Dr. David Turgoose, Attachment and Trauma Team at Great Ormond Street Hospital, and Dr. Simon Wilkinson, Consultant in Child and Adolescent Psychiatry at Great Ormond Street Hospital and Head of the Parenting and Child Team in the Department of Child and Adolescent Mental Health, discuss complex PTSD.
In this podcast David and Simon look at the expanding field of work relating to complex PTSD, and expand on the causes, explaining how it differentiates from standard PTSD. They specifically focus on looked after children, detailing how we can support them and mitigate the impacts in the group of, particularly prevalent young people.
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Useful links and resources
Evidence for two different ICD-11 posttraumatic stress disorders in a community sample of adolescents and young adults (2016)
David is a senior lecturer on the MA in Integrative Counselling and Psychotherapy with Children, Adolescents and Families. He is a clinical psychologist and, alongside his role at Roehampton, works in the Attachment and Trauma Team at Great Ormond Street Hospital. His clinical work focuses around assessment and psychological therapy with children with a history of developmental trauma, post-traumatic stress, attachment difficulties and neurodevelopmental presentations. Prior to joining Roehampton, David worked at a military veterans mental health charity, working therapeutically with veterans with PTSD and conducting research. (via The University of Roehampton)
Dr Simon Wilkinson is a Consultant in Child and Adolescent Psychiatry at Great Ormond Street Hospital and Head of the Parenting and Child Team in the Department of Child and Adolescent Mental Health. This team provides assessments and treatment for children who have experienced abuse and neglect. It also carries out multi-disciplinary expert witness assessments and where appropriate therapeutic interventions for the family courts. Prior to joining this team he worked for four years as a consultant at the South London and Maudsley Trust, specialising in the mental health of Looked After Children.
Intro: This podcast is brought to you by the Association for Child and Adolescent Mental Health, ACAMH, for short. You can find more podcasts and other resources on our website www.acamh.org, and follow us on social media by searching ‘ACAMH’.
Interviewer: Hello, and welcome to the ‘In Conversation’ podcast series for the Association for Child and Adolescent Mental Health. I’m Jo Carlow, a freelance journalist with a specialism in psychology. Today, I’m interviewing clinical psychologist, Dr. David Turgoose, who works in attachment and trauma team at Great Ormond Street Hospital, and consultant child and adolescent psychiatrist, Dr. Simon Wilkinson, also of Great Ormond Street in London. Today, we’re going to be talking about complex PTSD in looked-after and adopted children. David and Simon, welcome. Thank you for joining me. Let’s start with introductions. If you can take it in turns to say a little about yourselves and what you do.
Dr. David Turgoose: Hi, I’m David Turgoose. I’m a Clinical Psychologist in the Attachment and Trauma team at Great Ormond Street Hospital.
Dr. Simon Wilkinson: Hello. I’m Simon Wilkinson. We both work, as you said, in the attachment and trauma team at Great Ormond Street Hospital. That is a team who works with children who’ve experienced abuse and neglect. And we also do assessments for the courts of children who are going through care proceedings.
Interviewer: Great. Thanks for joining me. How did you become interested in this field of work?
Dr. David Turgoose: So, for me, way back when I was an assistant psychologist, before I qualified, I worked in a very nice team for looked-after children in County Durham, which was a psychology team, based within a local authority service, looking at attachment and trauma difficulties. And then, since then, I’ve been fortunate to work in various teams looking at complex trauma, including working with populations like asylum seekers and refugees, and then more recently with military veterans, as well as working in child and adolescent mental health services.
Interviewer: Thank you. And Simon?
Dr. Simon Wilkinson: Yes, so I actually worked in the team where I’m a consultant now. I did some of my training in the team. Just found it very rewarding, working with children who’d often had very disadvantaged starts in life. And subsequently worked in a looked-after child team in Croydon, where I was a consultant. And, again, found that we were sometimes able to make very big changes to children’s lives when we were able, for example, to stabilise a placement that they were in. And I did quite a lot of work with adolescents, and would notice during that work how often adolescents had been affected by traumatic events in their lives, and also family difficulties.
Interviewer: And today we’re going to be talking about complex PTSD. So just to go right back to basics, what constitutes complex PTSD?
