Trauma, and PTSD, expert, Professor Andrea Danese talks to freelance journalist Jo Carlowe.
Andrea discusses the impact trauma has on the child, the Topic Guide on Trauma he wrote with Dr Patrick Smith for ACAMH. He also talks about the recent paper in The Lancet ‘The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales’ Lewis, S J et al, and its findings.
Andrea Danese is Professor of Child & Adolescent Psychiatry at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London. He is also Honorary Consultant Child and Adolescent Psychiatrist at the National and Specialist CAMHS Clinic for Trauma, Anxiety, and Depression at the South London & Maudsley NHS Foundation Trust.
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Interviewer: Hello, welcome to the In Conversation podcast series for The Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlow, a freelance journalist with a specialism in psychology. Today, I’m interviewing Professor Andrea Danese. Andrea is a Professor of Child and Adolescent Psychiatry at The Institute of Psychiatry, Psychology and Neuroscience at King’s College London. He is also consultant Child and Adolescent Psychiatrist at the National and Specialist CAMHS Clinic for Trauma, Anxiety and Depression at the Maudsley Hospital in London. Andrea has co-written the ACAMH topic guide on trauma, together with Dr. Patrick Smith, who is reader in child clinical psychology and honoree consultant clinical psychologist in the same institutions. Andrea, can you start by introducing yourself with some details about your role?
Professor Andrea Danese: Thanks Jo. I’m Professor of Child and Adolescent Psychiatry at King’s College London, and in my research activities. I lead a number of projects on childhood trauma. We’re interested in looking at why some children are exposed to traumatic experiences and adverse childhood experiences, why some children, after these experiences, develop poor mental health and physical health. Ultimately, with the aim of understanding how best to support these children and treat them. With regard to my clinical activity, I lead national and specialist service for children who have developed post-traumatic stress disorder, anxiety and depression, here at the Maudsley Hospital.
Interviewer: And what prompted your personal interest in the field of trauma?
Professor Andrea Danese: I’ve always been interested in the brain since medical school. After that, I trained as an adult psychiatrist, back in Italy and I then moved to the Institute of Psychiatry to do a PhD in developmental epidemiology. Really, it’s through the work during my PhD that I learned more about the long-lasting effects of childhood trauma and adverse childhood experiences on mental health. So, that was really the experience, if you like, that focused my later work in this area.
Interviewer: Andrea, in your topic guide on trauma, there’s a rather sobering figure which states that, by the age of 18, up to 80% of children are likely to have been exposed to at least one potentially traumatic event. Can you elaborate on that? What types of events count as traumatic?
Professor Andrea Danese: Traumas are events that involve danger of death, serious injury or sexual assault. So, this is the definition that the American Psychiatric Association and the World Health Organization give to to trauma. The actual percentage of trauma varies quite widely and clearly, varies with the context in which children and young people live in. We found recently, in a large epidemiological paper in the UK, the first of its kind, that one in three young people are exposed to trauma by the age of 18, in the UK. So, this is a paper that has just been published recently in The Lancet Psychiatry. Of course, the prevalence, as I said, will vary and up to 100% of young people might be exposed to trauma. If, for example, we look at war torn countries where children clearly, are exposed to those kinds of experiences I mentioned, that would put them in danger of death or serious injury.
Interviewer: After a traumatic event, it’s common, I suppose one might say normal, for children to show signs of stress. But at what point do symptoms start to meet the criteria for post-traumatic stress disorder?
Professor Andrea Danese: So, that’s an excellent point and thank you very much for making it. It is one that I always try to make, that most children will develop emotional and behavioural symptoms after having been exposed to traumatic experiences. So, this is a normal psychological response to traumatic experiences and not a psychiatric disorder. However, if symptoms are very severe, impairing or persistent, it’s very important that parents contact their GP and raise concerns about their children.
Interviewer: So, what are the signs of PTSD in children and young people?
