Professor Richard Meiser-Stedman Hello,  and my name’s Richard Meiser-Stedman.   I’m a Professor of Clinical Psychology at  the University of East Anglia. I’m going   to be giving you a talk on how children  make sense of trauma. So, particularly,   how do children’s psychological coping  mechanisms affect how they respond   to traumatic experiences? And how that might  affect whether or not they develop PTSD. So, a little bit of an outline of what  I’m going to be talking about. So,   really focusing on PTSD primarily in this  talk, and something called the “cognitive   model of PTSD.” So, this explain – this  is – attempts to explain how cognitive   psychological processes affect how people respond  to trauma. A little bit on family influences,   a little bit on evidence from clinical trials  and treatment studies and also, just thinking   a little bit at the end about PTSD versus  depression. So, how do these sorts of factors   affect depression as well as PTSD? So, those  are the things we’re going to be thinking about. First off, well, what is PTSD? So, I’m just  going to go with the ICD-11 definition. So,   to get a diagnosis of PTSD you need to  have been involved in some kind of trauma,   which ICD classes as “an extremely threatening  or horrific event, or events.” And you need at   least one of the following symptoms.  So, some kind of ‘re-experiencing’,   some kind of ‘avoidance’ and  some kind of ongoing, sort of,   sense of ‘current threat’. And I’ve just listed  the symptoms here. These are fairly well-known,   so I’m not going to dwell on these too much.  Keeping with ICD-11 is that these also have to   cause some sort of ‘impairment’. They have  to, kind of, interrupt your functioning. So, where are we with children? So, we know that  children do get exposed to trauma. This is the   horrible reality. Several studies here,  the E-Risk Study of – a large twin study,   suggested that nearly – well, over 30% of  children by the age of 18 will have been   involved in a trauma and a lot of children in  the UK will grow up ex – being exposed to severe   domestic violence. In Switzerland, another  high-income country, over half of children,   according to one survey by Markus Landolt,  over half will have been involved in some kind   of trauma by age of 16. So, trauma is common  and is something we need to take seriously. The slightly better news is that not everyone  involved in a traumatic experience get – develops   PTSD. So, one study by Eva Alisic a few years  suggested that about 16%, give or take, of   children who’ve been involved in a trauma develop  PTSD. More so for interpersonal traumas, violence,   war and so on, compared to non-interpersonal  trauma, so car accidents, earthquakes,   things like that. Typically, more girls than  boys. So, that’s the, sort of, good news. What about – it’s not the case that everyone  – every child being – getting involved in a   trauma develops PTSD, but it’s still an issue  at prop – at, kind of, a population level. So,   again, that Swiss study suggested about  4% of children, when they were about 16,   had PTSD at that moment in time. So, it’s a common  enough condition and the E-Risk Study suggested a   lifetime prevalence. So, having had PTSD at some  point in their life, for these 18-year-olds,   was about 7.8%, give or take. So, this is a common  enough outcome. We do need to take it seriously. Very important to understand what  happens to PTSD naturally, though. So,   this very important meta-analysis from  Rachel Hiller clarified that in general,   what we see is nat – some natural recovering.  So, she and her team pulled together data from   lots of different studies and what she found –  these are studies of children who’d typically   been involved in a one-off traumas, so like  car crashes, assaults, medical emergencies,   things like that. And what she found was  that in the first month, the, sort of,   average proportion of children developing PTSD  would be about just over 20%. And as you can see,   with each timepoint following up, so  at three months, six months, 12 months,   the rates of PTSD decline, and it seems to be  settling down by six months and certainly a year. So, we’ve actually got two questions. So, first of  all, why is it that some children experience the   onset of PTSD and others don’t? But then, why is  it that some children get better and others don’t?   And this is really important. So, some PTSD early  on is fairly natural and even the children who   didn’t get full-blown PTSD, may well have had some  symptoms of PTSD. But if you do nothing, some of   those children and young people will get better on  their own. And so, it’s – that’s – this is part of   the complexity of children’s responses to trauma  that we really need to explain and understand. Now, the model that I and my colleagues  have really explored quite a lot in our   work in this area is the cognitive model of Anke  Ehlers and David Clark. It’s a wonderful paper,   it’s in – published in Behaviour Research  and Therapy in – back in 2000 and it’s   a, sort of, classic PTSD article and their model  is a classic. There’s a lot I could say on it.   I’ll just emphasise the three main features. So,  they would – their model suggests that it’s the   nature of the – or PTSD becomes persistent when  people’s memories of the trauma are, kind of,   stored in a different way. So, these are very  fragmented, often lacking some sort of context,   some sort of time and place. These can  be very overwhelming, very sensory laden,   very affect laden, lots of emotion in there.  So, the nature of the memories is different   in people with PTSD from people who’ve been  involved in a trauma who don’t have PTSD. Another critical process is the – how people  perceive and appraise their trauma. So, having   lots of negative appraisals around the trauma, you  know, why – you know, you’re thinking that maybe   your symptoms of PTSD are a sign you’re going  mad or a sign that you’re – that this is a –   having been involved in this trauma means  that you’re somehow damaged or cursed,   or you can’t trust anyone. The world’s unsafe.  