Dr. Simon Wilkinson: It might be useful just to think a bit about the history of the diagnosis. So the diagnosis was adopted in 1980, of PTSD, that the criteria for the diagnosis are that people are affected by re-experiencing the, well, first of all, you have to have experienced a traumatic event, a serious traumatic event, usually life-threatening, and then to be affected by re-experiencing that, either in the form of nightmares or flashbacks, for example, but to also avoid talking about it and avoid things that might remind you of it, and to be very hyper-vigilant to threats.
And what clinicians, researchers noticed over time was that, although this diagnosis was very helpful, it didn’t capture all of the difficulties that people can experience, particularly following multiple and often interpersonal traumas. And so, over time, these new criteria were developed. So they’ve been, they haven’t been formally adopted, but they will be for the ICD-11 criteria which are going to come into use in 2022. And in addition to those core criteria, there are going to be three additional criteria, around disturbances in self-organisation, is the bracket that they’ve been put in. And the first of those are interpersonal difficulties, which may include feeling detached in relationships or avoiding relationships, then having difficulties with regulating your emotions. Finally, having difficulties to do with negative thoughts about yourself or the world. So they might be feelings of worthlessness or of the world being a dangerous place.
Interviewer: And what types of situations put a child at risk of complex PTSD?
Dr. Simon Wilkinson: So, what we know for certain is that you’re more likely to develop this form of PTSD, or PTSD really more generally as well, if you encounter multiple traumatic events, particularly of an interpersonal nature. So they might be occurring within the family setting, for example.
Interviewer: So that is to differentiate them from, say, a terrorist attack or a natural disaster or something.
Dr. Simon Wilkinson: Yes. That’s right. Yes. So the research that’s been done on PTSD itself has already shown that you’re much more likely to develop PTSD if the trauma is of an interpersonal nature. And the research just extending that has now shown that you’re more likely to develop the complex PTSD if you experience multiple interpersonal traumas.
Interviewer: And does the complex PTSD manifest differently to PTSD?
Dr. Simon Wilkinson: Well, you have those additional criteria that I mentioned. Now, the way that people might be affected by those can itself be quite diverse. If you’re thinking about emotion regulation problems, they might include things like getting very easily angered or easily taking offence. The interpersonal problems in adults, that the research has been done so far, has shown that adults with the more complex form of PTSD tend to avoid relationships or feel detached and not satisfied in relationships. And there’s still clearly work to be done there in understanding how that might manifest in a different way in children who are, of course, much more reliant on, or dependent on, relationships and aren’t able to choose in quite the same way as to what kind of social settings they might come into.
Interviewer: So how might it manifest in this group?
Dr. Simon Wilkinson: Well, we need to do more research in that area to understand that. Even before these criteria were published, what we would do in our team is to do very broad and detailed assessments, which include assessments of learning, neuro-developmental assessments, looking for things like autism and ADHD, and then considering which of those symptoms might have been impacted upon by traumatic events. Those might include a child being very irritable or very quickly reacting to difficulties at school. And an assessment might indicate that a child like that had high levels of ADHD, which would be reasonable. But we would also want to think what specific effects the traumatic events might have had.
Dr. David Turgoose: Because if you look at the three additional criteria for complex PTSD, over and above just PTSD, as it were, if you think about emotion regulation, as Simon was saying, that might change depending on the developments of the child and the developmental stage that they’re at. So if a younger child has these real difficulties of emotion regulation, that might manifest, for example, as real behavioural difficulties at school, or a lot of restlessness, which again can overlap with criteria of other conditions like ADHD. And so part of our job is to really unpick what is behind what and trying to determine that.
Dr. David Turgoose: Equally, if a child’s at a later stage of their development, and maybe more in adolescence, there might be more complex emotions around shame or self-blame or deliberate self-harm, again as an indicator of emotion regulation difficulties. And then when you think about the difficulties with relationships, as Simon was saying, in adults that can often be a dissatisfaction with or an avoidance of relationships. But children, especially looked-after children, are reliant on those caregiver relationships, and that can present an additional need.
And one thing to say about looked-after children is that they might be at more risk of having experienced a trauma which has been directly related to their first experience of having a primary caregiver. So whether it be abuse or neglect at the hands of a family member. And then the additional complexity that that brings, in terms of their attachment relationships and then their framework for understanding their place in the world, and who adults are, and can adults be relied on to be sources of safety when they’re in distress. So that can often lead to additional challenges in terms of maintaining relationships with adults or with other peers the same age, and add an extra layer of complexity.
