Features

PTSD wake-up call

06 June 2019

Young people aren’t getting the support they need for trauma experienced in childhood, and it’s having serious consequences. Journalist Anna Scott reports.

Television presenter and baker Nadiya Hussain recently revealed in a BBC One documentary that her primary school bullying ordeal left her with post-traumatic stress disorder (PTSD), which she struggles with to this day. Away from the showbiz spotlight, student Luke blogged about his story on the Young Minds website (2019a): after his diagnosis of PTSD, he couldn’t go to school for a year because it filled him with anxiety. While 20-year-old mental health campaigner Flo Sharman recently told how her PTSD (only diagnosed at 16) was brought on by a traumatic operation she had as a baby (Therrien, 2019).

‘Childhood trauma is a public health concern, yet trauma-related disorders often go unnoticed’

These are not isolated incidents. One in 13 children in England and Wales have had PTSD before reaching the age of 18, a ground-breaking study published in The Lancet Psychiatry has suggested (Lewis et al, 2019).

After interviewing 2064 people born in 1994 and 1995, researchers found that 7.8% had suffered PTSD and almost one-third had experienced a traumatic incident in childhood (Lewis et al, 2019).

Of these 31% of children who had gone through trauma, 25% met the criteria for PTSD, and they were twice as likely as their peers to have a range of mental health disorders (Lewis et al, 2019).

If these figures weren’t eye-opening enough, only one-fifth of the children who had developed PTSD had seen a mental health professional, the study also revealed, and just one in three had talked to their GP about their mental health in the last year (Lewis et al, 2019).

The findings should serve as a ‘wake-up call’, believes senior researcher Professor Andrea Danese (King’s College Hospital (KCL), 2019). Experts have understandably raised concerns about the small proportion of young people with PTSD who access formal support or mental health services. Professor Danese, also a consultant child and adolescent psychiatrist at South London and Maudsley NHS Foundation Trust, said at the time: ‘Childhood trauma is a public health concern, yet trauma-related disorders often go unnoticed. 

He continued: ‘Young people with PTSD are falling through the gaps in care and there’s a pressing need for better access to mental health services. Child and adolescent mental health services need to make more resources available to address the needs of traumatised people.’ 

The scale of trauma and PTSD

It probably doesn’t help that the prevalence picture of PTSD in children and young people across the UK isn’t entirely complete – the research in The Lancet Psychiatry only covers England and Wales (not Scotland and Northern Ireland) and it’s the first study of its kind based in the UK (KCL, 2019).

However, mental health needs among children and young people overall have increased between 2004 and 2018, particularly in relation to anxiety and low mood, according to Dr Louise Theodosiou, vice chair of the child and adolescent faculty at the Royal College of Psychiatrists (RCP). 

‘The 2004 national prevalence study identified that about 0.1% to 0.2% of children and young people had PTSD symptoms (although this was based on a small sample), while the follow-on study in 2017 found increased rates of PTSD of 0.6% [NHS Digital, 2019]. This suggests rates of PTSD have risen slightly, but we would need more research to be able to say this definitively.’ 

But perhaps the fact The Lancet Psychiatry study is the first of its kind is the precise reason why we should all be taking notice. As lead researcher, Dr Stephanie Lewis, points out: ‘We conducted the first comprehensive study of trauma and PTSD in a large community sample of British young people… and these findings highlight the scale of trauma and PTSD in British young people for the first time.’

The other salient finding, of course, is the large proportion of young people not receiving the support they need. 

The sample in The Lancet Psychiatry study consisted of twins, many of whom had teenage mothers – older mothers who had their children via assisted reproduction were under-selected to avoid an excess of well-educated mothers (Lewis et al, 2019). But it also represented the full range of socioeconomic conditions in the UK – 25.6% of families researched live in ‘wealthy, achiever neighbourhoods’, 5.3% in ‘urban prosperity neighbourhoods’, 29.6% in ‘comfortably off’ neighbourhoods, 13.4% in ‘moderate means’ and 26.1% in ‘hard-pressed neighbourhoods’ (Lewis et al, 2019).

Risk factors for children

Being female, having a lower IQ or emotional and psychotic symptoms, experiencing victimisation and being at a socioeconomic disadvantage were found to be associated with an increased risk of PTSD in those children who had been exposed to trauma, according to the research (Lewis et al, 2019). For example, one in four were not in education, employment or training at the age of 18, and half had experienced social isolation or loneliness (KCL, 2019).

However, Dr Lewis, also a clinical lecturer in child and adolescent psychiatry at the Institute of Psychiatry, Psychology and Neuroscience, highlights the relevance of the type of trauma: ‘We found that the factors associated with the greatest risk of developing PTSD in trauma-exposed young people was the type of trauma they had experienced. Young people who had directly experienced an interpersonal assault or threat (physical or sexual) were seven times as likely to develop PTSD compared to those exposed to other types of trauma, such as road traffic accidents.’

