At 25, James* had been through multiple suicide attempts, psychiatric admissions and care placement breakdowns, he had been in trouble with the police, among other difficulties.
He was struggling, and so were the health and care professionals working with him. Was it depression, anxiety, borderline personality disorder? What was really going on for him? One thing seemed to be certain to everyone working with him; his ‘problem behaviour’, in all the forms it took, was all down to the he had experienced as a child.
There has been increasing discussion in recent years of trauma-informed care – and indeed of trauma itself, and the related concepts of adverse childhood experiences, also known as ACEs. We were pleased to be part of a recent day-long conference organised by the Association for Child and Adolescent Mental Health (ACAMH) on this matter, where we discussed James’ case, its implications, and other research in this area.
Of course, a psychologist may try to understand the trauma and ACEs with the individual who has adverse life experiences. But it’s important that the conversation around those ACEs does not override other considerations.
Here’s something that might surprise you – a 2018 paper suggested that 66% of people who go through trauma experience had outcomes for their mental or physical health. In fact, we also know that adversity can build resilience.
Back to James: when we did a development history, we found that he talked about being assessed at age five for ADHD by an educational psychologist. Unfortunately, being known to social services seemed to contribute to this being left untreated and instead, all his difficulties were put down to exposure to trauma and behaviour difficulties.
James’ untreated ADHD represents a number of significant missed opportunities to provide him and his foster family far better support. In turn, his case and that of many others demonstrates a lack of properly trauma-informed care in services today, despite some positive advances.
Our view is that trauma-informed care needs to be neurodivergence-informed care. Trauma, neurodivergence and mental health in children are often deeply entwined, in ways that current services often fail to recognise. This may be due to siloed working.
The ACEs revolution – and its limitations
The work of Felitti and colleagues on adverse childhood experiences (ACEs) was genuinely groundbreaking when it emerged over 25 years ago.
They documented severe adversities – abuse, neglect, household dysfunction – and demonstrated clear dose-response relationships at a population level. The more ACEs you experience, the higher your risk of poor outcomes in adulthood, from heart disease to depression.
This was transformative research. But here’s what it didn’t fully capture: not all children with high ACEs loads develop problems. Of course we must all tackle child abuse and neglect, but we have both met children who’ve experienced extreme abuse and neglect who also go on to live well. Resilience is far more common than we once believed. So what else is happening?
Embracing complexity
As clinicians, we often find ourselves overwhelmed by complexity. It’s human nature to deal with the first problem we see and then stop, and in some ways it seems increasingly so given the current growth in mental health diagnoses. But in child and adolescent mental health, complexity is the norm.
Take neurodivergence. Our colleague Professor Chris Gillberg proposed, back in 2010, that different forms of neurodivergence usually overlap. When another colleague, Jason Lang, studied children on an autism waiting list, looking at their full neurodevelopmental profiles – traits of autism, ADHD, Developmental Coordination Disorder, learning disabilities – he found that very few had autism alone. Most had traits of multiple neurotypes (the characteristic ways the brain processes information). Chris’ work led us to ask: could there be a relationship between childhood trauma and this neurodevelopmental complexity?
We sought to answer this question in 2017, working with behavioural genetics colleagues Lisa Dinkler and Sebastian Lundström, analysing a large Swedish twin . We looked at twins assessed for symptoms of ADHD, autism, tic disorders, and learning disabilities at age nine, asking: does abuse and neglect cause increased neurodevelopmental complexity?
The results – which genuinely astonished us – are available for Open Access in one of ACAMH’s journals. We saw that while children who’d experienced maltreatment were nearly ten times more likely to have three or more of those neurotypes, it was not the abuse and neglect that caused the complexity – rather, additional genetic factors were causing both the neurodevelopmental complexity and the increased risk of maltreatment.
We came back wondering: could these genetic factors be neurodivergence running in families? This isn’t to say that neurodivergent parents are bad parents – we know that neurodivergent parents are often better suited to parent children with neurodivergence. We love the story of a colleague of ours, an autistic child psychiatrist, whose autistic daughter told him, “Dad, I can’t look people in the eye.” His response was “don’t worry, honey, just look between the eyebrows” – a brilliant tip only an autistic parent could give.
However, add in social problems – poverty, benefit sanctions, food bank visits – a virtuous cycle can become vicious. Parental stress is one of the biggest predictors of child abuse and neglect. It’s that toxic mixture of stressors, not neurodivergence, that tips families into crisis.
These insights led us to develop the “double jeopardy” model. Our earlier research had shown that when ACEs and neurodivergence occur together, the risks add up – even if, as we mentioned at the top, this does not mean that every child who has experienced trauma will suffer adverse impacts.
So, in another study following Swedish twins from age nine to fifteen, we found that ACEs and neurodevelopmental conditions each uniquely predicted juvenile mania, an early indicator of severe mental illness. Crucially, children who had both had double the risk.