Interviewer: And in terms of this unpicking, being able to identify complex PTSD as against other conditions such as ADHD, presumably you’re going to have to take some kind of history. Is that more complicated with a child that’s looked-after or adopted?
Dr. David Turgoose: Yes. Definitely, we’d always take a developmental history when we’re doing any assessment, just because we need that level of detail to know exactly what this child’s journey has been. And that includes even in utero experiences when the mother was pregnant, around whether there was any kind of substance or alcohol misuse or if their biological parents had additional complexities as well around their own mental health or social support, which might have placed them in more difficult circumstances. But, yes, absolutely, we need a detailed developmental history and a sense of how pervasive these difficulties are. Whether they occur in different contexts or just at home or just at school.
Dr. Simon Wilkinson: That’s right. And we also take a very close look at any potential triggers for, say, behavioural difficulties, and see whether they could be explained by a child’s trauma history or history of attachment disruption. So something, potentially, at school, if they picked up on a potential criticism or were very quick to take offence, to understand that. Or at home, very quick to feel unsafe or not looked after.
Interviewer: And how, in terms of looked-after children, I’m just wondering, because you might usually involve the whole family in work and issues around attachment. How do you do that then, if a child is in care?
Dr. David Turgoose: We often see families where their child is either in a longer-term foster placement or has been adopted. In those cases, those carers don’t always know the full details of the child’s development, I think it’s fair to say. So we have to work very closely with other agencies, such as social work, to try and get as much information as we can and piece together the significant events from the child’s very early history.
Interviewer: We’re talking about complex PTSD in looked-after and adopted children, and I think you’ve already answered this to an extent, but can you say anything more about what makes this group and their needs of particular interest when discussing complex PTSD?
Dr. Simon Wilkinson: One thing which we’re very keen to stress is that looked-after and adopted children need detailed assessments of any presenting difficulties, because of the range of factors that they can be affected by. Now, if you think about some of the early histories that will have led children to becoming looked after and adopted, they will very frequently have involved issues to do with not being looked after adequately at home. So they are, by their nature, interpersonal, experiences of an interpersonal nature, which are often traumatic. And so that’s why, in this group, that having a framework around complex PTSD is important.
But we’re also very keen to emphasise the need for detailed assessments, because children can be affected and respond in very different ways. And so it’s important not to prejudge that by making diagnosis on the basis of history, of exposure to something alone, but really to take a very close look at a child’s developmental history, and how they’re functioning currently as well. So complex PTSD might be a diagnosis, but there are a whole host of other potential diagnoses and influences, whether they be genetic exposure to alcohol in utero and so forth, which also need to be taken into account.
Dr. David Turgoose: I think it’s also worth saying as well that the new diagnosis of complex PTSD does, importantly, go some way to capturing the additional needs which this population might have. But also there might be some limitations to it, in that we might often see in clinic, children who present with the three additional needs around complex PTSD, but don’t necessarily present with the core features of PTSD, around the flashbacks or avoidance and hyper-vigilance. But in order to get that complex PTSD diagnosis, you need to have the core PTSD symptoms and the additional complex PTSD ones. Whereas we might see, clinically, children who don’t meet all that criteria. So, still there could potentially be a bit of a gap there, where some children’s presentations might not completely fit in the diagnostic criteria.
Interviewer: And does the age of a child make a difference in terms of them presenting with those features?
Dr. David Turgoose: There’s really limited data, because complex PTSD as a diagnostic category is so in its infancy, that there really isn’t that level of data to be able to say this age range of children are likely to present in this way with these additional needs, compared to these. We can hypothesise in terms of how young people generally present in distress and compare that between younger kids versus teenagers, for example. But when we’re thinking specifically about complex PTSD, that’s still a very burgeoning early area of research.
Dr. Simon Wilkinson: No, that’s right. So it is really an area that we’re still finding our way in and there’s very limited, to date, research in children on complex PTSD. There are really only two papers that I’m aware of, Perkinick, 2016, and Sachser, 2017. And I’m sure our colleagues will be able to point you in the right direction with those. So it is an area where we need more information. And we would definitely expect there to be differences between the way that the problems are expressed in adulthood and childhood. And if you think about the criteria around negative thoughts, children are unlikely to be able to express those thoughts spontaneously, through not wanting to talk about them or perhaps not even being able to talk about them. So that does require quite a lot of unpicking and developmentally-sensitive assessment.
Interviewer: The two papers that you mentioned, are there any interesting results from those?
