Published: 08 May 2024
Professor Rachel Hiller from ARC West & ARC North Thames, Dr Rosie McGuire and Zoe Trinder-Widdess share findings from the ADaPT project, which investigated barriers to delivering mental health treatments to young people in care.
Post-traumatic stress in young people in care
There are more than 90,000 young people under the care of UK local authorities. Most of these young people have previously experienced maltreatment, alongside many other adversities.
Once in care, instability can continue. Separation from siblings is still common. At least one-third will change placements - and therefore homes and caregivers - each year).
The accumulation of these experiences can have devastating consequences for mental health. Decades of research on the mental health needs of young people in care has shown that around half have a diagnosable mental health condition. In fact, their rates are five times higher than in the general population.
We also know young people in care are 12 times more likely to have post-traumatic stress disorder (PTSD) than their peers. PTSD symptoms can be very difficult to live with and make the world feel very unsafe.
We have good quality screening tools and treatments to identify and address PTSD. Young people in care don’t have to live with the mental health consequences of their experiences.
Despite this, we know that in practice PTSD remains poorly detected in young people in care (Grasso et al., 2009; Hiller et al., 2022; McGuire et al., 2022). This can mean that they aren’t offered the support they need.
What is the best-evidenced treatment for PTSD?
Trauma-focused cognitive behaviour therapies (tf-CBTs) have long been the best-evidenced approach to addressing PTSD. Tf-CBTs include cognitive therapy, trauma-focused CBT or narrative exposure therapy.
These treatments help young people make sense of their experiences, process their emotions and thoughts, and develop ways of coping.
In the UK, the National Institute for Health and Care Excellence (NICE) guidelines have long stated that tf-CBTs should be offered to young people with PTSD, including when caused by very complex traumas.
There is good evidence of the effectiveness of tf-CBTs with children and young people. This includes meta-analytic reviews which bring together all the relevant research. These have shown tf-CBTs are as effective for children who have experienced multiple complex traumas as they are for those who have experienced one-off traumas. These treatments can lead to a large reduction in symptoms.
Findings from the ADaPT project
Our recent ADaPT (Assessment and Delivery of PTSD Treatments) project worked with mental health services who support care-experienced young people. It was funded by four NIHR Applied Research Collaborations (NIHR ARCs).
We wanted to understand the challenges services might face, and the barriers and opportunities to delivering treatments like tf-CBTs to young people in care.
We worked alongside 28 mental health teams across 14 regions in England. The teams included general Child and Adolescent Mental Health Services (CAMHS), specialist CAMHS for children in care, and social care mental health teams.
We trained the teams in cognitive therapy for PTSD and followed their progress for 12-18 months, via regular focus groups and interviews. In total we ran 58 focus groups and 62 individual interviews. This helped us identify key differences between teams who were able to use the intervention versus those who weren’t. These were:
- Commissioning and service set-up
Unfortunately, we found that young people in care in many regions in England would struggle to access NICE-recommended psychotherapy of any kind. This was often because of resourcing and commissioning issues.
To sign-up for our project, services had to identify as offering direct mental health support to young people in care. In reality, many specialist mental health services for young people in care were only commissioned to work with the young person’s network, such as the carer and social worker. They simply didn’t have capacity to work directly with the child, so this support was often unavailable or not considered.
Pathways between specialist teams and general CAMHS were often confusing and restrictive. This prevented young people from moving to a service that could offer direct interventions.
Many of the general CAMHS teams we worked with were able to use the intervention, but not with young people in care, simply because they didn’t see this group.
- Team buy-in and supervision structures
All teams who used the intervention were convinced of the effectiveness of evidence-based practice and screening for PTSD. This came from both leadership and the wider team, rather than just one or the other.
These teams all had in-house supervision structures specifically around tf-CBT and team members who were CBT advocates. It’s normal for professionals to feel anxious about delivering these therapies. A supportive team environment and strong supervision structures are crucial.
- Complexity of young people
All services said there were challenges to delivering direct psychotherapy to young people in care.
Often young people presented with a range of complex needs. These included placement instability, school disengagement, and risk or safeguarding concerns. Disengaging from treatment was also common. Coupled with poor commissioning and resourcing, this made delivering tf-CBT very difficult for many services.
The complexity of young people’s needs was a universal concern. It didn’t influence whether teams were able to use the treatment. Services using the treatment were still navigating these complexities. Ultimately, those who delivered the treatment all had an ethos of looking for reasons to provide the treatment, rather than reasons not to.
Summary
Young people in care have a right to access to best-evidenced mental health care. This project has shown the substantial challenges they are likely to face in accessing this support. It also highlighted the significant challenges experienced by services.
Despite these challenges, there are examples of innovative practice across the country. There’s potential for change even within very stretched services.
- Visit the UK Trauma Council website to see resources from this project, including animations and clinical skills videos.
- Read more about the ADaPT project.
- Find out more about the NIHR ARCs.
- Professor Hiller is presenting at this year’s #ARCseminar series. Sign up here.
- Join the NIHR ARCs national newsletter for monthly updates from across the country.
Professor Hiller is Professor of Child & Adolescent Mental Health at University College London and leads the Child Trauma and Recovery research group. Dr Rosie McGuire is a Post-Doctoral Research Fellow on the ADaPT trial. Zoe Trinder-Widdess is Head of Communications at ARC West.