Perhaps you see yourself as being, sort of,   unable to cope and weak. These sorts  of appraisals, these sorts of beliefs,   seem to be really important in driving PTSD,  according to this model, and then how you try   to cope with and respond to the trauma and  the aftermath is really important, as well. So, avoi – sort of, thought suppression and  other forms of avoidance is very powerful at   maintaining PTSD, according to this account. But  also, kind of, overthinking a trauma and asking,   sort of, lots of open-ended questions. So, this  is – sort of, a trauma-related rumination might   be very important. So, you know, “Why me? What  did I do to deserve this?” Sort of, repeatedly   thinking, “Well, what could I have done  differently?” There might be other things,   as well, sort of, certain safety seeking  behaviours. So, always carrying a phone with you,   always checking where loved ones are, things  like this, may well play a role in keeping PTSD   going. So, very much worth looking at more,  but that’s the basic summary of that account. So, we, first off, explored this model  in children in South London. Now,   our first study was of ten to 16-year-olds who  had been involved in assaults or car crashes,   and we recruited 100 of these. We saw them  at two weeks and then again, at six months.   Demographic factors were, basically, unrelated  to whether or not children develop PTSD. So,   the same was true for how badly injured the child  was. That didn’t really predict PTSD at all. So,   some children would walk out of the A&E a couple  of hours after their attendance. Other children   might get admitted. Didn’t really seem to predict  whether or not they got PTSD. What we saw was   the same pattern that Rachel Hiller’s work showed  earlier. A minority of children might get PTSD in   the first couple of weeks, but there’s quite a lot  of natural recovery. When we saw these children   at the six-month point, a lot of children had lost  their PTSD diagnosis and were doing much better. So, what about these cognitive processes? So,  certainly, what we found was that your – the,   sort of, subjective severity for that  individual child or young person was much   more important than the objective severity.  So, thinking that you were going to die,   saying you were really scared during the  trauma, this was strongly associated with PTSD,   much more so than the objective severity. We  also asked these children to give us an idea   of what their memories were like. So, here’s  – this is – so, we developed a questionnaire   for this study called the “Trauma Memory Quality  Questionnaire,” and this is free to use. Here’s   some example items. So, just captures how,  sort of, sensory-based these memories are,   how overwhelming and how vivid the memories are  and often, how difficult it is to put into words. And again, we showed a strong relationship between  – very strong relationship between scores in this   questionnaire, so of having these, sort of,  very different memories and both the early PTSD   symptoms, so at, sort of, about two to four weeks,  and there was a strong relationship with PTSD   at six months, as well. So, this was encouraging,  that the model is important. We also developed a   mod – a questionnaire measure of how children  saw themselves in the world after this trauma. And so, we developed a scale, we worked with  some Australian colleagues to develop this. We   developed the Child Post Traumatic Cognitions  Inventory, which again, is free to use,   and this has got two subscales. So, a, sort of,  sense of fragility and vulnerability, so “Anyone   could hurt me. Bad things could always happen,”  is one subscale. The other important subscales is   permanent and disturbing change. So, this is your  reactions to the trauma – the child’s reactions to   the trauma are a sign that something’s really gone  wrong now and they’re not going to be a normal   person again, their life is over, they’re damaged  in some way. And there’s lots of translations of   this, as well. You can download these from  the Children and War Foundation website. So, what did we find when we looked at  this measure in children? So, very strong   relationship with PTSD at six months. Ver – much  greater endorsement of these sorts of appraisals,   these sorts of beliefs, in children with PTSD  compared to children who didn’t develop PTSD.   And the data that came out from working with  our Australian colleagues showed that these   appraisals really kick in at an early stage.  So, even over the first couple of weeks,   it was – you could easily measure  and detect these sorts of beliefs   that children had around the trauma and it  was very strongly related to worse outcome. Interestingly, we don’t really find a massive  difference in the extent to which children   have these appraisals across time – across age  groups, sorry. Both, sort of, types of beliefs,   these fragile – sort of, sense of being  fragile and the sense of a permanent and   disturbing change were strongly endorsed across  the age groups and were strongly related to   PTSD regardless of age group. Not much in  the way of sex differences, interestingly. Ooh. So, that was a really important series of  studies and it really helped us to think, well,   this is an important way of approaching and  understanding how children respond to trauma.   We successfully received some money from  the Medical Research Council here in the UK   to look really closely, in much more detail, at  what happens in the first couple of months. So,   we think this was a really critical window when  we think a lot of natural recovery happens,   and we really wanted to understand what happens  here. So, we know that PTSD can be chronic. Can   we understand why some children go down that  chronic path? Why do some children maybe get the   initial onset of PTSD, but get better and other  children seem to be – it’s almost like water off   a duck’s back for many children. It – as horrible  as these things might be, they very quickly settle   down and there’s no lasting difficulties. So, can  we explain how children might recover from trauma? So, the ASPECTS study involved working with  Emergency Departments in the East of England. So,   there’s several Emergency Departments in  this region, and we worked with eight to   17-year-olds. We recruited 260. They had  all been involved in some kind of single   incident trauma. We saw them at two weeks –  well, we interviewed them and got them to do   some questionnaires at two weeks and nine weeks,  and they also did a structured interview for PTSD.   