We are The Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids. I'm Dr. Jane Gilmour, honorary consultant, clinical psychologist and child development programme director at UCL. And I'm Umar Toseeb, professor of psychology at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature and in conversation with invited authors, sift through the data, dilemmas, and debates. We leave you with our takeaways for academics and practitioners. Today we'll be discussing the psychiatric profiles of children in the care system. This episode is called Mental Health Needs in Care But Missed Out. I do want to ask once we get our guest on is, is it looked after children or children in care? And are those the same group of people, or is it different, or is it subgroups of a larger group? And it was interesting, because I know the NSPCC used both phrases. But I read, partly because you had raised this in a pre-conversation before, that the NSPCC suggests that young people themselves prefer the phrase "in care" because the other phrases are more systematised. I don't know if that's a [? detailed ?] piece of advice or if that's something that they have come to understand on the basis of their work with young people. But the idea of young people in care, whatever phraseology we use, comes from the seminal piece of legislation as the 1989 Children's Act. And it shows that if there's evidence of harm or suggestions that harm will occur, then those children will be taken into care. That's the phrase that are used. And those are in the sole or the joint care of a local authority. So those are the legal definitions. But I think you raise a really important point about saying, what phrase is preferred, whether that's from the literature or for the young people themselves. I was thinking about like, what do I know about children in care? And it was growing up with Tracy Beaker. Does anyone remember that TV show in the early '90s? Absolutely. The Dumping Ground. Yeah, The Dumping Ground. I feel like people say to me, oh, did you watch Dragon Ball Z or Pokémon? I'm like, no, I genuinely had no idea. But it seems like everyone I speak to didn't watch Tracy Beaker, and it was one of the best shows on TV. But it was a really nice TV show to watch, and I think maybe we'll find out in today's conversation. I think it glamorised what it's like to be in care, even though it wasn't particularly glamorous. My understanding is it wasn't particularly representative of what it's like to be in care. I mean, I guess, because it was a child's programme, it probably would necessarily have to gloss over some of the realities of it. But what I did think was really useful is that they were able to describe some scenarios that probably young people in care or young people in difficult circumstances would recognise in themselves. I think the ideas of care are interesting. I read a very interesting review by Lisa Bunting, who I think is at Queen's in Belfast, looking at the different rates across the UK in terms of regional rates and processes, which is very relevant for our paper discussion today for this group of young people. And what was interesting is that there is quite a wide range of regional variation across the UK, which is astonishing really given that we are one nation. But it implies that the nuance of a process probably has a significant impact on who's identified and how those young people are managed and cared for. So, for example, Scotland has a different definition of neglect as compared to the rest of the UK. And there are different rates. So I think the idea of definition is really interesting raised as a concept. I think the other thing that the Bunting review looked at was the categories of abuse. And I think that was something that you were interested in too, wasn't it, Umar? Yeah, I was really thinking about how we could try and unpack with our guest and who are the children in care and what are some of the reasons that children go into care. And I think, based on my reading of the paper and some of the reading, it seems to me that abuse, neglect, witnessing domestic violence, parental mental illness, maybe substance abuse by the parent does seem to be the key reasons why children go into care. But there may be other reasons and those categories probably don't capture everything, but they seem to be the main ones. My reading the literature-- and I wouldn't say that I know this literature well. And certainly Eva, our guest, will be much better placed to make some commentary on this. But my understanding of the literature is that rates of emotional abuse, in particular, have increased particularly since the early 2000s. Now, whether that's because of a change in definition, whether that's because of a systemic understanding-- often, in care situations, a case will change policy. And perhaps there's a lower rate of concern in the social care system-- or whether that's an increased awareness of what emotional abuse is and the concern and effect that that might have on young people. And we talked a little bit in a previous episode about the impact of so-called witnessing minor acts of violence in a family context. Now, that is an experience that would be described in the context of emotional abuse. So I wonder if that's in there, but maybe we can ask Eva about that in more detail because I think she will know this literature in some detail. Yeah. And I think if we're thinking about children and young people's mental health and development, we've talked about some of the reasons why someone might go into care. And those themselves, those reasons might be associated with poorer outcomes in children. But then also what is it about care or being in care that then might be associated with poorer outcomes. So instability so moving around different care homes or care providers, being separated from your parents or your siblings, brothers and sisters, that might also be associated with poorer outcomes. And then depending on where you move-- and I don't know enough about the care system, but you might have to change schools. And then that might mean that you have a separation from friends and having to make new friends. So if we think about this as the reasons why you're go into care might be associated with poorer mental health. But also, things about being in care might also be associated with poorer mental health. Yeah, there's additional challenges in