Professor Andrea Danese: So, what we look at when we undertake assessments for PTSD is first of all, whether they have been, indeed, exposed to traumatic experiences. In children who have been exposed to traumatic experiences, we look at a cluster of symptoms that are typical of developing post-traumatic stress disorder. So, what we look at is whether children relive traumatic experiences through, for example, distressing memories or nightmares. We look at whether they show avoidance of anything that reminds them of their trauma. So, context or people that reminds them of their trauma. We look at whether they express feelings of guilt, isolation or detachment and finally, whether they still feel under threat, as we can understand because they continue expressing irritability, impulsivity or difficulty concentrating, for example.
Interviewer: And who would normally pick up on this? Will it be the parents, GP’s, schools?
Professor Andrea Danese:What we know from the research we have undertaken is, first of all, that it’s very difficult for parents and teachers to really understand when children develop post-traumatic stress disorder. I say that because only a small fraction of children who have PTSD, we found, end up seeing a GP. About one in three sought help from a GP and only one in five ultimately, were in contact with a mental health professional. So, it’s very difficult. But typically what happened is that parents, teachers typically identify some of these symptoms and concerns and therefore then, try to seek help from GP’s.
Interviewer: If it gets missed, is it because teachers assume a child is, I don’t know, withdrawn or behaving badly?
Professor Andrea Danese: What often happened is that some of the symptoms of PTSD that I mentioned, for example, reliving traumatic experiences, are not observed. These are memories that come into the child’s mind. What might be more likely to be observed is that the child becomes very avoidant of some situations or disruptive if the child is put in those situations. Also, because of the feeling of threat, children might be irritable, might be struggling with their attention or might be impulsive. So, quite often, the referral is not initially for post-traumatic stress disorder, but more for those disruptive behaviors that children might express. So it’s really important then, particularly for mental health professionals, to be mindful that despite the reason for referral, they need to also consider broader psychopathological assessment which might ultimately identify symptoms of PTSD.
Interviewer: And how is that formal diagnosis made? Can you explain the assessment procedure?
Professor Andrea Danese: In terms of the assessment, what we do clinically, is interviewing both the children and their parents and assessing those symptoms I mentioned. So, reliving, avoidance and the associated emotions and the physiological hyperarousal. When those symptoms are present, together for more than one month and they cause significant impairment, we make a diagnosis of post-traumatic stress disorder.
Interviewer: And, of the children exposed to trauma, how many actually go on to develop PTSD?
Professor Andrea Danese: So, what we have found in this latest paper, which is very much along the lines of previous research findings, is that about one in four trauma exposed children develop PTSD. This is the overall figure but one of the substantial findings was that the percentage of trauma-exposed children who develop PTSD really is a function of the type of trauma that they experienced. So that, for example, direct interpersonal trauma, which would include experiences of maltreatment, bullying or sexual assault, is the type of trauma that carries disproportionate risk. So, it occurs in about 20% of the cases of trauma, but it accounts for up to half of the cases of post-traumatic stress disorder.
Interviewer: Okay. So, it’s something about it happening to you, as opposed to being a general condition of everybody around you.
Professor Andrea Danese: There are different types of traumas. In addition to direct interpersonal types of traumas, you might have accidents that happened to the child. We may have the child witnessing traumatic experiences that someone else experiences. And finally, we have what we call network traumas. So these are traumatic experiences that occur to someone in the child’s network but the child doesn’t directly experience or witness.
Interviewer: I’m wondering are there other conditions as well as PTSD that a child may present with, following a trauma?
Professor Andrea Danese: Disorders that have higher base rate, so that are most prevalent in the general population, such as depression, conduct disorder and alcohol problems, for example, are also more common in trauma-exposed young people. So, that’s a very important point because, in some cases, the assessment of psychopathology, after traumatic experiences focuses, very narrowly on the assessment of post-traumatic stress disorder. But the evidence that there are other conditions that are more prevalent after trauma really suggest that the assessment of psychopathology of the traumatic experiences needs to be quite broad. So, to identify all cases of children who develop psychiatric disorders and therefore then, offer treatment.
