PTSD in very young children, and proof-of-concept trial – In Conversation Prof. Tim Dalgleish

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In this podcast we hear from clinical psychologist Professor Tim Dalgleish, director of the Cambridge Centre for Affective Disorders and Programme Leader at the Medical Research Council Cognition and Brain Sciences Unit at the University of Cambridge.

The focus is on the JCPP paper ‘The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital-attending children and a randomized controlled proof-of-concept trial of trauma-focused cognitive therapy, for 3- to 8-year-olds’ doi/10.1111/jcpp.13460

The study is in two parts, and Tim explains the methodology, findings, and implications of your findings, so from both studies, for professionals working with young children and their families.

Professor Tim Dalgleish
Professor Tim Dalgleish

I am broadly interested in affective neuroscience in relation to clinical depression and post-traumatic stress disorder (PTSD). I am particularly interested in mental control and emotion regulation in these conditions and the psychological and neural substrates of these processes.

Transcript

[00:00:27.724] – Jo Carlowe: Welcome to a different type of in conversation podcast from the Association for Child and Adolescent Mental Health, ACAMH, where we will look at the paper, ‘The early care and treatment of post-traumatic stress disorder in very young children, diagnostic prevalence and predictors in hospital attending children, and a randomised controlled proof of concept trial of trauma focused cognitive therapy for three to eight year olds’, published in the Journal of Child Psychology and Psychiatry, the JCPP. I’m Jo Carlow, a freelance journalist with a specialism in psychology, and I have clinical psychologist Tim Dalgleish with me.

[00:01:05.000] Tim is the director of the Cambridge Centre for Affective Disorders and Programme Leader at the Medical Research Council Cognition and Brain Sciences Unit at the University of Cambridge. Tim is also a co-author of the paper that we’ll be looking at in today’s podcast. If you’re a fan of our In-Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Hi Tim. Thank you so much for joining me. Can you briefly introduce yourself?

[00:01:33.324] – Professor Tim Dalgleish: I’m a clinical psychologist and an academic researcher at the University of Cambridge. So I run a research programme that tries to understand and develop new psychological treatments for common mental health problems across all age groups, in particular post-traumatic stress, which is what we’re talking about today.

[00:01:50.982] – Jo Carlowe: Before we look at the paper in more detail, can you explain the difference between a PTSD and an acute stress disorder, ASD, diagnosis? As I’m sure you’ll mention both in the course of our conversation.

[00:02:04.532] – Professor Tim Dalgleish: So as psychologists, I think we conceptualise how people respond to trauma when they struggle with their mental health as a broad set of symptoms of post-traumatic distress, but within a psychiatric approach there are actually diagnoses which take sets of these symptoms and apply labels to them, and these diagnoses obviously have a lot of influence in the delivery of healthcare and so on around the world. So within the domain of post-traumatic stress there’s a notion of post-traumatic stress disorder, which is a set of symptoms that people present with when they’re having difficulty, which really refers to people who are a month or more after a traumatic event.

[00:02:48.605] So what that leaves is the period immediately following the trauma where there’s no diagnostic label to capture people who are finding that period of time very difficult. So a new diagnosis was generated called Acute Stress Disorder, which tries to capture people who are struggling in the acute aftermath of trauma. So within the first 30 days and its real rationale was, can we use a way of thinking about how people are managing in those first 30 days to predict who’s going to go on and get post-traumatic stress disorder, PTSD, further down the line. So it’s a kind of early warning diagnosis that was generated to fill that vacuum.

[00:03:28.130] – Jo Carlowe: Thank you, Tim. That’s really helpful. Let’s turn now to your paper, ‘The early course and treatment of post-traumatic stress disorder in very young children, diagnostic prevalence and predictors in hospital attending children, and a randomised controlled proof of concept trial of trauma focused cognitive therapy for three to eight year olds’ published in the JCPP. The study is in two parts. Tim, can you start with a summary of study one and its aims.

[00:03:57.246] – Professor Tim Dalgleish: Maybe a bit of scene setting first. So these studies are really trying to understand the nature of post-traumatic stress reactions in our very youngest of trauma survivors aged two or three years up to eight years. So sort of the preschool years and the reason for this is that historically the view has been that these very young kids are actually incredibly robust and resilient in the face of trauma, but what we’ve come to realise is just that, they’re not resilient or robust at all, but that we’ve been applying the wrong metrics to understand what their problems are.