This matters because services work in silos: there’s a mental health pathway and a separate neurodivergence waiting list, but there usually isn’t a combining framework. What this means is that neurodivergence gets hugely underdiagnosed in the context of trauma. In a study here in Glasgow, also published in JCPP Advances, an Open Access journal by ACAMH, of young people at high risk of first-episode psychosis or borderline personality disorder, 83% had experienced adversity but only 13% had a neurodevelopmental diagnosis. When we conducted comprehensive assessments, 78% showed neurodevelopmental traits.
Back to James. Had someone insisted at that crucial point when he was five – “You need to see this boy, his behaviour can’t simply be explained by difficult life circumstances” – things might have been different. What if he’d had a holistic assessment considering both trauma and neurodivergence? Perhaps his foster placements wouldn’t have broken down, and he could be thriving now with healthy relationships and education prospects.
The Bridge to better care
These various findings led us to design the BRIDGE project, in which we looked at the unique needs of young people with complex unmet needs that are characteristic of borderline personality disorder, and again found that this group are regularly mislabelled or excluded. Despite a strong desire to conduct comprehensive assessments and implement multidisciplinary working for these young people, given the strong evidence that good standard care works, young people are regularly missed.
If you have any engagement with the NHS, whether professional or personal, you might not be surprised to hear that. Of course, it’s not for a lack of passion and effort, but we can’t ignore the fact that frontline staff are often.
This sounds bleak. But there are solutions, and they don’t require expensive hyperspecialist services. In fact, the opposite is true.
What we’re calling for might sound straightforward: understand each person’s “make and model.” More than just identifying a single diagnosis and treating based on that label, services need to offer relationally conducted comprehensive assessments – and we need to work with young people and families to develop a shared understanding of why they feel stuck.
Yes, this sounds obvious. But services are set up in silos. When resources are tight – as now – there’s more pressure to retreat into separated lanes. Yet this apparent simplicity is a false economy. Research in Borderline Personality Disorder and Emotion Dysregulation has shown that when usual services are well-supported and high quality, they can match specialist interventions. The problem isn’t that we need more hyperspecialists – it’s that we need to support the community practitioners already doing the work.
Being trauma-informed must also be neurodivergence-informed. The fundamentals are the same: kindness, compassion, stability, predictability. An autistic child who hasn’t experienced ACEs needs these as much as a trauma-affected child who isn’t neurodivergent.
Understanding someone’s make and model isn’t just about one diagnosis or another. It’s asking: Does this person have particular relationship difficulties at school? Sensory sensitivities that could be helped with ear defenders? What are their strengths and challenges? This might sound like straightforward holistic care – but actually, done well, it’s person-centred care through precision medicine.
Learning what works
This worked in Finland, which halved its suicide rates between 1990 and 2022 through early intervention models for addiction and personality disorders, focusing on marginalised communities.
In Scotland, our community-based trials have led to specialist infant mental health teams in every health board and influenced service development for young people with personality disorders.
Lived experience experts can be the key. In our new Partnership for Change trial, lived experience Family Engagement Workers are employed within infant mental health teams to break down barriers where parents feel judged, using a poverty-aware and neurodivergence-aware approach. In our view, 999 times out of 1,000, parents are doing their very best without adequate support.
We’re also learning from the Global South. Countries like Uganda have excellent task-sharing frameworks, where trained community members deliver care. We want to train community partners to make evidence-based assessments, filling the “missing middle” between GPs and specialists. This would include supporting school practitioners, nurses, and staff who already see complexity, through comprehensive assessments, formulation, relational approaches, and supervision.
The true meaning of trauma-informed
Here’s what we need to remember: if a child has a history of trauma, that is the child who, more than any other, needs to be considered holistically. There’s evidence that if children have ACEs, they (and their family) are less likely to be considered as potentially having a neurodevelopmental condition. This needs to change. We need to think about their neurodevelopmental profile and mental health, as well as their trauma history – not just one or the other.
Early intervention is both treatment and prevention. Clinicians need awareness of the overlap between neurodivergence, ACEs, and mental illness. Even if we’re encouraging practitioners and academics to embrace complexity, the implementation remains a challenge, and it applies equally to social services colleagues. In Glasgow, senior social workers’ awareness of trauma-neurodivergence interplay has grown significantly in just the last few years.
Just as the NHS Long Term Plan sets out, we also need to move from hospital to community, from treatment to prevention, and from single diagnoses to understanding each person’s unique make and model. When we get it right – when we see the whole person, work across boundaries, support rather than blame families – we change lives.
James is still working on his recovery. But imagine if his educational psychologist’s concerns at age five had been heard. Imagine that holistic assessment. His story might have been completely different. The next James – the child whose complexity is being missed right now – doesn’t have to follow that path. But only if we embrace complexity, break down silos, and commit to understanding each person’s make and model.
ENDS
Professor Helen Minnis is Professor of Child and Adolescent Psychiatry at the University of Glasgow. Dr. Ruchika Gajwani is a researcher in psychology at the University of Glasgow. Both spoke at a recent Association for Child and Adolescent Mental Health (ACAMH) webinar on trauma-informed care.
* Not his real name, although all details are true.