But I’m going to focus on the pretty extensive  questionnaire battery that we asked them to do,   and that looked at the CPS – that included  the CPSS, which is a good measure of PTSD   symptoms. The questionnaire battery  also looked at psychosocial factors,   so social support and things like that,  and also, these cognitive processes,   so how children were trying to cope with and make  sense of these trau – these – this experience. So, the mean age was 14, so it was, sort of,  tending towards more adolescent than child.   Quite a mixed group ethnically.  Slightly more boys than girls,   and a range of, sort of, socioeconomic  backgrounds. And here’s the data in terms   of the types of trauma. You can see quite  varied, but all single incident trauma. So,   road traffic collisions, assaults and so on.  But yeah, again, a wide variety of, sort of,   inj – severity of injuries. Most children weren’t  admitted, but about a quarter or so were admitted   to hospital for, like, an overnight stay. That  was – and then, that typically was perhaps the   more – some of the more serious high-impact car  crashes, where they might have a broken leg,   something like that. Some children did end up in  Intensive Care, but it was only a small group. Okay, so what happened to these  200 plus children over time? So,   we’ve been very thorough in looking at the ways  in which one can assess for PTSD and of course,   there’s ICD, there’s DSM and DSM and ICD both  have, sort of, different ways of classifying   PTSD. It doesn’t matter how you measure it. The  rates of PTSD got bett – decreased over time. So,   at two weeks, reasonably high rates of  PTSD, sort of, one in six, one in five,   something like that. If you do nothing, you  have a – maybe have a conversation with my   wonderful colleague, Clare Dixon, who helped us  get this data, and my colleague Anna McKinnon,   who helped gather these data. Maybe having a chat  with them is really important, but – at two weeks,   but what seemed to happen was that the symptoms  settled down and by the nine-week point,   there’s quite a lot of natural recovery,  no formal psychological intervention. And again, as with our previous work, we found  no relationship between most demographic factors,   the severity of their injury. The only thing  that really stood out, perhaps, was you were   at slightly greater risk if you were a bit  older, but wasn’t as important as other factors,   and being assaulted was quite significant.  That was quite a big deal. Interestingly,   being admitted was actually protective against  PTSD and you can come up with your own reasons   why you think that might be. My guess is that  maybe – well, you – maybe you get more attention   from hospital staff or maybe either – it was the  children who got into road traffic collisions who   typically got admitted. Our assaulted children,  who had – really had been through an awf – some   awful trauma, they typically didn’t get admitted.  So, I think it could just be an artefact of it. Right, so what we wanted to do is consider, well,  what happens to these children over time? So,   we considered this – the three groups of children.  So, we could divide these groups – these children   into three groups. The low symptom group, which  is the biggest group, is the blue line here. They   never really got any clinically significant  symptoms on the CPSS. They were doing fine,   and then, the two other key groups. So, they  were the persistent group, who had PTSD when   we first saw ‘em at two weeks and continued to  have PTSD at that nine-week point. And then,   also, the other group, final group, the recovery  group. So, initially doing quite badly, but with   the passage of time, seemed to, sort of, really  spring back. And so, what we wanted to do is see,   well, can we differentiate, you know, what’s go  – are there different things going on for these   children? And we did this by comparing  them on a questionnaire battery that   we got ‘em to do about two weeks – at that  first timepoint, two weeks after the trauma. Okay, so, what I’m going to do is just give you  some – and I – a feel for the data and show you,   as we’re going along, some of the questionnaire  items that they completed at that two-week point.   So, first of all self-blame. Now, in this  instance, self-blame was completely unrelated   to which trajectory you went down. Now, these  events often were, sort of, very much accidents.   Maybe they could’ve done something different, but  it was only – unlikely that many – children came   away with strong – a strong level of blame in  the first place. But you can – as you can see,   the spread of scores tend to be  towards the low end and two is,   like, the lowest score you can get. So,  most children didn’t really have much   self-blame and even if they did, it didn’t  seem to be associated with PTSD anyway. Similarly, with social support, most children  said, “Yeah, I’ve got pretty good social support.”   Most children were saying, “Yeah, I’ve got people  I can turn to and talk to about what’s gone on,”   and there were no differences between these three  groups, the low symptom group, the recovery group,   and the persistent PTSD group. So, these sorts of  factors weren’t really that important. And this   is where we start to get into the elements of the  cognitive model of PTSD. So – and in both of these   mechanisms, these processes, we – what we see  here is that the recovery and persistent groups   score higher than the low symptom group. There’s  no difference between these two groups, so, the   recovery group and the persistent group.  