So the risk of developing PTSD was greatest after a direct interpersonal assault or threat, with sexual assault being particularly high risk – 74% of young people experiencing sexual assault developed PTSD (KCL, 2019).

In its guidance, NICE advises healthcare professionals to be aware of factors that might lead to the development of PTSD, which include experiencing or witnessing single, repeated or multiple events, such as serious accidents, physical and sexual assault, childhood or domestic abuse, and trauma related to serious health problems (see ‘I was seen as a neurotic mother’ below), such as admission to intensive care, war and conflict and torture (NICE, 2018).

 


‘I was seen as a neurotic mother’

Sophie’s son Tom, now 10, was diagnosed with PTSD at the age of five, following surgery and other treatment for hip dysplasia.

‘I think I always knew that his treatment was having an emotional impact,’ says Sophie. ‘Especially when, aged two, he was in a cast from nipple to toe for four months and became mute, only saying “mummy” as we drove away from the hospital when it had been taken off.

‘He would get very angry, even as a little toddler aged two. He had bad separation anxiety – especially with me – so while a lot of his anger was aimed at me, he didn’t want to be apart from me. He was very quiet  at other times, especially if we could get him to school. There was a lot of slamming of doors, to the point where there was hole in his bedroom wall.

‘There was little support from my GP – I was seen as a neurotic mother who was over-compensating for a child who had been through a lot of surgery and recovery at a young age. In the end, I arranged to see a private psychiatrist who spent time with him and us. She diagnosed him and we had various play sessions and strategies at home.

‘At the age of five, a school teacher noticed that he was so quiet and reserved in class that we were referred to CAHMS and had six sessions with a Barnado’s play therapist, who was very good. She would come to the house and had a box of things that made him happy and calm.

‘After that we moved him to a prep school, partly to help him catch up because he repeated a year at the age of six after his pelvis was broken and reconstructed. The school counsellor at the prep school did a couple of terms with him, and is still there if we need her.

‘Once he started at the smaller prep school there was less noise and he felt safe. Things got better and today, aged 10, he is a transformed child.’

Names have been changed


‘PTSD is a condition that might develop after a person is exposed to a very threatening or horrific event,’ says Dr Theodosiou. ‘Whether a person will develop PTSD is connected to how life-threatening they thought the event would be. If people have had an anxiety condition before the event, or a previous traumatic event, this can make it more likely that they will get PTSD.’

Another scenario that led to PTSD in The Lancet Psychiatry study was network trauma – a traumatic event affecting someone the young person knew, which they learned about but did not directly witness (KCL, 2019).

Mental health difficulties are also a risk factor for PTSD – the recent Lancet research found that three in four of the young people who had developed PTSD had another mental health condition at the age of 18, such as depression (KCL, 2019). They were also at high risk of harm to themselves – one in four had self-harmed and one in five had attempted suicide since the age of 12 (KCL, 2019).

‘These findings highlight that young people with PTSD often have complex mental health difficulties,’ Dr Lewis says. ‘And they highlight the substantial impact of PTSD on young people’s lives. For example, young people with PTSD are more likely to struggle with their daily activities and to harm themselves compared to their peers without PTSD.’

The impact

PTSD can affect a young person’s ability to attend school, to concentrate, to enjoy social activities with friends and family and to develop increasing independence, Dr Theodosiou adds, and there are a number of symptoms of PTSD to look out for (see PTSD: the symptoms, below). ‘Sufferers may have repeated flashbacks triggered by sounds related to the trauma, or if they hear about an experience like theirs,’ she says.


PTSD: the symptoms

  • Flashbacks or nightmares about what happened – ‘re-experiencing’
  • Avoidance or emotional numbing – trying to keep busy and avoiding thinking about the event or doing things that might trigger memories of the event
  • Being tense and on guard all the time in case it happens again
  • Anxiety
  • Hyperarousal, including hypervigilance, anger or irritability
  • Problems sleeping and eating
  • Survivor’s guilt – where the sufferer feels bad because others suffered more than them
  • Problems with alcohol or drug abuse
  • Diarrhoea
  • Muscle aches
  • Difficulty remembering all of the traumatic event
  • Negative alterations in mood and thinking
  • Disconnecting from thoughts, feelings or memories – dissociation
  • Emotional dysregulation
  • Interpersonal difficulties or problems in relationships
  • Negative self-perception (including feeling diminished, defeated or worthless)

‘They may avoid the situation or the area where the event occurred, or people who were connected to the event. They may have intensely distressing dreams that might make them reluctant or afraid to fall asleep. They may also be unable to stop thinking about the event, be highly distressed, or constantly looking out for other threats in a hypervigilant manner. PTSD can also cause low mood or increased irritability.’

