people. So, in terms of treating PTSD, we have good evidence that trauma-focused CBT is really effective at reducing PTSD symptoms. So, the NICE guidelines, which pull together lots of different research evidence, to make suggestions for Clinicians in practice, they suggest that trauma-focused CBT should be the first line of treatment for PTSD, with EMDR following, if the patient has no response. But, again, there’s some debate around the appropriateness of these approaches for complex trauma, or developmental trauma, which is often the type of trauma we’re talking about for young people in care, where they’ve experienced maltreatment early on in life. But there are now multiple reviews showing that trauma-focused CBT is actually effective for children who’ve experienced maltreatment, including studies specifically with children in foster care. So, we really do have strong evidence suggesting that we should go ahead with this treatment for these young people. But we do know that, in practice, there are barriers to using this. So, we know that there’s a lack of access to training for Clinicians, so they may just not know how to deliver this treatment in the first place. And then there’s also a lack of supervision and support for Clinicians that are going on to deliver this. And there are, of course, concerns around the potential emotional burden of this treatment, for both the Clinician and the patient, because there has to be some discussion around the trauma, which can be daunting for both parties. And then some Clinicians also have a different psychological orientation, which doesn’t always suit these cognitive behavioural approaches. But, again, we don’t know whether these barriers are unique or perhaps more pronounced for children in care, or if this is a problem across the board that these treatments are not being delivered. So, we wanted to explore in this project whether there were differences in the identification in P – of PTSD and the use of NICE recommended PTSD treatment, so trauma-focused CBT or EMDR, for young people in care, compared to those not in care. And we wanted to know, for a presentation, a symptom presentation of PTSD, what were Clinicians choosing as a diagnosis instead, if not PTSD, and how was this affecting flow-on treatment decisions? And we wanted to know whether basic professional factors, such as background and experience, how that affects their decision-making and whether it – that’s different, depending on if a young person is in care, or not. So, in this study we had 270 UK-based professionals, and these were pretty representative of the types of professionals we actually have in the UK. So most were based in CAMHS, so that’s Child and Adolescent Mental Health Services, but we did, also, have Clinicians from the charity, private and social care sectors. And this typically reflects the types of Clinicians that young people in care would see, because they’re not always – as I mentioned, they don’t always meet criteria for CAMHS, so sometimes that means they then go on to receive support from charities or private sector Therapists, as well. And I’ve broken down the professional backgrounds of these Clinicians into three categories, which I will refer to again later. So, diagnostic frameworks refers to Clinicians who have been trained in diagnostic frameworks, so that’s typically Psychiatrists and Clinical Psychologists. And then we have psychological therapies, so these are Clinicians that have been trained in planning and delivering therapies. And then we have Allied Health and Social Care Professionals, who are, for example, Mental Health Nurses and Social Workers, Occupational Therapists. So, that’s how we’ve broken down the categories, so we’ll look at whether Clinicians in those categories make different decisions. So, for all of our participants, they were randomly shown one of two clinical vignettes, and these were exactly the same in terms of the background and symptom presentation that was described. The only difference is that in one, Connor still lives with his mother, but in the other, he’s taken into care and lives with a foster carer. So, we then asked the participants what they thought the primary presenting problem was, from this list, which includes post-traumatic stress disorder, among many other diagnoses and difficulties. We then asked them what treatment approach they would take from this list, again, which includes trauma-focused CBT and eye movement desensitisation and reprocessing, or EMDR. And then we asked whether they thought there were any other potential secondary diagnoses that they would explore, and, again, gave them this list which included post-traumatic stress disorder. So, interestingly, we found that, actually, yes, Clinicians do make different diagnosis and treatment decisions for young people in care, compared with young people who were still living with their parent. So, we found that PTSD was diagnosed twice as often for young people – for the young person described as still living with his mother. And when we looked at whether professional characteristics predicted this decision, actually, the only difference we found was between diagnostically trained professionals and Allied Health and Social Care Professionals, where those diagnostically trained were more likely to give the PTSD diagnosis, which makes sense. But years of experience, and experience with PTSD cases, was not related to this decision-making. And then we also found there was a difference in the frequency of choosing trauma-focused CBT or EMDR for this young person. So, it was less commonly chosen where the young person was described as being in care. And none of the professional background factors actually predicted this decision, so it suggests there’s something a bit more complex about this decision-making. So, other interesting things that we found is that, actually, diagnosis of PTSD was quite low across the board. But where it was identified, Clinicians were three times more likely to select a NICE recommended PTSD treatment. But, that being said, the pathway from PTSD to a NICE recommended PTSD treatment was actually still quite low. So, for the whole sample of those who selected PTSD as the primary diagnosis, around half then selected a NICE recommended treatment. And we also found that attachment disorder was chosen much more often for young people in care, compared to their