They’re both scoring fairly highly. So,   they both endorsed a fair amount of threat  during the trauma, and they said, “Yeah,   this was a really distressing experience. This  was really scary. I really thought I might die.” They also said that they really struggled to make  sense of what was going on. It was a real blur,   they couldn’t think clearly, it was  very confusing. And this is another   process that’s highlighted in the  Ehlers and Clark cognitive model,   and this is meant to, sort of, put you at  risk of having those much more fragmented,   sensory-based, confused memories of the  experience. So, struggling to make sense of the   trauma as it’s occurring perhaps puts you at risk  of struggling – of laying down these, kind of,   coherent, clear memories of what happened and this  confusion process, sort of, seems to capture this. When we looked at the memory characteristics  of this group, this is where we started to get   differences between all three groups. So,  the PTSD – persistent PTSD group, sorry,   they scored highest on this measure. And they  were significantly higher than the recovery group,   who in turn, were scoring more highly than the  low symptom group. So, there’s something about our   memory characteristics as being really critical  and particularly, kind of, differentiating between   now, the group who get better and the group who  had initial symptoms, but didn’t get better. And this pattern was most acute, though, for  appraisals. When we asked children to think – tell   us, you know, what did they think about this,  the children who went down the PTSD group were   marked – were scoring much more strongly than  the group who recovered. So, thinking – in fact,   this ended up being more important than your  early PTSD symptoms in deciding whether or   not you had later PTSD. So, there was a huge  range of responses to this trauma in terms of   what it all meant, but some children really  saw this in a very negative way. They really   saw themselves as being very damaged.  They really saw the world as being very,   sort of, frightening and unpredictable  and this was really critical for them. Was something we looked at here was a short  questionnaire of trauma-related rumination,   so things like, “I couldn’t – I keep wishing I  could go back in time and, sort of, mentally undo   this. I keep wondering why me?” Now, these are,  sort of, very open-ended questions and I guess   that’s something that we all think these about  – sorts of things about things in life. And when   we get really stuck think – overthinking this  kind of stuff, the suggestion is this, kind of,   keeps the trauma very much active in our brain.  And so, we start to get a bit of a paradox here. Of course, what we associate PTSD with, in one  sense, is avoidance and not wanting to think   about the trauma, but there’s also – sometimes  people – the suggestion is people can get stuck,   kind of, overthinking, “Why me? What did I do to  deserve this?” So, it’s a bit of a – it is a bit   of a paradox, but it shows the, kind of, range  of reactions and the range of things that people,   in particular children, are struggling to do.  They’re trying to perhaps push away the horrible   gory details, but they’re also trying to think,  “Well, why me? What did I – why did this happen to   me?” They’re trying to make sense of it, and yeah,  again, the persistent PTSD group were scoring   higher than the recovery group, who in turn,  scored higher than the low symptom group on this. Now, finally, this was a, sort of, slightly  speculative measure. We wondered, well,   maybe if you, kind of, made a deliberate effort  to talk through what happens and maybe make   sense of it in your mind, get it clear, try  and piece it together and so on, maybe this   would protect you from developing PTSD further  down the track. So, rather than using avoidance,   maybe if you try and confront it, try and make  sense of it, try and get it clear in your mind,   try and talk it through, this would help. So, what  you can see is, on the left – the red there, the   low symptom P – group, PTSD symptom group, there’s  quite a lot of children were using this thing. Now, we – this concept we class as  ‘adaptive processing’, but it’s very   much in, sort of, speech marks, because I’m not  sure how – you’ve got to be very careful with   this. You can see there was a whole bunch of – a  real range of responses in that low symptom group.   Some were definitely, definitely using this, the  bulk were doing it somewhat, some weren’t really   doing this. But what you’ll notice is that the  recovery in persistent groups were actually – were   saying yes to these sorts of things even  more than the average child in the low group. I actually wonder if this is, sort of, suggestive  of, kind of, the potential for rumination.   Actually, you might try and be making sense of  this. You can either overdo it and get, kind of,   stuck overthinking it, or yeah, you struggle  to, kind of, get some sort of coherent account,   or you struggle to really, kind of, bring it  together. So, doing this to some extent seems   probably to be fine. The children in the lowest  symptom group are doing this to some extent,   but if you get stuck over doing it – overthinking  this, this is a – this can be a problem, I’d say. So, just to, sort of, summarise where we’re at.  