an already vulnerable young person having to adjust to a new family environment. If that young person's lucky or a new system, if that young person is in a system of care rather than a foster family and so on, understanding and recognising who they are in the context of that, as you say, shifting to a new school and a whole new social environment, which we know, particularly for teenagers, will be an enormous draw on their capacity to cope. Being integrated into one's peer group is one of the key developmental tasks of a young person and so disrupting everything that they know. And it may be close by, but it certainly will be a different setting. So I think that's a really good point. Already vulnerable young people are having to deal with new demands and so there's an additional task there. I really want to talk about attachments and attachment theory. But actually, let's just introduce the guest and then hopefully we can unpack some of that with the guests. Today, we're joined by Dr. Eva Sprecher from University College London. Eva is the lead author of the paper, "Sufficiency of current practise-- How well does the Strengths and Difficulties Questionnaire detect clinically elevated PTSD, anxiety, and depression symptoms in children in care?" which was published in JCPP Advances. Welcome, Eva. Thank you for having me. No, thank you. So let's start with some just big picture questions. When we're thinking about children in care, what are the proportions of children who are in care? Is it a large amount of children who go into care? Is it a small amount and have those numbers changed in recent years, or is it quite static? Just give us some sense of what numbers are we talking about. So in the UK, there are about 100,000 children living in care. And globally, that's more like two million. So that number actually sounds quite small. And the reason for that is because lots of countries don't have formal state care systems in the same way that the UK does, particularly in parts of the developing world. When we're talking about rates of young people living in care, it's something like 1% of young people are living in care at any time. Or 1 in 30 will have experience with the care system at any point in their childhoods. So that's what we're talking about. I know this has been touched on, but those rates are different across different areas of the UK and across the four nations of the UK. And that was driven partly by the fact that the care system is a devolved issue. So what that means is every government in the UK has its own systems and rules around the children's social care system. But also we know from a wide range of research that entry into care is driven by rates of poverty. And we know that poverty rates are very different across the four nations of the UK. So some of the highest rates of children coming into care are in Northern Ireland, which makes sense because some of the highest areas of poverty in the UK are in Northern Ireland. So in some ways, that sort of fits the-- I'm really interested in that idea of poverty. And we've had a few episodes in our podcast series looking at the effects of poverty and associations with poverty. And it's a very powerful explainer. Could you go into a little bit more detail about describing what the mechanisms might be and what the associated factors might be and why poverty has such a close association with the care system? Yeah. So I think it's a really complicated created relationship, so there's probably no straightforward way of unpicking the chicken and egg between poverty and entry into the care system. So of course, if you have two parents and those parents really are struggling with substance use, difficulties, or poor mental health, they're more likely to not be able to be working in full-time employment and therefore living in poverty. So those experiences might be driving experiences of poverty and driving experiences of young people coming into care. But you can also think about this the other way around that for families who maybe, over many generations, have been living below the poverty line, impacts of poverty is really toxic. And not being able to have sufficient food or good housing or live in a safe area, all of which are associated with poverty, those also drive the rates of substance misuse and poor mental health and domestic violence. So those things all cluster together. I mean, it does feel that a really big thing that we could do to address the rights of young people experiencing abuse, neglect, or these other really difficult early experiences would be to address poverty more widely. So yeah, it's a complicated relationship. And am I right in thinking-- and, Eva, you will know this literature better than I. But there is a particularly tight association between neglect and poverty and that neglect has a variety of very pernicious effects almost in addition to the other challenges described in abuse. Would you think that's a fair summary of the literature? Maybe you want to unpack that a bit. No, I'd say that that's fair, that if a parent is really trying to juggle all the things which they might need to do to make ends meet, it's much more likely that neglect will take place, especially if there are those other factors in play that we've already mentioned, for example, parents struggling with really severe mental health challenges which might be linked to those things. So that definitely is the case. I think sometimes we're quite resistant to think about all different types of adversity as sitting neatly in different buckets. So the idea that here's a child who's only experienced neglect but nothing else, or here's a child who's been exposed to parental domestic violence but nothing else, or here's a child who's been exposed to emotional abuse but nothing else. It's really rare that that's the case. That's normally not what we see amongst young people in care. They've normally experienced quite a few different types of adversity. And the threshold for coming into care is normally pretty high. So normally, there's been a layering of lots of different experiences, which makes it really hard to look at things individually. But there has been some good research, which has pulled apart the effects of threat-based, early, difficult experiences and deprivation or neglect-based early experiences. And we do see somewhat different outcomes, but neglect is