Interviewer: Given that many children exposed to potentially traumatic events do not develop PTSD, what is it that makes those children more resilient?
Professor Andrea Danese: The study of resilience and vulnerability has produced important evidence in the literature, but we don’t have very consistent evidence across different studies. Perhaps we can point out that social support after exposure to trauma is very often seen as a protective factor. In contrast, there are a set of factors that might increase the risk of trauma-exposed children to develop post-traumatic stress disorder. They would include previous psychopathology, previous victimization, living in disadvantaged socioeconomic conditions and crucially, as I mentioned already, the type of trauma. This is something that tells us about the risk in the general population and as I said, we have made some steps forward in terms of understanding factors of resilience and vulnerability in the population of trauma-exposed children. However, we still have very little to guide clinical assessment of resilience and vulnerability. So, we are now studying ways in which we can combine these factors of resilience and vulnerability to build individualized risk prediction for the next child I will see in the clinic, which is something that we still really don’t know much about.
Interviewer: That’s really interesting. How far off are those studies from coming to fruition?
Professor Andrea Danese: We are now at the end of a project funded by NSPCC and DSRC that is really focusing on that question in terms of understanding, particularly with regard to children who have been victimized, how we can use big data types of approaches to really come up with individualized risk prediction. But part of this work was also included in the recent paper on post-traumatic stress disorder, where we use very similar approaches to understand how we can use all the knowledge we have on resilience and vulnerability to make individualized risk prediction. I would say we’re at the very beginning of the process but it’s a very important clinical direction that could give us very useful information.
Interviewer: I’ve heard that girls are at greater risk of developing PTSD than boys. Is that correct?
Professor Andrea Danese: It is, it is. So, we find in our paper that girls are about twice as likely to develop PTSD compared to boys. However, we are not quite clear why that is the case and one of the possibilities is that they tend to experience more of those types of traumas that are more strongly associated with PTSD and psychopathology later on. So, those types of direct interpersonal traumas we discussed.
Interviewer: And some children who develop PTSD in the aftermath of trauma, recover without professional help. That’s my understanding. So, given that fact, how do you know when to intervene?
Professor Andrea Danese: You’re right. So, about half of children who develop PTSD in the aftermath of trauma will recover without professional help. This is based on, of course, what we know from the published literature, which is not very large, but we know that there is a group of children with PTSD who might recover spontaneously, without intervention. However, we have another group, possibly half, possibly more than half of those with post-traumatic stress disorder, who if they do not receive treatment, they will develop long-lasting and increasingly more complex psychopathology that is very difficult to treat at later stages. It’s very important, I think, that all children who have a diagnosis of post-traumatic stress disorder are treated because we have no means to make accurate predictions of what the outcome for that specific child will be without treatment. There is a huge risk and impairment associated with PTSD. So, this is again, from the recent paper and what we have found is that the level of complexity, risk and impairment in young people with PTSD is really very high. So three out of four young people with PTSD will have at least one additional diagnosis. So, depression or conduct problems or alcohol dependence, for example. So, the kind of psychopathology we see in children who have a diagnosis of post-traumatic stress disorder is complex. In addition. The risk is high. So, that one in two young people who have a diagnosis of PTSD has self-harmed in the past. One in five attempted suicide and one in four was not in education, employment or training. So, they were really functionally impaired in a very important period of their development.
Interviewer: So, the treatment is crucial. Can you talk a bit about the interventions that are available?
Professor Andrea Danese: NICE, the National Institute of Clinical Excellence, just released an updated guideline for assessment and treatment of post-traumatic stress disorder, both in adults and in young people. Based on that evidence, the new guidance were released just in December 2018, here are two interventions that are highlighted as evidence-based.