So, what we’ve shown is that the onset of PTSD   symptoms we can understand, particularly in  terms of, sort of, how threatened you felt   during trauma, how confused you were. Also, I  think being assaulted was involved in having   an onset of PTSD. That seemed to be a marker for  a worse outcome. But whether or not you continue   to have PTSD over time seemed to be quite –  these other cognitive processes kick in. So,   in particular, the nature of your  memories, if they’re, kind of,   much more fragmented sensory-based, if you’re  ruminating more about the trauma, if you’re,   kind of, o – almost, yeah, overthinking it,  working very hard to try and piece this together,   and how – critically, how you see yourself, about  how a child sees themselves after this trauma   is really important. So, children are actively  trying to make sense of this. They’re actively   trying to think it through. They’re thinking  about the consequences for the rest of their   life. Some will be able to make sense of it, but  some really get stuck and they’re not recovering. So, obviously, this is just a couple of studies  where we’ve looked at – or a handful of studies   in the UK and my colleagues in  Australia and New Zealand have   looked at this stuff and was showing  a strong relationship with PTSD. But   is this replicated elsewhere? We’re just  a couple of groups. What about elsewhere? My colleague, Gina Gomez, did a quest – she  did a systematic review. She appraised all the   studies that have looked at PTSD in children and  looked at PTSD and also measures of appraisals,   and she – pardon me, measures of appraisals.  And she found 25 studies, including over 9,000   children, and across all of these studies,  the relationship with PTSD was really strong.   A correlation, if you’re interested in  statistics, a correlation of .59. So,   really very, very strong. It’s consistently  involved, or associated with, PTSD. Now, of course, not all studies may be able to  show what is driving what, but certainly, in – our   experience has been it seems to be the appraisals  pushing later PTSD. And there’s evidence now for   this mechanism, particularly, yeah, these beliefs,  appraisals around the trauma, being important   in PTSD for children all round the world. So,  we’ve got ele – data from Palestine, Sri Lanka,   China and so on. And one really excellent slide  that I just want to briefly highlight, it’s this   one by Ponnamperuma. Apologies for probably  pronouncing her name incorrectly, but in   her data in Sri Linka, a lot of trauma that  these children in Sri Lanka have experienced,   the war, as well as the tsunami from  14 years ago, the relationship between   appraisals and PTSD was very strong. Similar  to what we found in the UK and Australia and   New Zealand. And what she did was she got  these children to do measures of, like,   how many traumas they’ve been involved  in, also social support and so on. And when she put all these measures into a model  of PTSD, a linear regression model of PTSD, we can   see what, kind of – what is the most important  and how – what mechanisms are key. And yeah,   there was relationships between gender, the amount  of trauma you’d been involved in and ongoing   adversity. These were all related to worse PTSD.  But what you can see there in the final column,   this is the, sort of, correlation of .49 is the  – quite clearly the strongest of – correlation   between appraisals and PTSD, even after you  account for all the other effects of social   support, gender, the amount of trauma a child has  experienced. What – how the child was seeing the   trau – seeing themselves in the world after  this trauma was really crucial in whether   or not they had PTSD. So, this aspect of the  cognitive model is critical, really important. What about multiple trauma? So, a lot  of the traumas that I’ve talked about so   far were these single incident traumas.  What about multiple trauma? So, again,   some fantastic work by Rachel Hiller and Sarah  Halligan over in Bath. They were – they recruited   a large sample of a hun – of children, 120, who  were in care and who’d been involved in quite   a lot of abuse and so on. About one in three of  these children were pro – likely to have PTSD, and   she worked with them and followed them up over a  year. And what she found was that PTSD was, yeah,   strongly related to the same sorts of factors. So,  the nature of – the meanings around the trauma,   so those appraisals, so using the same measure,  this – the Children’s Post-Traumatic Cognitions   Inventory. Strong relationship there and strong  relationship, as well, to the nature of their   memories and also, how they were coping. And so,  in particular, both the, you know, the, sort of –   that involves avoidance and ruminations,  or overthinking, “Why me?” and so on. And the appraisals were really critical and they  were predicting PTSD 12 months down the line,   in a way that even the degree of maltreatment  that they – these children had experienced,   that didn’t predict how much PTSD they  continued to experience a year down the   line. So, these cognitive processes  really seem to be pretty crucial,   pretty central to determining whether or  not a child has a good or a bad outcome. Okay, so we just want to think a bit more about  broadly – you know, more broadly about what’s   going on for children. Obviously, what I’ve  focused on a lot here is, sort of, individual   psychological processes, so how the child  records the trauma, what their memories are like,   how they make sense of it and so on. It would be  remiss of me to not think about, well, what goes   on more broadly for these children? What’s going  on in their – let’s say their family structures? So, what we know is that there  is definitely a link between,   say, parent – aspects of the child’s environment  and how the child gets on. So, one of the key   things seems to be the parent mental health.  