[00:04:31.335] So we’ve been taking the adult diagnoses of PTSD, and the acute distress disorder that I’ve just talked about and seeing if these very young children would meet criteria for those diagnoses, and it turns out they don’t really because those diagnoses were designed for adults. So now we have some much more developmentally appropriate ways of thinking about these problems in young kids, but we know very little about how those problems develop over time, how they start and how to treat them. So this paper was really trying to fill some of those gaps.

[00:05:01.879] So the first study asked some simple questions, which is if we get a large group of kids, so more than 100 in this case, who attend accident and emergency after a traumatic event who are in this very young age group, how many of them end up with these developmentally appropriate post-traumatic stress reactions compared to the old adult ones and what’s the course over two, three, four months of their symptoms? Do they mostly go away or do some of them stay and require treatment? So those are questions, before the study, that we didn’t really know the answers to.

[00:05:34.856] – Jo Carlowe: Can you say something about the methodology that you used for study one?

[00:05:39.336] – Professor Tim Dalgleish: What we did is we work with our clinical colleagues in accident and emergency departments within the UK and asked them to allow us in and we would then approach the families of very young children who had been coming into A&E after a traumatic event and ask them if they’d be willing to take part in our study, where we would look at their mental health symptoms within the first couple of weeks after the trauma and then again three or four months later in order to see what their immediate reactions might be and how those reactions changed over time.

[00:06:12.200] – Jo Carlowe: And what can you share the findings?

[00:06:15.286] – Professor Tim Dalgleish: So what we found was validating what I’ve just said is that the developmentally appropriate criteria for post-traumatic stress disorder captured far more of the clinical distress in this younger age group than the adult diagnoses that had been used in the two, and that around 10% of young people have clinical levels of problems in this age group, both immediately after the trauma within a few weeks, but also later on in about three, four months down the line and those are the proportion that needs some kind of intervention and help. Within the first month there’s this diagnosis of acute stress disorder, which I talked about before and all we’ve got at the moment is this adult version of that diagnosis.

[00:06:56.937] There’s no developmentally tailored version of that diagnosis for this young group, and we found that that diagnosis captured none of the clinical distress in this age group in the first month after the trauma. So it’s essentially of no use whatsoever. Then we looked to see if just a more developmentally appropriate set of symptoms based on the young child PTSD diagnosis was more sensitive, and that was much better at capturing clinical distress in this young age group. So the conclusions were around 10% of very young children are having clinical levels of difficulty, and the current acute stress disorder diagnosis isn’t really fit for purpose in picking those up in the first month.

[00:07:36.642] – Jo Carlowe: Given that the adult based DSM-5 acute stress disorder diagnosis is not fit for purpose as an acute prognostic algorithm for young children. Is it still widely used in that way, and what revisions would you like to see?

[00:07:51.495] – Professor Tim Dalgleish: So I think it just needs to follow the same trajectory as for the PTSD diagnosis, which is to have a developmentally tailored version that’s sensitive to the ways that young children express their distress, so the problems might come out in difficulties in their play or reverse developmental milestones like increases in bed wetting and so on, and you can imagine none of these things is in the adult diagnosis. So I think we just need to extend this very welcome approach of tailoring the diagnosis to the developmental stage to the acute stress disorder time course as well.

[00:08:27.256] And then I think that will make good progress. Until then I think we’re just stuck with it, and I think it is the only diagnosis available for use and that’s not such a problem in the UK where we tend to intervene clinically based on clinical need, but in other systems such as North America, the US, where access to insurance is based on diagnosis it’s a significant problem.

[00:08:49.323] – Jo Carlowe: I note that a limitation of the study was a lack of participation by families. I’m just wondering how you envisage improving family engagement for future research.

[00:08:59.577] – Professor Tim Dalgleish: Yeah, I think it’s a function of this particular study. So you can imagine you’re going into A&E with your very young child who has just been attacked by a dog or being in a car accident or has been in some kind of interpersonal assault of some kind and then you’re really, really concerned with the physical injuries and prognosis, and then what you’ve got is a clinical psychologist like me coming up and saying, would you be willing to take part in a study on post-traumatic stress and I think for a lot of families that’s not their immediate priority. So you don’t push people.

[00:09:31.565] So I think it’s partly a function of the context in which we were trying to recruit but of course, if we really want to understand the immediate mental health consequences in their course over the first few months that’s the place we have to recruit from. So I’m not sure it’s a very easy to get around that. One component that feeds in, I think, is a sort of denial of mental health problems in children by parents a little bit. So I think education and help with understanding that these problems can be very easily treated and dealt with will improve that aspect of the recruitment difficulties.