Dr. Simon Wilkinson: Well, they do seem to show, so far, that separating the two diagnoses is legitimate, and that there are different treatment responses to the different types of PTSD.
Interviewer: That’s interesting.
Dr. Simon Wilkinson: In that, as you might expect, the complex PTSD is likely to require more therapeutic work and to have a greater impact on functioning.
Dr. David Turgoose: So often the first stage, when there is a new diagnostic criteria, is just to try and show, through research, that it can be measured accurately and that we’re actually measuring something that is valid as a diagnostic criteria. So what the early research has shown, like Simon said, is that there is a a sub-group who present just with the core PTSD symptoms, and there is a sub-group who present with the PTSD plus complex PTSD symptoms. So, it does make sense to delineate them in that way. And they’re establishing some measures to try and accurately measure that to help us when we’re doing our assessments. And that’s the first stage, basically.
Interviewer: Can you say anything at this stage about the interventions that are known to work best with, well, let’s say looked-after children or adopted children with complex PTSD?
Dr. David Turgoose: Again, because it’s such an early and new area, we don’t have those large trials where we can say with any confidence. What we know is that the NICE guidelines recommend a trauma-focused cognitive behavioural therapy approach. And at the moment their guidelines, where there’s additional needs and complexities, is to do it for longer, have more sessions. And there’s guidance, whereby, if for any reason, that doesn’t seem to be having the desired effect, then you could try EMDR, eye movement desensitization and reprocessing, as an additional option. But in terms of, do we know what works for complex PTSD in children? We don’t know yet. Yes.
Interviewer: What factors may predispose a child to a greater risk of developing complex PTSD? And, conversely, what factors are known to protect against this?
Dr. Simon Wilkinson: Yes. So this goes back to some of the risk factors for PTSD as well, in that we know that more trauma exposure over a chronic period of time, particularly of an interpersonal nature, substantially increases your risk. And there are other things which also increase your risk. One is having limited family support. And another is the thoughts that you might have around the time of the trauma, particularly thoughts that something very bad was going to happen to you that you might never recover. And the thoughts that you might have following the trauma, as well, particularly of still feeling unsafe or very under threat. And if you think about how a child who’s living in a family where abuse is occurring is likely to feel, then you can see how that would substantially increase the risk of complex PTSD, because even after particular traumas, they will still have a feeling of not being safe. So we would expect that to increase their risk of developing PTSD.
Interviewer: What about factors that are known to protect against complex PTSD? Can you say anything about that?
Dr. David Turgoose: I guess one way of thinking about it is almost looking at the converse of the risk factors. So there’s some research that suggests that if someone has the support of at least one helpful adult, or one person with which they’re able to establish some form of secure attachment, that can be helpful. There’s evidence from adult literature about general intelligence or some temperamental factors which might protect some people against developing complex PTSD. Family functioning, that kind of thing, which although they are potential protective factors, when we think about in the context of looked-after children as well, even they seem fragile, because they are about social support and safe adults and things like that, which are more likely to be lacking in that population.
There are some things around the chronicity and time at which the trauma occurs. So if a child is removed from that traumatic environment at an earlier stage, that’s better in terms of the prognosis. And also what happens to a child after they’re removed. So it’s not always guaranteed that that child would go straight into a long-term, stable foster placement, for example. They might have various placements before adoption, for example. Or there might be ongoing discussions around courts in terms of contact and access, in terms of biological families as well. So even after they’ve been removed from a traumatic environment, the children might still not have a sense of safety and stability for quite a long time after that, which we do know as well can be protective, to quite quickly have the opportunity of a safe, consistent, stable environment, with carers who can respond to them in a safe, consistent way, and help them make sense of some of the emotions that they’re experiencing in a way that they might not have had in a very inconsistent and potentially neglectful or abusive care relationship prior to that.
Interviewer: So given those factors, are there any changes you would like to see in terms of policy or training that tie in with that, in mitigating those things?
Dr. David Turgoose: It’s hard to comment on national policy, for me, anyway. But I’m thinking in terms of, locally, more training for foster carers or adoptive parents, social workers, teachers, in the potential impacts of early trauma in terms of a child’s attachment relationships or how their trauma symptoms might manifest at home or in school. Because they can differ, depending on where the child is. So definitely more training on that would be welcome. I think that is happening in some cases, but maybe not across the board. I’m not sure about that.