There’s pretty consistent relationships between   parents’ own depression or parents’ own  PTSD and children’s PTSD. Some studies,   including the work of my colleague Patrick  Smith, down in London, with children in Bosnia,   his work suggested that the relationship is  bidirectional. So, both the parents’ mental   health problems aggravate the child’s distress and  similarly, the child’s distress and mental health   difficulties are aggravating the parents’ mental  health. So, it’s a complicated picture, but that’s   what some of the evidence seems to be suggesting,  but there’s definitely some sort of association. Well, what about, sort of, cognitive processing,  sort of, how people make sense of this – these   experiences? And one of – and one thing  that we’ve shown, and this was, again,   analysis done by Rachel Hiller using some of  the data we collected down in South London,   where parents saw that their – or had the belief  that maybe their child was permanently scarred   psychologically by these experiences, that  seemed to predict their own PTSD. So, their   own reactions, and these were young children,  these were, sort of, two to ten-year-olds, this   particular study, where the parent saw that they  were worried that their child had experienced a,   sort of, permanent psychological harm, that seemed  to then be involved in the persistence of their   own PTSD. So, quite important to understand that  parents themselves are trying to make sense of   this and this is going to have knock – serious  knock-on effects. And, of course, if they’re   struggling with their own mental health, that  may well have knock-on effects to their child. In another study, called the PROTECT study,  again, this was run by Sarah Halligan and   Rachel over in Bath, they got a large sample of  children, a bit younger, six to 13-year-olds,   all involved in a single incident trauma.  And what they looked at was how – and they   looked in more detail about how parents’  coping affected how – and what the parents   unders – how parents understood the trauma,  how much of an impact did that have on their   child’s recovery at the time? And what this  data suggests is that there are various   ways in which parents’ appraisals around  trauma and what the parents do to, sort of,   support their children or protect their  children after trauma, might be important. So, again, this – where a parent really  saw their child as being, sort of,   damaged in a, sort of, very permanent way, and  of course, there are these, sort of, beliefs   in society around trauma that it’s a scar you  cannot recover from, where parents believed this,   this seemed to not only predict child’s acute  traumatic stress reactions, so the first month,   but also a few months down the line there was a  – definitely a significant relationship there,   where – yeah, this was significant. They  saw their child as being more vulnerable.   If they were worried about their child being  harmed again, this was a significant thing,   and if they blamed themselves for the trauma in  some way, that would predict, to some extent,   their parents’ – sorry, their child’s traumatic  stress symptoms six months down the line. And what’s crucial here that – is their children  were completing a self-report measure of PTSD. So,   it was – yeah, so we were asking the  parents to tell us how they were thinking,   how they were responding to this trauma and the  children themselves were telling us how they were   getting on. And yeah, we found this relationship,  even when the – even between the respondents, so   that’s quite important. This isn’t just parents’  questionnaires relating to how they thought their   child was doing. This was actually the children  telling us exactly how they were getting on. Similarly, where the parents were trying  to perhaps avoid any potential threats or   harm in the future, so perhaps being very  careful about their journeys and so on,   there wasn’t a huge relationship. That definitely  was correlated with worse PTSD for the children.   So, there are definitely – there seems to  be something around how parents support   children. Perha – this is perhaps younger  children, but – slightly younger children,   but something about how parents were responding,  that seemed – and their way of thinking about   all this, seemed to be having an impact on how  their children were responding. So, I – yeah,   it is something we need to be aware of. Don’t  want to blame parents, but we need to be aware   that their own interpretation of this and their  own understanding seems to be playing a role here. Okay, what can we learn from treatment? So,  we’ve known for some time that children can   get PTSD. Obviously, we need to intervene and  support those children who aren’t getting better   on their own. Now, multiple guidelines  from the UK, Europe, internationally,   suggest that some form of trauma-focused cognitive  behavioural therapy is efficacious for PTSD. Now,   trauma-focused CBT encompasses a whole bunch  of approaches. There’s the – Judith Cohen’s   manual of Trauma-Focused CBT developed in the US.  There’s various other approaches out there. That’s   probably the most commonly studied one. Here  in the UK, we use Cognitive Therapy for PTSD,   a lot of which is developed by my colleague,  Patrick Smith, based on the Ehlers and Clark   model by Anke Ehlers and David Clark. But  there’s multiple manuals out there that   you can use. And – but as a class of therapies,  they have been shown to be pretty efficacious. So, this is a recent systematic review  and meta-analysis by Thole Hoppen and his   colleagues in Germany and what he showed was  that both for single incident trauma and for   multiple traumas and PT – multiple event trauma,  these sorts of psychological therapies for PTSD,   so things like trauma-focused CBT, were  pretty efficacious, and this is good to   know. Sometimes I think people get worried that  maybe these psychological therapies won’t work   so well with multiple traumas, so things  like abuse. Actually, the evidence is that   they typically will do quite well. So, this  is good news. We’ve got therapies that work. And a bit more work done on this literature  recently by Anke de Haan, again from Germany.   She got a huge team of people to share their data  with her and she was able to do what’s called an   individual participant data meta-analysis.  