[00:10:07.380] – Jo Carlowe: Tim, let’s turn to study two which was a randomised control trial. What was its focus and what did you find?

[00:10:15.440] – Professor Tim Dalgleish: So this kind of flows from what we’ve been talking about. So if you imagine that the way that post-traumatic stress manifests itself in these very young three to eight year old children it’s quite different from older children and adults. Then the way you might develop and apply a psychological intervention in these very young children would also be quite different. So we were developing a new intervention to help these very young kids and their families, and we wanted to do a first randomised control trial which is the sort of gold standard test whether intervention is useful.

[00:10:48.484] So what you do there is you randomly allocate children either to the new intervention or a control condition, which in this case was the usual NHS care they would have got anyway, and you see if your outcomes are better with a new intervention compared to the control condition. So that’s what we were doing here, testing our new intervention in a randomised control trial to see if it could improve outcomes for these very young kids.

[00:11:14.129] – Jo Carlowe: Can you describe the intervention itself, the new intervention?

[00:11:17.964] – Professor Tim Dalgleish: It’s a psychological intervention based on a broader family of psychological interventions called cognitive behaviour therapy, and what it does is it works with the children and their families over twelve to 15 weeks. So a session each week of an hour, an hour and a half to try and look at the different symptoms and difficulties the young kids have and to try and work to correct those. So the basic idea is that very young children like older children and adults extrapolate beyond the original trauma in terms of their distress.

[00:11:53.056] So rather than thinking or feeling well, one bad thing happened and I need to get past that. It’s more global beliefs such as everything’s bad, the whole world is dangerous. I’m vulnerable. I’m never going to be safe. I’ll never be okay. Everything has gone wrong, and of course very young children don’t verbalise these, but they come out in their drawings, in their dreams, in their play. So it’s really trying to correct those broader beliefs by integrating new information by doing new drawings, playing in different ways to try and get back a sense that although one bad thing happened, the world and themselves are not as vulnerable and dangerous, as they’re now starting to think they might be.

[00:12:33.271] – Jo Carlowe: And what did you find with the use of the new intervention.

[00:12:37.088] – Professor Tim Dalgleish: We were incredibly surprised how powerful it was. So every child who received the intervention had complete remission of their post-traumatic stress, compared to only about eight to 10% of the children in the control condition, which was usual NHS care, and that’s not a disservice to the NHS. It’s just that there aren’t any interventions in the usual NHS care for this age group, and there’s nothing really for them to get. So it was an incredibly encouraging result and a good platform for our future trials in this area where we want to obviously get larger samples and do a longer term test.

[00:13:16.497] – Jo Carlowe: So do you see this intervention being adopted for NHS care in the future?

[00:13:21.510] – Professor Tim Dalgleish: Yeah. So what we did was an early stage trial, so it was about 40 children involved. So now we need to go to a much bigger trial where we selectively recruit from different Emergency Departments or demographic areas. So an in inner city group or a rural group, and we make sure that the results generalised all these different demographics and they come out in a much larger sample, and then also we want to follow them up for a bit longer to check that they’re still okay, six months or a year down the line.

[00:13:50.344] So first of all we, kind of, expand the parameters of this first trial and check that everything works again, and then we move towards trying to change policy or rolling out the intervention as a standard NHS provision.

[00:14:03.915] – Jo Carlowe: What are the implications of your findings, so from both studies one and two for professionals working with young children and their families.

[00:14:12.493] – Professor Tim Dalgleish: They are several fold really. The first is that there are quite significant levels of post-traumatic stress in these very young children, but you need to be developmentally savvy when you’re trying to pick them up. So use developmentally appropriate clinical criteria to try and understand what the difficulties are and that the adult criteria are basically not fit for purpose for this age group, and that when you do that and you get around 10% of children and young people who you should really be monitoring to check that they’re getting the help they need. Then the second thing is that there are interventions coming down the line that will be really helpful for this group and seem to be very efficacious and effective in relieving them of these post-traumatic stress problems.

[00:14:55.249] – Jo Carlowe: You mentioned the implications for policy just before. I’m just wondering what message policymakers should take from your findings?