actually, as you said, no less toxic that the long-term effects of abuse. So we tend not to get into a bit of an olympics of what's the worst adversity. Once a child comes into care, we believe that actually a threshold has been passed that they've had a really difficult start and we need to think about how we support their mental health from that point onwards. And so these children who go into care, I think it would be really helpful to think about what it means to be in care. What are we talking about? Are we talking about foster homes? Are we talking about adoption? Are we talking about kids who are maybe no longer with their immediate family but with their extended family. And then there's, I think, the dominant view where a kid gets taken away from their family and is put-- maybe it's with a stranger. Are those all of the likely options and likely things that you're referring to when we talk about children in care? Yeah. So there are really specific legal definitions of what it means to be a child currently in care. And then there's this wider definition of what it means to be care experienced, which encompasses quite a big umbrella of different things. So for a child to be in care, the local authority or the government or the state needs to at least have some parental responsibility for that child. Actually, some children can typically be in care where the local authority is somewhat their legal parent or sharing that, but they can still be living with their birth parents at home. So for the majority of young people who are currently living in care, they will be living in foster or kinship care. So around 70-ish percent of young people in the care system live with foster carers who are people who are normally strangers to them upon entering care. And then there's actually a subgroup within that foster care group who live with kinship or connected carers, who are people they would have known before they came into care, like grandparents, uncles, or family friends. And they take on a role in formally caring for that child, even though the local authority is still kind of the legal parent there. So that child is still in care. But then there's a really large group, the remaining 30 or so percent who are living in lots of different other settings, which might be group children's homes. We're not talking about big Oliver Twist style children's homes. We're talking normally about homes for between two and six children. There's also some supported lodgings which used to be called semi-independent living so when young people might be 16 plus living in group flats where there might be a member of staff at the front desk certain hours of the day. Some young people live in youth hostels. Some young people are living in secure children's homes where there are some concerns about their safety or the safety of others. Unfortunately, quite a large number are in inpatient units, in hospitals or incarcerated in young offender institutions. And so they're actually a really wide range of settings when we're talking about what it means to be living in care. But the vast majority will be living with foster carers, kinship carers, or in children's homes. And just to quickly touch on adopted young people. We' normally not talk about adopted young people as living in care, because they're living with their adoptive parents and the adoptive parents are the legal guardian. So that child is no longer under the care of the local authority, although around 5% do come back into care later. Children who are adopted, normally are adopted very young out of the care system in the first year or two of life. And it's quite unusual to be adopted later than that. And it's actively discouraged, for example, foster carers to adopt children out of the care system, which is very different in the States. And there's now something called a special guardianship order, where kinship carers-- if a grandparent is caring for a child with the local authority, they can actually step into that parenting role and take on some of that legal responsibility. And finally, just to say, lots of young people have something a little bit like care experience but might live in the wider community. So young people may be living with a grandparent, because their birth parents are not able to keep them safe or look after them. But maybe the local authority was never involved. So that's very much like living in care. But those children don't have the care of the local authorities, so they're not a child in care or what's sometimes called, but not the preferred term, a looked-after child. So you've brilliantly described a variety of scenarios that, as Umar said, that may have different challenges within them. Are there data suggesting that there is a preferred outcome? Now, of course, taking a child out of their family of origin is quite a dramatic intervention and it's usually made-- as you say, the threshold is pretty high. And we know that our preference is to maintain the child in their system if they're in their existing family, if that is safe for them. But you've described lots of scenarios. Is there one that is associated with a better outcome? Now, I could make some guesses given some of the things that you've described, but do we have data suggesting that one setting is better than another in terms of outcome? Or is there a best fit for a young person, depending on their needs? Yeah. I think it's, again, a really complicated issue that's going to be why-- I'm asking all these complicated questions. I'm sorry. No, no, we tend to-- the accepted wisdom for a long time was that adoption was the best outcome, because it offered that real legal security for young people who had entered the care system. And then there is also some evidence which has come out around securing early stability where a child, quite early, lives with a member of their extended family or family friends so a kinship or connected carer. Having that stability with a kinship carer early can be really beneficial. However, again, it's a little bit chicken and egg. Because when young people are able to live with an extended family member, maybe that means that some elements of the family system are intact which could be a protective factor. Or maybe it means that that young person was able to come into care at a point where their emotional and behavioural needs were such that they were able to safely