Addressing the trauma-related distress of young people in care: A randomised feasibility trial across social-care and mental health services

Background: Young people in out-of-home care (Looked after Children; LAC) represent a particularly vulnerable group of youth. A central experience of most is prior exposure to significant, often prolonged, trauma or maltreatment. Rates of posttraumatic stress disorder (PTSD), a trauma-specific mental health outcome, are 12x higher in LAC compared to their peers. Such symptoms can have a devastating impact on LACs wellbeing, including being associated with high rates of psychological comorbidities, as well as elevated suicidality and selfharm, social problems, and behaviour problems. Despite trauma-exposure being a central feature of the pre-care experiences of most LAC, and the consequences of leaving PTSD symptoms unaddressed, there remains no routine screening of these symptoms in LAC and little evidence of effective treatments for this group.

Aims and Objectives: The key aim of this project is to assess the feasibility of conducting a later-stage multi-site RCT that would evaluate the effectiveness of a disseminable and cost-effective intervention for clinically-elevated PTSD symptoms. The two key objectives are to (1) evaluate core procedural and protocol uncertainties necessary for the later-stage scaled-up trial and (2) explore the acceptability of the intervention and key practical considerations from the views of stakeholders.

Methods and Timeline: This project, which will run over 28-months, is a collaboration with Bristol Children's Services and a LAC-specific mental health team (LAC-CAMHS). In Phase 1 (~months 2-10) social workers will be trained to screen 10-17 year olds for PTSD symptoms, using an established short screening tool. Eligible young people will then be invited to participate in the trial (maximum N=50; 25 per arm). Phase 2 (~months 6-24) will be a two-armed parallel-group feasibility RCT. Following consent, young people and their carer will be randomised to either the target intervention (to be delivered within the local LAC-CAMHS) or care-as-usual, where we monitor what support they receive. The intervention is Teaching Recovery Techniques, an established 7-session groupbased trauma-focused programme, with 5-sessions for the young person and 2-sessions for the carer. Feasibility outcomes will primary be assessed via post-intervention qualitative interviews with young people, carers, and service-providers (clinicians and social workers). Young people and carers will also complete questionnaires pre-randomisation (baseline), post-intervention, and at 3-month follow-up, to assess core feasibility
questions around assessments for the future trial (e.g., retention rates, missing data, ceiling/floor effects).

Anticipated Impact and Dissemination: The key output from this trial, if deemed feasible, will be the development of a detailed protocol for a fully-powered multi-site RCT. This work focuses on a group of young people who have some of the worst psychological outcomes of any group of UK youth, yet some of the poorest empirical focus. Thus, findings from the feasibility trial and any future effectiveness trial stand to have significant academic and non-academic impact. The final 4-months of the project will focus on disseminating findings to relevant non-academic audiences (e.g., workshops with Local Authorities, CAMHS) and academic audiences (e.g., papers, conferences), and write-up of the follow-on protocol/application. We have extensive connections with relevant sites/organisations across the UK to support dissemination activities

Most children who have been removed from their family home and placed under the care of a Local Authority have been exposed to many frightening experiences, including witnessing violence, not being fed or cared for, or being abused. These experiences can lead to significant emotional difficulties. One such difficulty is posttraumatic stress
(PTSD), which can involve symptoms like having constant “flashbacks” of scary experiences, and feeling like you are always in danger. This can have a big effect on children’s lives. Yet, we do not have a good idea of how to help young people in care who are experiencing high PTSD symptoms. One idea we have is to use a group-based programme which has successfully helped other young people who have been exposed to different kinds of stressful experiences (for example, war). To test whether this programme
could help children in care too, we first need to see whether social workers have the time to check in with a child about PTSD symptoms; whether young people and their carers are willing to be involved in a research project which will test out the treatment programme; and whether mental health workers might face any problems when
delivering the programme. This project aims to answer these questions. We will train social workers to complete an 8-question interview with 10-17 year olds in care, which will look at their PTSD symptoms. If they are experiencing high symptoms, they will be invited to take part in a research project. If they would like to join the project, children will be randomly selected to take-part in the group programme, or be given care-as-usual. The group programme involves the young person taking part in five weekly meetings, where they will learn skills to reduce their distress, and be supported to work through their difficult memories. Their carers will also take part in two meetings which will teach them how to support their young person.
When developing the project we talked to foster carers and young people in care, along with social-care and mental health staff. We listened to what young people thought would help most, and learnt about problems carers and services face in helping young people. This helped us to create a project that aims to best meet the needs
young people, carers, and services. These groups will continue to provide advice while we complete the project. When finished, we will present the study results in workshops with social-care and mental health staff. We will also present at large conferences about foster care and write a report that we will give to young people and carers. We will use social media, the news, and public lectures to share our findings with the public.