One is trauma-focused CBT and this is really the intervention that is most strongly endorsed in the guidance. Trauma-focused CBT is a type of cognitive behavioral therapy that supports the child in reprocessing some of the memories of trauma through sequential steps. First, looking at psychoeducation. So, to explain the normative responses that children and young people have after traumatic experiences and also, supporting parents in providing supportive practices in the relationship with their children. We then have a phase of stabilization that includes skills for relaxation as well as effective modulation. So, how to regulate the emotions and this is very important because some of the work will elicit quite strong emotions. Some of the work will be based on the trauma, itself. So, it’s important that we provide the skills to children on how to cope with those strong emotions. When those are established, then we focus on the trauma narration. So, we help young people to go through their traumatic experiences and really make a narrative discussion of the trauma and their experiences. So, to make sense of what happened to them and also, to understand that they can talk and they can think about these experiences without overwhelming emotions. Because at that point, they will also have built stronger ways of regulating their emotions. Then, finally, we focus on mastering the trauma reminders. So, those contextual details that might trigger relieving symptoms in children with post-traumatic stress disorder. So, this is the trauma focused cognitive behavioral therapy.
So, a second type of treatment that has been looked at and has some evidence of efficacy is EMDR. With EMDR, we think that the child could be supported reprocessing trauma memories in the same way that we have described also, for cognitive behavioral therapy. However, the level of evidence for EMDR is still not as established as for cognitive behavioral therapy. The guidelines suggest that EMDR should be considered really, for those young people who cannot engage in trauma-focused cognitive behavioral therapy at present.
Interviewer: What does the research show us about the efficacy of trauma-focused CBT then, in young people?
Professor Andrea Danese: So, as I said, the evidence is really quite good for trauma-focused cognitive behavioural therapy and it’s not very clear yet for EMDR, although the evidence for efficacy in EMDR is better and stronger in adults. So, there is still a place for using it in the clinic but typically, for children who cannot engage in trauma-focused cognitive behavioural therapy for any reasons.
Interviewer: What about medication? Is that used to treat PTSD in children and young people?
Professor Andrea Danese: Currently, there is no clear evidence base for using pharmacotherapy to treat specifically, in post-traumatic stress disorder in young people. However, as we discussed, three out of four young people with PTSD will have other diagnoses and some of those diagnoses are very responsive to pharmacological treatment. So, what we do is still using pharmacological treatment in many cases of post-traumatic stress disorder, but that treatment is not targeting the PTSD symptoms themselves, but rather the comorbid psychopathology.
Interviewer: I was wondering about online CBT approaches because we all know that young people are very comfortable with computers and handheld devices. So, I wondered if that’s being used with children and if so, if it’s effective?
Professor Andrea Danese: Absolutely. So, this is, I would say, at present, one of the key research directions that people, including Dr. Patrick Smith, are really developing. Its importance is in the fact that they can very well expand on what cognitive behavioral therapy can do, but they can make the treatment available at a much larger scale. That’s very important because we don’t have therapists who have experience in delivering trauma-focused CBT in some areas and, as we said, not many young people get to see mental health professionals. So, it’s really important to develop this type of treatment to increase accessibility of treatment for young people with PTSD.
Interviewer: I was wondering about very young children. Let’s say six and under. What interventions are considered considered helpful for very young children?
Professor Andrea Danese: The research base is smaller than the research base for older children, but what we know is that adapted forms of trauma-focused cognitive behavioral therapy can be used effectively in young people. So, what we need to do, of course, is to consider that their development is not as advanced as the developmental stages in order children. So, we want to limit, for example, cognitive components of the trauma-focused cognitive behavioral therapy, but focus more on the behavioural aspects of treatments. So, to do small exposure experiments that can help them develop more adaptive ways of coping with the traumatic memories and the emotions that are triggered by those memories.
Interviewer: You mentioned earlier that the family is often involved in the treatment too. Can you say something about that whole family approach? Is that recommended?