So, lots of data from lots of trials,   and what she was able to show was that things  like trauma-focused CBT are efficacious,   really helpful for PTSD in children,  regardless of our age, gender and,   sort of, characteristics of the trauma. Whether  or not a carer was involved in the treatment,   but also, critically, the children who had  quite bad PTSD symptoms got the most benefit. So, even though we might be thinking, well, maybe  trauma-focused CBT is fine for perhaps milder   cases. Actually, no, the kids with really severe  PTSD seem to get really, quite a lot of benefit   from these sorts of treatments. So, this was a  paper published in The Lancet Child Health. So,   really strong evidence for this class of  therapy is but how do they work? You know,   what’s the active ingredients and can we –  does this help us understand better how – yeah,   perhaps can we understand how  children recover and get over   trauma? And this could be very useful for  our understanding of PTSD going forwards. So, just one study that has unpacked this.  This is the study that we led in East   Anglia. The – this was using children that  we identified through the ASPECT study. So,   those children who weren’t getting better at  the two-month point, we said, “Would you like   to come into a clinical trial?” And we were  trying to work with them fairly early on,   not in the first few weeks, obviously, but  about two to six months post-trauma. And we   recruited from the Emergency Departments, but  also, we took referrals from CAMHS and GPs, so   Child and Adolescent Mental Health Services, but  also Doc – Hospital or Family Doctors and so on. So, we – it wasn’t a huge study. We recruited  29 children, and they were randomised to either   cognitive therapy for PTSD straightaway, so that’s  a form of trauma-focused CBT, or they were put on   a waiting list for ten weeks. And as you can see,  perhaps not a big surprise, the children who got   the cognitive therapy, their symptoms really came  down quite a lot. The children on the waiting list   group didn’t get so much of a response. We  – they then were offered the same therapy.   Really important to highlight that once they’ve  got better, they stayed well. We saw them at six   months and 12 months for follow-up and they were  staying well, and also, their depression and other   wider functioning improved. So, this is generally  good news. What we wanted to do is unpack well,   why is it that maybe some – yeah, what seems to be  changing? What seems to be underpinning recovery? So, again, we did the same sort of  thing. We got them at both – at baseline,   mid-treatment and post-treatment. We got  ‘em to do a series of questionnaires,   and what you can see is that the – at baseline,  the children in the – who were allocated – there   was about 14/15 children allocated to the waiting  list arm of this – in this trial, they endorsed   some self-blame, but maybe a little bit more.  I don’t think it was statistically significant   than the kids in the cognitive therapy  group. But neither group really changed   over time in terms of their self-blame. So,  that didn’t seem to be involved in recovery. Similarly, both groups have said, “I’ve got  pretty good social support. I’ve got – I can   speak to my friends or family. I’ve got  someone I can talk to,” and that didn’t   really change over time. So, these bars here,  the red bars are for the waiting list group,   the blue bars are for the cognitive therapy  group, and we’ve got before therapy and after   therapy, or before waiting list and after  waiting list. So, not much change here. What about our other cognitive processes that we  looked at over time? So, what you can see here in   terms of both memory quality, the appraisals,  rumination and safety-seeking behaviours,   the wait list group, no real change over time  and some things are even getting slightly   worse. But the cognitive therapy group we saw  a marked shift. So, they had about, I think,   on average, about eight sessions of cognitive  therapy and we were able to, in that time,   really improve the quality of their memories. They  were much more, sort of, sensory based, much more   overload and overwhelming. Their appraisals  really dropped significantly. The rumination   came down quite a lot, as well, and they dropped  this safety-seeking behaviour. So, they were less   likely to be, kind of, checking everyone around  them, less likely to be having their phone to   hand and ready to call someone at a moment’s  notice for support. That dropped quite a lot. And I’ll just say that on these charts here,   the bottom is, basically, the lowest score you  can get. So, you can’t go lower than 11 on the   memory quality questionnaire. You can’t go lower  than 25 on the appraisal measure and so on. So,   the shift here is really quite marked.  They really did come down quite a lot. Another thing we can do with these treatment  trials is say – do something called a mediation   analysis. We know that receiving some form  of trauma-focused CBT seems to be critical in   getting better. That seems to yield much better  improvements, but we can also understand well,   how – well, we can explore how does that have an  effect? And this is called a mediation analysis.   So, what all these trials that are listed  here from all around the world, we’ve given a   little bit of information about each one on this  slide, what you can – all these studies showed   that the effect of receiving trauma-focused  – some form of trauma-focused CBT compared   to being on some kind of controlled condition,  was mediated through change in appraisals. So,   the improvement which you then got in  your PTSD symptoms seemed to come about   through a change in appraisals, and  five clinical trials have shown this. So, both our – the relatively small trials that  we’ve done here in the UK, slightly larger study   by Carmen McLean and Edna Foa over in the US  with sexually abused children, sexually assaulted   children, and then two large studies by the groups  in Germany and Norway, showed that, yeah, this   change of appraisals over – through the course  of treatment really seemed to be critical in your   PTSD symptoms coming down. So, strong evidence  both from – that was strong evidence both from the   prospective longitudinal studies as people develop  PTSD, but also from how children get better,   that it’s – how children see themselves, how  they see others is a really crucial ingredient. Now, I’ve focused today a lot on PTSD and well,  in this talk, I’ve spoken a lot about PTSD.   