peers. And I think this is because a stereotype that’s held around young people in care, where it’s thought that they will have attachment difficulties, kind of, regardless of what’s gone on. But in our clinical vignette that we presented Clinicians, although we did mention difficulties with relationships, actually, the common symptoms of attachment disorder, such as a lack of remorse, attention seeking or inappropriate comfort seeking or boundaries, they actually weren’t included in the description of Connor. So, this is interesting that it’s still picked up so often, when he was described as being in care. So, other interesting things that we found, is, actually, across the whole sample, around 22% of participants chose PTSD as the primary diagnosis, so it was quite poorly recognised across the board. And we found that where it was identified, Clinicians were three times more likely to select a NICE recommended treatment, so trauma-focused CBT or EMDR. But, even there, across all of our sample, only around half of Clinicians that selected PTSD went on to choose trauma-focused CBT or EMDR. So, it does suggest there is still a bit of a gap there. And then, interestingly, attachment disorder was chosen as a primary diagnosis for many young people in care, many more than for the non-care experienced description in this case. And this is interesting, because whilst in the vignette we did mention difficulties with relationships, we didn’t mention many of the other common symptoms of attachment disorder, such as, the lack of remorse, attention seeking, inappropriate comfort seeking or boundaries. So, the fact that that wasn’t mentioned, but it still came up so often as the diagnosis, I think suggests that there’s a bit of a stereotype there, for young people in care, which could lead to them getting incorrect diagnoses and support. And then, interestingly, developmental trauma was the most common problem chosen, across the board, regardless if Connor was described as in care or not. But this diagnosis wasn’t linked with an increased likelihood of selecting trauma-focused CMT – CBT or EMDR, in the same way that PTSD was. And, actually, this diagnosis led to quite different treatment decisions, depending on care status. So, for a young person in care, DDP or other psychotherapies were more often chosen, when developmental trauma was suggested. But for young people not in care, when Connor was described as living with his mother, trauma-focused CBT was chosen much more often. So, that’s interesting, because it suggests that with this diagnosis or presenting problem that actually it’s causing treatment pathways to diverge, depending on the young person’s background. And here’s an example, just some descriptive data, so this shows that when PTSD is chosen as the diagnosis, the treatment pathways are much clearer, so there’s much less dispersion around which treatments are chosen. But when developmental trauma is chosen, as you can see, treatment decisions are much more dispersed, and a range of things are being chosen as the treatment pathway. So, this study has several strengths and limitations. I think we did well to recruit such a large sample of mental health care providers, that were pretty representative of those that are supporting young people in the UK, particularly those in care. And we’ve used unique experimental methods to investigate this kind of decision-making that might be happening, but we do acknowledge that the clinical vignettes we’ve provided are artificial, it’s very basic information, and often, Clinicians will have more information than that to make these important diagnosis and treatment decisions in practice. But I think it is important to also acknowledge that sometimes triaging decisions are made based on this very basic amount of information, and that can lead to young people being referred into a service where – with an inaccurate diagnosis or put onto a treatment pathway that’s not appropriately supporting their needs. And I think it’s also worth saying that quite often, Allied Health and Social Care Professionals could be making these triaging decisions, and as we pointed out, there is actually a difference in – between these professionals and diagnostically trained professionals, in their ability to pick up a PTSD diagnosis, so I think that’s important to acknowledge, as well. But, of course, in real life, there’s many more complexities that go on, that affect these diagnosis, but, more importantly, treatment decisions that are actually happening. And Clinicians actually have to take into account their capacity and resources that they have to provide support, as well. So, to sum up, we found that identification of PTSD was low, overall, and where it was identified, a NICE recommended treatment for PTSD was selected more often, but not always. And I think, most importantly, we found that there is a potential bias in diagnosis and treatment for young people in care, compared to their peers, which might mean that they’re not getting the most effective evidence-based treatments to support their needs. So, going forwards, we need to improve the training that we have for Clinicians. We need to raise awareness of this bi – potential bias, and make Clinicians more aware of PTSD, and, potentially, systematically screening for PTSD in young people in care, where we objectively know that that diagnosis is much higher for those young people. And we need to improve the training and supervision that Clinicians have for delivering treatments like trauma-focused CBT. And we need to do more work to understand the barriers that exist in services, that might prevent these treatments from happening. And that’s actually what we’re doing in a study at the moment, the ADaPT trial, which Rachel Hiller is running at UCL, and I’m working on alongside her. We’ve trained up over 200 Clinicians in trauma-focused CBT, mainly those that work within looked-after children services, so that we can better implement this treatment for these young people, and raise awareness of the fact that PTSD is much higher in these young people, and that they might need this specific type of support. So, if you want to read a little bit more about this work that we’ve done, the paper is now published. And if you have any questions or comments about this work, you’re welcome to get in touch, but thank you very much for listening to this presentation.