live in that kind of setting. So again, we do tend to see somewhat better mental health of young people living in foster care, but maybe that's because foster carers feel better equipped to care for young people with slightly lower emotional and behavioural needs than children who are living in those group residential homes where there's higher staffing and staff, might feel more equipped and supported to look after young people with higher needs. So it's a bit hard to say, are those the young people who maybe had less difficulties at the point where they came to live with whoever they were living with, or is there something about living in foster care specifically, which is beneficial or being adopted specifically which is beneficial, or is it more, if you come into care really early, that allows us to intervene at an earlier point? So it is quite complicated. And it's my belief and also not really so much just my belief but on the basis of speaking to lots of people who've grown up in the care system, that there is no one right fit. It's about thinking about what an individual, young person needs. So even though we might see, oh, the outcomes look really good for foster care, that's what we should push for. If we've got a teenager who's about 15 when they come into the care system, often people will say, it's really weird for me to join someone else's house, someone else's family. It didn't feel right. I didn't know how to get used to their way of doing things, whereas I felt a much greater sense of comfort living in a children's home where I was able to develop my own routine and, us together, we're able to define what that household and what that family looks like. So I think sometimes there's a push towards, oh, let's close all the children's homes and let's just go for a foster care approach. But actually, if you speak to lots of young people that they wouldn't support that, because residential care can be what some young people really need and what works best for them. One of the things that I wanted to ask you and I'm not sure it's relevant, but I think it links to my next question. So the first part of the question was, what are some of the challenges that children in care experience that children who aren't in care would experience? But I think, based on what you've said so far, it's not a homogeneous group so they're not necessarily going to experience the same challenges so maybe I will phrase that differently. And so your paper is about whether the Strengths and Difficulties Questionnaire, which is a common screening tool for risk of mental health difficulties, can be used to screen for mental health difficulties for children who are in care. So I suppose, why would you expect there to be a difference? So I think that there are two parts to that question. So I'm going to answer your first question about the additional pressures on young people living in care, because there are certainly some which are unique to this context. And then I'm going to come to your second question. So young people living in care, they do have a higher rate of experiencing adverse experiences to the wider population. Like I said, the threshold for coming into care is pretty high. So normally, by the time a young person's come into care, they've either experienced some exposures while in the womb, maybe to alcohol or substances which can really have an effect even before young people are born. And then all the experiences we've talked about in terms of abuse, neglect, exposure to domestic violence, substance use, and parental poor mental health. So there's a lot which happens when young people come into care or before young people come into care. But after young people enter care, it really doesn't end. Some young people report that coming into care itself was their most traumatic experience. And if they're having symptoms of PTSD, often the thing which is reoccurring to them is that experience of coming into care. It can be so scary to be taken away from everything you know, often in the middle of the night, possibly in a police car often with people really upset. Potentially, there's been some crisis. And that in itself is often experienced as traumatic. And once young people come into care, there are experiences of instability, which can really further compound this disruption in children's early lives. We know that around half of young people live what we call "out-of-county," meaning that they no longer live in the area where they grew up or where they came into care. And the charity, Become, which works with care leavers or young people with experience of care, highlights that many young people are moved hundreds of kilometres away from their homes, away from communities, possibly away from really anyone they know and that obviously takes a massive toll. And also, it's not uncommon for young people to move around multiple times in a year. There's a small but definite group of young people who are moving more than three times a year while in the care system, which is incredibly disruptive. There are also additional systemic pressures that young people in care face. They do have a really difficult time in terms of securing housing, employment, and having that security in their education, which is really not surprising if you've moved around so many times in your life. And just to give you one example of a young person we interviewed as part of a really big study of young people in care in the UK called Rethink. This young person, she'd lived actually in a really stable placement with her foster carer for many years since she was really little. But then on her 18th birthday, she had to go and apply for benefits and become a tenant in that household in order to stay put. She'd been there since she was a little child. But on her 18th birthday, illegally, she had to become a tenant and she had to apply for housing benefit and pay it to her foster carer. And it wasn't a question of the money, but that stigmatisation often forces lots of young people to move out of where they're living prematurely and to not have that safety net, because often young people can't move back to live with their foster carers, because now that room is reserved for another young person and there's all sorts of DBS checks and criminal records checks that they would have to do to come back and stay overnight. So that safety net is really not there. And