Interviewer: And how can you identify which children are at greatest risk and most need of intervention?
Dr. Simon Wilkinson: We’ve been talking about looked-after and adopted children. It’s also well worth thinking about other children who are likely to be at high risk of these sorts of problems. So there, I am thinking about, for example, children who are with youth offending teams, children who’ve been excluded from school, children who might be on child protection plans, or on the edge of care. So other high-risk groups where you would want to have an index of suspicion about exposure to difficult events and traumatic events within the home. And then to be aware of the potential impact there, and to ask questions about what children have experienced, and listen to the answers. And also to use things like screening tools, to pick up on difficulties, mental health difficulties, in high-risk groups, like the ones that we’ve mentioned.
Interviewer: Right. So those children on the edge of the system and also children who are looked after, they may not have someone advocating for them in the way that a loving parent would or might. So what can you do to ensure that those children aren’t overlooked and don’t slip through the net?
Dr. Simon Wilkinson: Yes. Well, it goes back to some of what David was saying about the importance of permanent placements wherever possible. And if there is one policy area that we’d like to influence, it’s really to have that as a priority, to achieve for as many children as possible, so that they have an opportunity to develop those close and consistent relationship with the caregiver, who is then able to love them and advocate for them. And, ideally, for those children and adolescents to remain in placements post-18.
Interviewer: So let’s talk about interventions. What is the prognosis like for children with complex PTSD who were not helped? So what is the likely trajectory in terms of their mental well-being, supposing that nobody reaches them or very little is done?
Dr. Simon Wilkinson: Yes. So another thing that we know about PTSD is that there are a certain proportion of children whose symptoms will resolve over the first few months of their exprience of PTSD. But for those children whose symptoms don’t resolve… there’s around ten per cent whose symptoms don’t resolve… they’re very likely to be persistent. So with complex PTSD, we would expect those difficulties to be persistent and not resolve without treatment.
Interviewer: I was going to ask you about any particular studies or programmes that you would like to mention in terms of your work with looked-after and adopted children. I know you said some of the research is scant, but is there anything that’s worth a mention?
Dr. Simon Wilkinson: So we’re interested in modular treatments for children with complex PTSD. And we know there’s been work that’s been done there in adults. And there’s a need for more research in that area for children. And we’re also interested in any kind of work on early intervention, and particularly early intervention for children’s attachment needs. And there’s work, for example, that’s been done by the NSPCC on detailed assessments of parents and children under five, to see whether they can remain at home with parents, or whether they need to be looked after in an alternative setting. And providing interventions for those families to see whether they can be helped to remain at home. And we’ll be very interested to see the results of that research.
Interviewer: We talked earlier about interventions. Can you say a little bit more about what is being done to support children with complex PTSD, looked-after and adopted children with PTSD?
Dr. David Turgoose: Yes. So when a child presents with quite complex difficulties about PTSD, it’s really important, even more so than normal maybe, to take a very individualised and formulation-based approach, where you can see the child for their individualised needs, and meet the family, where they’re at in terms of what are their main difficulties, rather than having an off-the-peg therapeutic intervention, which is a one-size-fits-all. It’s very important to see all the different difficulties that might be going on and to take a very modular approach, where you might tackle one difficulty at a time. The advantage of that is that it can be more engaging for a family or a child. You’re meeting them where they’re at in terms of what the child can cope with or what the most pressing difficulties are.
And in terms of those different types of intervention, one of the main ones when we work with looked-after children and adopted children presenting with complex PTSD, is supporting the parents and the caregivers because that attachment relationship is a key protective factor. Helping the caregivers to understand, giving them psychoeducation about the trauma, and about understanding why the child might be having the difficulties that they’re having. And that’s very much with a view to sustaining and stabilising the placement, ’cause we know how important that is for children.
It’s also specific approaches to helping the young person regulate their emotions. Because what we know is that any child’s ability to recognise and regulate their own emotions develops from those very early attachment relationships. And where that’s been disrupted by trauma, often there’s a lot of work to do in just helping that child improve their emotional literacy and give them some kind of skills, as well as giving the parent and caregiver some skills to help the child regulate their emotions.