And if PTSD is left untreated, the symptoms may get worse. ‘Sufferers may become more and more withdrawn and less able to communicate with their family and friends,’ continues Dr Theodosiou.

Without treatment, a substantial proportion of young people with PTSD have persistent symptoms, adds Dr Lewis. ‘Our finding that only a minority of young people with PTSD access mental health services is particularly troubling, because mental health professionals can successfully treat PTSD [with talking therapies, for instance],’ says Dr Lewis. ‘Providing effective treatments early on could prevent mental health problems continuing into adulthood.’ 

Falling through the gaps

As a society we must get much better at identifying when seemingly ‘difficult’ behaviour may be a reaction to a traumatic event, or a sign of emotional distress, says Matt Blow, policy manager at the mental health charity Young Minds. ‘Too often the symptoms of trauma are not recognised well enough or understood,’ he says.

One issue may be that PTSD is missed when other mental health conditions are being treated (Lewis et al, 2019). ‘Our results suggest that young people with PTSD typically present with complex comorbid psychopathology and require comprehensive psychiatric assessment and treatment,’ The Lancet Psychiatry study reads. ‘Clinicians should also be aware that co-occurring psychopathology can mask the diagnosis of PTSD in trauma-exposed young people.’

Matt believes clearer guidance is needed: ‘Professionals need a framework so they know how to look at what’s causing different behaviours and feel confident identifying when a young person may be reacting to trauma.’

Dr Lewis agrees that the high mental health burden and impact of PTSD ‘indicates that it is important for health services to build clinical expertise to identify and address the complex needs of young people with PTSD’.

Young Minds has called on the government to implement a national commitment to addressing childhood adversity, ensuring that all professionals who are working directly with children and young people get proper training about how trauma can affect behaviour, and how best to provide support (Young Minds, 2018a).

‘If a child becomes aggressive with a school nurse who is trying to give them an injection, that could be a response to violence or drug misuse in their family – but the nurse needs clear guidance on how to identify this,’ says Young Minds director of evidence and policy, Dr Marc Bush.

Lack of funds and access

Young Minds has also carried out a series of Freedom of Information requests to find out where the extra £1.4bn the government committed to Child and Adolescent Mental Health Services (CAMHS) in 2015 for a five-year period has gone (Young Minds, 2018b). 

In total, less than 1% of the total NHS England budget is spent on CAMHS, and only 8.7% of the total mental health budget goes on under-18s (Young Minds, 2018b). In 2017-18, 
43% of clinical commissioning groups (CCGs) in England had increased their CAMHS budgets by less than the extra money they had been allocated, and over half of local authorities have actually cut their budget in real terms since 2013-14 (Young Minds, 2018b). 

‘The overwhelming conclusion from our research is that, while the extra investment has made a significant difference - and now represents around a quarter of CAMHS funding overall [in England] – it simply isn’t enough to tackle the crisis,’ the Young Minds research reads.

It’s not clear why so few young people with PTSD access health services, according to Dr Lewis. ‘It’s likely that a combination of factors contributes, including those that prevent young people and their families from seeking help, such as stigma and shame, [as well as] barriers within health services, such as a lack of resources.’

More child and adolescent psychiatrists are also needed, Dr Theodosiou adds. ‘Young people’s mental health needs may not be being recognised because they are not in contact with services and professionals who can adequately assess them and help them to access support.’

What’s your role?

Given the lack of children accessing services, community practitioners (CPs) can play a vital role in getting help for children who may be experiencing PTSD. They’re ideally placed through their contact with young people and families to spot any signs of PTSD, signpost clients to further help and support them in seeking it. The NICE PTSD guideline is a good place for you to start. ‘It can help them recognise specific symptoms associated with PTSD, allowing the child to be referred to their GP, who should take responsibility for the assessment and initial coordination of their care,’ says Paul Chrisp, director for the centre for guidelines at NICE.

‘The guideline also highlights the type of treatments that can be offered, informing the school nurse or health visitor how the child’s care will be managed,’ he adds. 

Governments across all four UK nations recommend that CPs encourage parents of children who are showing the signs of PTSD to visit their GP. 

A spokesperson for the Welsh Government says: ‘GPs are able to offer tailored advice and referral to the most appropriate support service within their area.’

A Department of Health in Northern Ireland spokesperson adds: ‘If a professional or community-based organisation is involved with the young person they can also consult with CAMHS directly for advice and CAMHS may accept the referral directly, advise contact with the GP, or signpost to another service if that seems appropriate. 

‘The Family Trauma Centre, which is delivered by the Belfast Trust, is a regional service that will also consider [direct] referrals and can provide consultation and advice where there may be concerns in respect of PTSD.’

In Scotland, The Anchor, or the Glasgow Psychological Trauma Service, has the specialists to help children and adults experiencing PTSD. ‘Children referred to the service would get specialist help quite quickly here,’ a spokesperson for NHS Greater Glasgow and Clyde says. 