that's so challenging. So the rigidity of the systems can really compound what already has been a really difficult start. So that was a long answer. But my answer to the second part of your question is really short which is what we expected to see when Strength and Difficulties Questionnaire was the same as what we'd expect to see with the general population. The Strengths and Difficulties Questionnaire is not designed to detect all mental health difficulties. And it's certainly not designed to detect PTSD, which is one of the most common mental health conditions we see amongst young people in care, unsurprisingly. And so all that we were doing is testing what to most psychologists will be quite obvious, that this questionnaire, which is not designed to detect specific things, is going to miss those specific things in this likely trauma-exposed group. But the beauty of your question, may I say, is a very well-written paper, Eva. And I really enjoyed reading it, because you're saying, well, look, this is an obvious question, but it's such an important one. And we can only say that these processes are inadequate with the data that you've delivered. And so it's such a valuable and simple question. And as you say, this is not about the invalidity of the SDQ. It's about the system and the processes that are required to describe and delineate a very vulnerable group, many of whom we know will have PTSD. So I think it must have been very satisfying to look at the data. I can only imagine, because asking that very clear question and having such a clear outcome allows you to message with absolute clarity and I think it will have an impact one hopes because the data is so clear. Yeah. I think if we-- just conscious of the time just think about wrapping up here. But one of the things that I want to ask you is, so what does that mean now for people and providers and people who use the Strengths and Difficulties Questionnaire to screen for common mental health difficulties? And what you're saying is and I think what your paper finds is that it's not great at picking up PTSD, which it wasn't intended to do, now what? So what do we do? Yeah. So while it was, in some ways, satisfying to look at that data, it was actually really heartbreaking because we were so upset, really, to see how many young people are being missed by this screening tool. And actually, England is doing really well in that they have a screening tool. In the other countries of the UK, there is no statutory screening tool. So in a way, we love the Strengths and Difficulties Questionnaire and we wish everyone was using it. But as we said, it's not enough. So this is a nice time for me to plug a new randomised control trial, which we're doing called the MyVoice project, which is trialling introducing comprehensive mental health assessments for young people living in the care system where there are concerns about their mental health, to try and do a quite detailed look to understand what exactly are young people facing, to try and get them the right support and get everyone on the same page. We're talking GPs, social workers, carers, and young people themselves to be able to put words to what's going on for them. So many young people we speak to in our research, we will always let them know, you know, you have scored highly on this questionnaire. Maybe you're being affected by memories from the past of what's happened, which are really getting in the way of you living your life day to day with flashbacks and nightmares. And they'll say, I thought I had to live with that forever. I didn't think that that was to do with mental health. I thought that was just going to be my life. And to be able to say to young people, actually, there are things we might be able to do about that, and there are some treatments which might help to address those difficulties, was actually a revelation to so many young people who never had that conversation with a professional before. It's also worth saying we're really happy to see that there's been a good appetite amongst policymakers for looking into this area in more detail and thinking about statutory practise. And we've been having conversations with the Department for Education, who are responsible for mental health of young people living in care, to think about what statutory practise could look like in terms of screening to try and identify where young people might be struggling and get them into services. We know children in care are less likely to be accepted into mental health services, unfortunately, and less likely to get access to evidence-based treatments, which is yet another layer of disadvantage that they're facing. So yeah, we're in those conversations. And it's been really great to see quite a lot of uptake of that. And the UK Trauma Council recently published a recommendations report around improving access to mental health services for young people living in care. And there has been quite a lot of uptake of that into the Education Select Committee for supporting children in care. So we hope to see a lot of movement in this space. And we're really excited about it. But this study did feel like a bit of a puzzle to say what we probably all could have guessed. But, as Jane said, that those are hard numbers. I just want to wrap up and finish there. But I want to do that by saying, what's been really nice about this conversation with you, Eva, has been that I think you've demonstrated as an individual what an all-round good researcher and academic does. You've answered a research question which is of scientific importance, and there's a need for it, talked about your experiences of speaking to children and young people who are in care, so you've got that PPIE. You've talked about engagement with policymakers. And then you've also tried to think about and explain and you have done about the practical implications and limitations of your work. So I think, in a single session, you've really encapsulated what it means to be a researcher and academic in the UK in the times we live in. So I think that's a really, really good thing other than as well as the topic of the conversation, which was also fascinating. So thank you. Thanks very much. I'm really lucky to be part of a really excellent research group and also to be working on a topic which I care so strongly about. And we always think, well, we're about 100 years too late on