Professor Andrea Danese: The evidence base for family-focused interventions is limited by the fact that we haven’t done much research on this issue but, from our clinical perspective, I think that this is very important for a number of reasons. One is that parents often have experienced traumatic events, themselves. Sometimes, the same as their children and, as a result, might have psychopathology of their own. So, it’s important to help parents cope with their own mental health problems so that they will be in a better position to then support their children. Also, we increasingly understand that the way parents respond to the traumatic experiences of their children influences the risk of developing PTSD and possibly, the outcome of trauma-focused cognitive behavioral therapy. So, it’s really important to think about post-traumatic stress disorder and the response to stress as a family issue because the parents, of course, are in the best position to support children at home and sometimes are very much affected in the same way their children are. So although now, we don’t have a very rich research evidence, clinically, this is something very important and yet it’s something that happens only rarely due to the structure of services and the funding. So, although we typically assess both the young people and the parent’s psychiatric disorder after traumatic experiences, we often have to refer parents to different services for their own mental health needs. This, we feel, makes the treatment of the child and the parents, both, disjointed and perhaps less effective over all.
Interviewer: You’ve talked about the paper that you’ve published in The Lancet. In Lancet Psychiatry, looking at the epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. Can you say anything more about some of the findings?
Professor Andrea Danese: What I can say is that the paper gives the best estimate so far, for the scale of trauma-related mental health problems in young people in the UK, but also points out the fact that most young people with post-traumatic stress disorder are falling through the gaps in care. And therefore, we really need to do more in terms of understanding a system that supports children and their family to recognise these problems and to receive adequate treatment.
Interviewer: Andrea, what else is in the pipeline? Is there any research or innovative pilots that are yielding interesting results?
Professor Andrea Danese: Much is happening. For example, we are expanding further on the approach I told you about in terms of capitalising on big data approaches to build better, individualized risk prediction in young people exposed to trauma and to understand which of them will be at greatest risk of developing PTSD and psychopathology. We think this is really important because we can allocate rationally, the limited resources we have in those circumstances and generally, to provide treatment incomes. We are trying to understand why some types of trauma are so strongly associated with psychopathology and disproportionately so and this goes back to the discussion we had about maltreatment and bullying. So what are the psychosocial, biological mechanisms that translate exposure to trauma into risk for psychopathology.
On the treatment side, we need to develop better early intervention for trauma-exposed young people who are at greater risk of developing psychopathology. Surprisingly, this is an area that has received very little attention because most of the resources clinically, are typically put into treatment. But we think that if we can have interventions that act early in the process of developing psychopathology, then that could have important and probably, cost-effective repercussion for the clinical outcomes later on. And finally, as also we discussed, we are trying to consider how to use new technologies to make treatment more accessible and fun for young people who go through these difficult experiences.
Interviewer: Andrea, thank you ever so much. Is there anything else that you’d like to add that I haven’t asked you, perhaps as a takeaway message for those who are listening to this podcast?
Professor Andrea Danese: Well, I want to thank you for giving me another opportunity to really highlight the burden of psychopathology that many young people who experience trauma experience and how difficult it is for them to get the help they need. I think that not only this is important from their own point of view so that we can help them, getting better. But it is also important because these young people really struggle in daily activities and they are at very high risk of harm. So, by providing this treatment, we give them the best opportunity to really become productive members of society. This means that any funding that goes into helping these children might have very positive even societal and economic repercussions later down the line. What we find is that very often, we see older adolescents and I know many of my other colleagues see adults who have experienced trauma and report post-traumatic stress disorder symptoms lasting for years. So, it’s really important to treat post-traumatic stress disorder early to avoid many years of distress, impairment and cost to the services because when we treat these conditions later in life, they are always much more difficult to treat because they become more and more complex. And also, if people want to read more about our recent paper, they can find it in the February edition of The Lancet Psychiatry. The paper is open access and its title is The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales, with Dr. Stephanie Lewis as first author.
Interviewer: Andrea, thank you ever so much. That was really interesting. You can find Professor Andrea Danese’s and Dr. Patrick Smith’s topic guide on trauma on the ACAMH website www.ACAMH.org and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H. You can find Professor Andrea Danese on Twitter @Andrea Danese. That’s spelt A-N-D-R-E-A underscore D-A-N-E-S-E.Close: This podcast was brought to you by The Association for Child and Adolescent Mental Health, ACAMH for short.