Dr Theodosiou says CPs also have a role to play in offering consolidated care with other healthcare professionals, such as attending appointments with children and families (with their consent) and starting to tell their story with them. ‘It can be difficult to tell a painful story more than once,’ she says. 

The Lancet Psychiatry research has begun to give a clearer picture of PTSD in children and young people. Despite its very real prevalence, it’s important to understand that not all children exposed to trauma will develop PTSD, highlights Dr Lewis. 

‘Most people – including children and young people – experience some psychological symptoms after trauma,’ says Dr Lewis. ‘These symptoms usually subside within days to weeks. If these symptoms persist for more than a month and cause problems with their daily lives, or if the symptoms are very severe, young people and their families should seek support from their GP, who will consider referring them to mental health specialists,’ (see Helping young people to recover from PTSD, below). CPs are well placed to look out for the signs, and point parents in the right direction for help, as part of a network of practitioners around a child or young person. Though, of course, experts point out there are a number of actions that need to happen to ensure young people with PTSD get the help they need.


Helping young people with PTSD to recover

‘PTSD may make sufferers feel ashamed of their symptoms and possibly feel shamed by the traumatic event, so it’s important to work very sensitively with children and young people,’ says Dr Louise Theodosiou, vice chair of the RCP child and adolescent faculty.

She says that work needs to happen within the family – explaining what PTSD is, learning what help a young person may have been offered in the past, and exploring any other mental health problems the child might have.

Dr Stephanie Lewis, clinical lecturer in child and adolescent psychiatry at the Institute of Psychiatry, Psychology and Neuroscience, adds that, based on their understanding of what a child is experiencing, healthcare professionals can make a plan with the child and their family to address these difficulties. ‘This will include referral to mental health professionals who can provide specialist assessment and effective treatments.’

Dr Theodosiou adds: ‘For the first month after a trauma it can be useful to actively monitor the child or young person. If, after a month there are signs of PTSD, or if during the first month the young person is very distressed, then cognitive behavioural therapy can be helpful. Another treatment that is recommended is eye movement desensitisation and reprocessing.’


Resources

  • The Royal College of Psychiatrists has information on PTSD geared towards parents and carers bit.ly/RCPsy_trauma
  • Young Minds – the mental health charity for young people – provides guidance on what PTSD is all about bit.ly/young_PTSD
  • The Mix is a charity offering information, support and guidance to 13- to 25-year-olds experiencing mental health symptoms bit.ly/mix_under25s
  • PTSD UK is a charity helping people with PTSD and their loved ones ptsduk.org
  • Find clinical guidance on PTSD and its treatment from NICE at bit.ly/NICE_PTSD

 

References

 

King’s College London.  (2019). Troubling extent of trauma and PTSD in young people. See: www.kcl.ac.uk/news/troubling-extent-of-trauma-and-ptsd-in-young-people (accessed 15 May 2019).

Lewis SJ et al (2019). The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. The Lancet Psychiatry 6 (3).  See: www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30031-8/fulltext#seccestitle150 (accessed 15 May 2019).

Mind (2019). Dissociation and dissociative disorders. See: www.mind.org.uk/information-support/types-of-mental-health-problems/dissociation-and-dissociative-disorders/#.XNbnBtNKiqQ (accessed 15 May 2019).

NICE. (2018). Post-traumatic stress disorder, NICE Guideline NG116. See: www.nice.org.uk/guidance/ng116 (accessed 15 May 2019).

NHS Digital. (2019)  MHCYP 2017: Trends and characteristics. See: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017 (Excel document, accessed: 21 May 2019)

NHS Digital. (2018). Mental health of children and young people in Great Britain, 2017. See: digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017 (accessed 19 May 2019).

Therrien A. (2019) PTSD affects ‘one in 13 by age of 18’. See: https://www.bbc.co.uk/news/health-47317891 (accessed 19 May 2019)

Young Minds. (2019a) Why I had a year out of school for my mental health. See: https://youngminds.org.uk/blog/why-i-had-a-year-out-of-school-for-my-mental-health/ (accessed 19 May 2019).

Young Minds. (2019b) PTSD. See: https://youngminds.org.uk/find-help/conditions/ptsd/#the-symptoms-of-ptsd (accessed 29 May 2019).

Young Minds. (2018a)  Government must “break the cycle of trauma” to tackle children’s mental health crisis. See: youngminds.org.uk/about-us/media-centre/press-releases/government-must-break-the-cycle-of-trauma-to-tackle-children-s-mental-health-crisis/ (accessed 15 May 2019).

Young Minds. (2018b) Children’s mental health funding: where is it going? See: https://youngminds.org.uk/blog/childrens-mental-health-funding-where-is-it-going/ (accessed 15 May 2019)

 

Image credit | iStock

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