this topic already, so we're working really hard alongside lots of care experienced people to try and make a much belated change. And it's slow progress, but we try our best. So, Eva, I think you're a rising star. And I think your passion for the project really comes through, as Umar said, so I think it's been a real pleasure to have your thoughts on this. And I look forward to seeing you change the policy using your data. It's fantastic. Thank you so much. Thank you. Wish us luck. I was thinking when we were talking to Eva was there are two more potential episodes from this that I was like, OK, we need to talk about this, but we don't have time today. The first one is people and individuals who've been in care and then their interactions with the criminal justice system and offending, because I think there is some correlational evidence that if you've been in care, you're more at risk of then being in prison and so it'd be nice to speak to somebody who has that knowledge of that pipeline or that trajectory or that pathway between those two. And the other one is PTSD. So we touched upon PTSD a bit, but I think that maybe there's a need and maybe our listeners can say, yes, we do need to know more about this. What is PTSD? What actually is PTSD? Because I think that term in life, in society is used a bit flippantly sometimes. But what does PTSD actually look like in a child or a young [AUDIO OUT], and how might that be different to when we just flippantly talk about PTSD, having PTSD, or having a specific experience which leads to PTSD? I think that's a really good point. And in fact, the co-occurrence between PTSD and conduct disorder-- and obviously conduct disorder, it is most extreme-- will mean there's an inevitable engagement with the criminal justice system. So there's a great review by Bernhard and colleagues showing that the rate of co-occurrence between conduct disorder and PTSD can be up to 40% And there is a meta-analysis, and it's looking at some of the shared risk factors so exposure to a violent event, for example, as well as risk taking in the population that have both of these conditions. So I think there's a lot of interesting overlap between those two conditions and also a lot of interesting disconnect, if you like, between the response to that. So if you are considered as somebody that has conduct disorder, post 18, you're in the criminal justice system almost inevitably. Whereas if you were considered somebody who was, let's say in inverted commas, "acting out" and had PTSD, you would be invited into the mental health system and be treated in a different way. So you would be offered, for example, trauma-focused cognitive behavioural therapy or in some cases, EMDR, Eye Movement Desensitisation and Reprocessing. So there's an evidence base for both. And I think the way that you are understood by those around you will have a huge impact on your trajectory. Are you cared for by mental health treatment package, or are you considered somebody that needs to be punished for your actions? So I think that's a great point to raise, and I think a really important one. Yeah. And I think this brings me, if we're there, to my academic takeaway. And I stopped myself from saying this during the recording earlier when we had the guest, which was Eva was saying that we can't just say these are the kids in care, and then these are the outcomes, or something like that. And what I wanted to say at that point was, oh, yeah, you should listen to our other episode about labels and diagnostic labels where I'm like, we can't put people into boxes. And I think it is that when children-- yeah, I think it was the point where children are in care, but actually they have lots of other stuff going on as well. It's not just that these children are in care. And I think, for me, that is the takeaway, again, from us with some of the episodes, which is we can't just look at the one thing that we're interested in. So when we're thinking about children in care, we're not just thinking about, oh, well, these children are in care and it is the care or being in care that's leading to these adverse outcomes. Actually, those children have lots of other stuff going on as well, things that have happened before they got into care, things that are happening whilst they're in care. And it might not be the care that's leading to certain outcomes. So there, it's that point of, let's look at the whole child. Let's look at all of those strengths and challenges that child is experiencing, and then do something with that rather than just looking at the variable of the child in care. And actually with lots of population-based, longitudinal study data, it's easier, to some extent, to do that because you have information about the rest of those children's lives. You don't just know that they are in care. You also know when they were born, how many siblings they had, what age they left their family home, what their mental health was of their parents financial situation, all of those things and neighbourhood deprivation you have that, and then you build a picture about the child rather than just looking at that one thing. I think that's a good point well made. I think from a clinical point of view, I think the takeaway is, somewhat-- I don't know if this is an obvious point, but it really struck me when Eva said that we know from her data and her team's data that over half the young people who had a mental health condition within their group were missed. And these are treatable conditions. And those young people were-- it was a revelation to those young people saying, well, perhaps those PTSD features could be treatable and they might be resolved. And that's the really important thing. | think the other obvious thing to say is that-- and I think Eva did make this point-- that the SDQ is an excellent measure, but it was designed to screen and paint a picture with a broad brush. And so there's nothing wrong with this tool. It's that that these data highlight that we've got to ask the specific questions to get an accurate picture of these high-risk populations. We've got to use the right tool to get the job done. And next week we'll be speaking to Dr. Nina Higson-Sweeney about fatigue and depression. And part of that discussion will be around the IMPACT study, which we previously discussed with Ian Goodyer on an episode earlier in this series. [MUSIC PLAYING]