[00:15:02.953] – Professor Tim Dalgleish: The main area of policy is something like the NICE guidelines, which really recommends evidence-based interventions for particular clinical presentations. So I think there we’ve already got very clear evidence that we need to assess post-traumatic stress differently in this young age group, and I think the NICE guidelines need to be mindful of that, and to be fair I think they are. Then I think in future it will be, well what can we do to help these very young children?

[00:15:28.449] And I think once we have a larger trial completed there’ll be a sufficiently strong evidence base for NICE to recommend this kind of intervention for this group of young people. The more difficult problem is, even if the policy changes are these implementation questions going to be realised within the NHS in terms of services and delivery and there, of course, it’s a much broader funding problem. So even if we’ve got very good evidence-based treatments it doesn’t necessarily mean that they’re going to be available widely within CAMH services and within NHS services because the funding is not there for children and young people’s mental health at the moment.

[00:16:06.470] – Jo Carlowe: I’m also wondering if you envisage your research having global reach, you know, perhaps impacting the future criteria in any future DSM.

[00:16:14.903] – Professor Tim Dalgleish: The good news is the DSM has already changed the PTSD criteria, and one would hope that the acute stress disorder criteria will change in the next instantiation, because now not just in young people, but even in adults. I think that diagnosis is being shown to be not really fit for purpose.

[00:16:32.966] – Jo Carlowe: Tim, in the paper, you state that a fully powered definitive trial is necessary to evaluate treatment efficacy. You did mention some follow-up research. Can you say anything more about what you have planned?

[00:16:44.493] – Professor Tim Dalgleish: We’re currently putting a funding application together to the funders who funded the first trial, which we’ve been talking about, the National Institute for Health Research for a fully powered efficacy trial of the kind I talked about before. So much larger sample, longer follow up, broader recruitment net because I think that’s what’s needed to definitively develop the evidence base in this age group. So these are called definitive trials because the idea is that you do something sufficiently large and longer term that you only really need to do once to make a definitive contribution to whether it’s an evidence based intervention and I think that’s what we need, and hopefully NIHR will look favourably on our application when it goes in.

[00:17:27.531] – Jo Carlowe: Good luck. Tim, what else is in the pipeline for you?

[00:17:31.196] – Professor Tim Dalgleish: So I’m part of a collaborative group including Richard Meiser-Stedman, University of East Anglia, Patrick Smith at King’s College London, Anke Ehlers and David Clark, Oxford and Emeritus Professor Bill Yule from London, and we’re working broadly in post-traumatic stress problems in children and adolescents of all ages, and two other big projects that we’re working on are internet delivered intervention for teenagers with PTSD and this is app based, but therapist supported. So you still have a therapist, but teenagers like it because it’s a much more little and often intervention where quite a bit of it is online or via the Apple via text with a smaller number of face-to-face sessions.

[00:18:15.873] So all the feedback from young people is they find it less comfortable, the standard come in for an hour a week and sit in the chair opposite someone and talk about things. They much prefer this little and often interactive format. So we’re just doing our first randomised control trial of that app-based intervention and the other trial which we’re just finishing now, we’ve just recruited our 120th and final participant is, for again, older children and adolescents who’ve experienced chronic and repetitive trauma. So things like abuse, domestic violence.

[00:18:50.077] So more severe, chronic, long lasting traumatic events than the sort of single incidents that we’ve been talking about with this current paper, and we’ve got a more complex and longer version of our intervention which aims to help that group of people. So we’ve now collected the data and we’re just going to see how good that intervention fairs for these more chronically and complex traumatised youngsters.

[00:19:17.756] – Jo Carlowe: Thank you, and Tim, finally, what’s your takeaway message for those listening to our conversation?

[00:19:24.534] – Professor Tim Dalgleish: Post traumatic distress affects everybody, even children down to as young as two years and we just need to find the right way to listen to those children about the difficulties they are facing, but the really good news is that we’ve got fantastic interventions across the age range which can really get rid of these problems. So we need to be sensitive that the problems exist, but we need to be optimistic and hopeful that we can do something about them.

[00:19:50.908] – Jo Carlowe: Brilliant. Thank you so much. For more details on Tim Dalgleish visit the ACAMH website, www.acamh.org and Twitter @acamh. ACAMH is spelt A-C-A-M-H and don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.

Discussion

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Loved the podcast. I wonder as an Imdependevt therapist if there’s a way I could be involved doing CBT with young children in the larger cohort study. I work with 12-16 year olds currently and adults with PTSD.

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