Of course, it’s not the only outcome, mental  health outcome that is important after trauma.   We know that there’s a whole host of anxiety  conditions and depression that can result. So,   one systematic review led by Viktoria Vibhakar,  published in the Journal of Affective Disorders,   back in 2019, I think, showed that as many as  one in four children will be quite depressed,   will be, kind of, clinically significant levels  of depression after trauma. There’s lots – you’re   twice as likely to have depression if you’ve been  involved in trauma versus if you haven’t. So,   it’s important to consider other outcomes other  than PTSD, and depression is one we’ve looked at. So, in both – just want to, sort of, compare and  contrast the results for PTSD with depression   in the two studies I mentioned earlier,  the ASPECTS study and the PROTECT study,   these two perspective longitudinal studies.  And in both of these studies we had measures   of PTSD and depression and of course, in both we  measured appraisals and memory quality, and we did   this with the same questionnaires. And  what you can see with the data is that   the – and the appraisals and memory quality were  measured at two weeks, or there – near enough,   in the first month of a trauma. What you can  see is that appraisals at that early stage   were strongly related – this is a – these are  strong correlations with later PTSD, but also   later depression. Really, it’s a similarly strong  relationship there, so very important. So, what we   know as well is that these – if we can unders – we  need to take seriously how children see themselves   and others after the trauma. This is important  and not just for PTSD, but also for depression. Now, in memory quality, what we showed  here was that the nature of the trauma   memory was also important in depression,  but perhaps not quite as much as PTSD. So,   there’s some evidence of specificity. So, while  appraisals seemed to be similarly strongly   involved in both PTSD and depression, it looks  like that the nature of your memories is more   important in PTSD than depression. It’s not a huge  difference in the strength of those correlations,   .58 versus .59 – or .49, .39 versus .30, but  there seems to be some sort of discrepancy there. Okay, well, thank you for listening. I’m just  going to, sort of, sum up. Yeah, we know that   recovery after trauma, but particularly single  incident traumas, is pretty normal. Certainly,   in the, sort of, very easy to – relatively easy  to study single event traumas, like car crashes,   assaults, most children will probably be  okay. Even if you do get some early symptoms,   things might settle down. But we know from  studying those children that the children who   don’t settle down seem to have much more  memories that are much more fragmented,   they’re much more negative in their  appraisals around their trauma,   and they’re more likely to use rumination. And  these seem to be quite critical processes and   we’ve seen that in a few different studies,  and we’ve seen this round the world, as well. It’s a bit of a paradox, though. There’s this  interesting paradox that children are both   pushing away memories of the trauma, but they’re  also overthinking. So, there’s a weird, kind of,   relations – a weird series of relationships,  weird series of mechanisms going on here,   that perhaps we think children are,  sort of, avoiding the gory details,   but are still actively trying to make sense  of this experience. They want it to fit. They   want it to make sense, but sometimes,  tragically, they just get really stuck   in trying to resolve this, and this is a  crucial thing, we think, with PTSD now. A lot of these mechanisms, a lot of  these processes I’ve talked about today,   these cognitive processes, seem to be important  for both single and multiple trauma. And what   we’ve been able to establish so far from clinical  trials, that these are definitely worth targeting   in psychological therapies. If we really try and  tackle how children see themselves and others,   if we try and get more coherence  with their memories, that we see   shifts in those processes and that seems to  be involving children recovering from trauma. I guess some – and so there’s, you know, hopefully  lots here for you to think about. I guess,   you know, one thing, and I’ve touched on this  during my talk, there’s a lot – there’s a,   sort of, pervasive sense, sometimes,  of gloom around trauma. We maybe see   society – certain societies, certainly  in the UK, I think there’s a lot of,   kind of, fear around PTSD and trauma and  the, sort of, perception that you can’t   recover and you might be stuck – you might be  permanently, sort of, scarred as a consequence. Well, this seems to be, really importantly,  actually making people more distressed and   maintaining the difficulties and of course, what  I’ve been able to show today, as well, as I – from   some of the excellent clinical trials that are  out there, actually, we know from – the bulk of   that evidence suggests that actually, children  can get over these experiences. So, we need to   be very careful about how we talk about trauma and  not, kind of, conveying those sorts of ideas. As   important as it is to recognise the horrendous  damaging effects of trauma on children and   we need to take this seriously, we need to, sort  of, fight this, sort of, permanent damage view. So, thank you so much for listening. Really  want to acknowledge the wonderful contribution   of my colleagues, who helped us gather all  these data and there’s more besides. I – but   these are some of my key colleagues  I’ve worked with on some of this work,   and I must acknowledge the funding of the UK  Medical Research Council and the UK National   Institute for Health and Social Care Research.  If you’d like to go and download, most of these   measures are actually available on the Children  and War website, I think I’ve given – which I’ve   given there, or you can find my personal  website. Thank you again for listening.