And when people think about trauma-based psychological interventions, we often think about memory reprocessing or re-scripting, where the specific memories of the trauma are discussed in lots of detail. And that is something that can be included in this kind of modular psychotherapeutic approach, but not always the the best place to start, because it can be very challenging for anybody, not least a child with these difficulties. And, often, it’s a case of not necessarily reliving these memories, because that’s very much about tackling, reliving symptoms around flashbacks and nightmares, but more about tackling the underlying beliefs that the child might have developed off the back of these experiences. So we tend to think of beliefs being about themselves, potentially feeling ashamed or not worthy. Those kind of things. Or thoughts about other people being unsafe or unpredictable. Or thoughts about the world more generally being an unfair or an unsafe place. So it’s those underlying beliefs which are really key in terms of often maintaining the mental health difficulties.
One additional thing that we do in our clinic as well is, particularly where a child has a very complex experience of trauma, and might be left fairly confused or uncertain about how this all fits, is we take a narrative approach, where we work with, sometimes the social workers, and also the carers, to help that child build up a framework or a narrative, just for understanding what’s gone before and where their current situation fits within that, which we can find can be quite therapeutic in itself, just to gain that understanding.
Interviewer: Simon and David, what more could be done at a local and national level to help looked-after and adopted children with complex PTSD? This might be in terms of better training and more resources, new areas of study, and so on.
Dr. Simon Wilkinson: Well, one thing we’ve mentioned already is having a low threshold or a presumption of vulnerability for children who’ve experienced multiple traumatic events, even if they’re not, at any one particular time, presenting with overt mental health symptoms. Certainly for children who are presenting with complex PTSD-like problems, those problems are very likely to be manifesting across all sorts of different settings. And they may have lots of different professionals in their lives. So it’s really important then that those professionals communicate well and that there are systems in place to facilitate that. So that you have somebody at the school whose job it is to support looked-after children, and that person communicates well with social workers. And that there is a relationship between the CAMHS service and the social care department, where there is lots of cross-working and lots of communication.
Interviewer: I asked you earlier about the likely trajectory in terms of a person’s well-being and future prospects, really, if they’re not… if a child, a looked-after or adopted child, doesn’t get the help they need or early intervention with PTSD. Can you elaborate a bit more?
Dr. Simon Wilkinson: Yes. Well, we know that some children seem to show resilience to difficult events, but others will be be affected in ways that can impact across the lifespan. And once you’ve dropped out of school, for example, that places you at high risk of gang involvement or criminal involvement, sexual exploitation. All of which have a huge impact, not just on the individual, but also society at large. And as time goes on, and these difficulties become increasingly hard to help with, especially if you’re thinking about people whose trust in others, whose trust that other people can help them, has been eroded. So all of this just emphasises how critically important it is to help in the early stages of somebody’s trajectory, both in providing mental health support which is joined-up, but also in ensuring that placements are given all of the support. So foster carers, adoptive parents are given all of the support that they need to address problems when they first arise.
Interviewer: What else is in the pipeline that you’d like to mention?
Dr. David Turgoose: So, obviously, we work in a children’s hospital setting, so we have, in terms of research interests, outside of looked-after children as well. So at the moment, we’re looking into how best to support children affected by medical trauma, for example, and that angle of PTSD. And again, in terms of complex PTSD, because it’s such a new area of interest, we’re looking into how to accurately measure that in our population to make sure that we have the questionnaires and the diagnostic tools to make sure we’re measuring it accurately.
Interviewer: Finally, perhaps from both of you, can you give a takeaway message for those listening to our conversation today?
Dr. Simon Wilkinson: Thank you. Yes. So I just wanted to repeat that children who’ve been through multiple traumatic events like that may well have long-term vulnerabilities, and may also have difficulty sometimes engaging in more straightforward ways in therapeutic help, so that the care needs to be flexible and focused on engagement, and addressing young people’s concerns. And because those problems can be long-term, it’s incredibly important to retain therapeutic optimism and to communicate that to children and families.
Dr. David Turgoose: Yes. I would echo the same, but plus, so, as a psychologist or any kind of mental health professional, you’ll be looking not just at the individual but also the system around them. And I think with young people, looked-after children, adopted children, who’ve experienced trauma and are presenting with complex PTSD, that’s even more important to be able to identify the important people in their lives, usually their family and friends, and to help support them to support the child as well. And that can be even more important in this population.
Interviewer: Simon and David, thank you ever so much.
Interviewer: For more details on Dr. David Turgoose and Dr. Simon Wilkinson, please visit the ACAMH website, www acamh.org, and Twitter, @ACAMH. ACAMH is spelled ‘ACAMH’.