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yingchou-han-IJrIeCs3D4g-unsplash.jpgIt has been well-documented that young people with experience in the child welfare system (hereafter called young people in care) have far higher rates of mental health difficulties than the general population of youth. Many of these young people have experienced trauma and other major childhood adversities, including abuse, neglect, and exposure to domestic and/or community violence. Once in care, many young people find themselves separated from siblings and moving between different homes (and thus, caregivers). Such experiences can have profound and lifelong consequences for mental health and broader well-being. Research reviews estimate at least half of young people in the care system meet criteria for a mental health condition (Bronsard et al., 2016), with rates of many common mental health conditions far higher in these young people than in their peers. Chronic mental health difficulties are also the norm – we found that 70% of young people who are experiencing clinically-elevated mental health difficulties in their first year in care are still experiencing similar or worsened difficulties two years later (Hiller et al., 2023a). This shows that moving into care, which is an intervention in itself, is not always enough to expect improvements in mental health. With the right support, young people in care can thrive, but there remains an urgent need to understand how best to support social care and other systems to provide high quality support.
Much of our research has explored barriers to young people in care accessing best-evidenced support for their mental health needs, with a particular focus on (complex) posttraumatic stress disorder (PTSD). We know that rates of PTSD can be very high in this group of young people (Grasso et al., 2009; Hiller et al., 2021). Our work has also shown that cognitive models of PTSD are applicable, with maladaptive cognitions (e.g., “The world isn’t safe for me”; “It was my fault”; “I’ll never get over this”) being a primary driver of both ‘standard’ PTSD symptoms and complex PTSD symptoms in children and teens in care (Hiller et al., 2021). We also know that trauma-focused cognitive behavioral therapy (CBT) treatments are effective for young people who have experienced multiple traumas (Hoppen et al., 2023). Yet, in practice, at least in the United Kingdom (UK), it is very rare for young people in care to be assessed for PTSD, let alone to have access to best-evidenced treatments.
In our recent work with mental health teams across England, we saw that the vast majority of services were not using standardised mental health screening tools with young people in care (Beyond the Strengths and Difficulties Questionnaire; Goodman, 1997), which is used for government reporting. Partly, this is driven by beliefs that young people in care who are experiencing mental health difficulties do not meet existing diagnostic structures that inform conceptualisations of mental health – despite much evidence to the contrary. Sometimes, there is concern that screening will highlight a level of need in the population that existing service structures do not have the capacity to address. In a recent randomised vignette study, we showed that mental health professionals make different diagnostic decisions when they know a young person is in care. For example, when presented with identical symptom vignettes, if a child was said to be in care, professionals were less likely to identify PTSD and endorse an evidence-based PTSD treatment and were more likely to endorse attachment problems (McGuire et al., 2022).
Related to assessment practices, we also explored what helps and hinders mental health services in the delivery of trauma-focused CBT treatments. Here, a key barrier was that mental health services, particularly services specifically developed for young people in care, are often not commissioned to provide individual psychotherapy. They are solely commissioned to work with the network around the child. Yet, young people in care are rarely referred into systems (e.g., child and adolescent mental health services) that could provide this treatment.  If they are referred, the service might reject the referral because the young person is in care. This creates a difficult cycle, adding to an accumulation of inequity experienced by young people in care.
Mental health and child welfare systems face major challenges – with chronic underfunding and staff shortages a problem in many countries. It is easy to feel overwhelmed by the complexity of challenges facing services and young people. Yet, even within these systems, our implementation work has shown change is possible. First, much can be resolved by ensuring social care and mental health service leadership meet. Such meetings facilitate clearer understandings of pathways and preferred referral practices, clarify misunderstandings, and aide a shared language around mental health. Second, in mental health services, we often found that professionals talked about trauma as a mental health outcome (e.g., “They have developmental trauma”). Yet, developmental or complex trauma can lead to a range of different mental health outcomes. Using ‘catch-all’ terms like ‘developmental trauma’ to describe mental health can mean young people in care miss out on receiving a thorough and comprehensive assessment and formulation of their needs. Mental health assessments should use existing standardised screening tools alongside clinical judgment and include a clear and concise report for appropriate information sharing. Young people should also have the opportunity to have their voices heard in this assessment. Third, the expectation should be that young people in care systems are offered best-evidenced mental health treatments that match their assessed needs. Complexity should not be a reason to discard evidence-informed assessments and interventions (Hiller et al., 2023b). Young people in the welfare system have a right to accurate knowledge of their mental health needs to facilitate appropriate psychoeducation and support.
About the author
Rachel Hiller, PhD, is Professor of Child and Adolescent Mental Health at University College London (UCL) in the United Kingdom, where she leads the Child Trauma & Recovery research group. Her work is in the area of complex child trauma and mental health, with a predominant focus on the mental health and wellbeing of young people with experience of the child welfare system.
Bronsard, G., Alessandrini, M., Fond, G., Loundou, A., Auquier, P., Tordjman, S., & Boyer, L. (2016). The prevalence of mental disorders among children and adolescents in the child welfare system: a systematic review and meta-analysis. Medicine95(7), e2622.

Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A Research Note. Journal of Child Psychology and Psychiatry, 38, 581-586.

Grasso, D., Boonsiri, J., Lipschitz, D., Guyer, A., Houshyar, S., Douglas-Palumberi, H., Massey, J., & Kaufman, J. (2009). Posttraumatic stress disorder: The missed diagnosis. Child Welfare88(4), 157-176.

Hiller, R. M., Fraser, A., Denne, M., Bauer, A., & Halligan, S. L. (2023a). The development of young peoples’ internalising and externalising difficulties over the first three-years in the public care system. Child Maltreatment28(1), 141-151.

Hiller, R. M., Lehmann, S., Lewis, S. J., Minnis, H., Shelton, K. H., Tarren-Sweeney, M., & Taussig, H. N. (2023b). Accommodating complexity: The need for evidence-informed mental health assessments for children in out-of-home care. Journal of the American Academy of Child and Adolescent Psychiatry, 62(1), 12-18.

Hiller, R. M., Meiser‐Stedman, R., Elliott, E., Banting, R., & Halligan, S. L. (2021). A longitudinal study of cognitive predictors of (complex) post‐traumatic stress in young people in out‐of‐home care. Journal of Child Psychology and Psychiatry62(1), 48-57.

Hoppen, T. H., Meiser-Stedman, R., Jensen, T. K., Birkeland, M. S., & Morina, N. (2023). Efficacy of psychological interventions for post-traumatic stress disorder in children and adolescents exposed to single versus multiple traumas: Meta-analysis of randomised controlled trials. British Journal of Psychiatry222(5), 196-203.

McGuire, R., Halligan, S. L., Meiser‐Stedman, R., Durbin, L., & Hiller, R. M. (2022). Differences in the diagnosis and treatment decisions for children in care compared to their peers: An experimental study on post‐traumatic stress disorder. British Journal of Clinical Psychology61(4), 1075-1088.