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Meuleman EM, Karremans JC, van Ee E. Stronger together: the longitudinal relations between partner responsiveness, dyadic coping and PTSD recovery. Eur J Psychotraumatol 2024; 15:2358682. [PMID: 38836379 PMCID: PMC11155418 DOI: 10.1080/20008066.2024.2358682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/12/2024] [Indexed: 06/06/2024] Open
Abstract
Background: Past research has primarily focused on negative associations between PTSD and relationships. Therefore, this investigation delves into the potential positive role of these relational aspects in aiding PTSD recovery during treatment.Objective: This study aimed to examine the impact of dyadic coping and perceived partner responsiveness on treatment trajectories of PTSD patients.Method: The study included 90 participants, who were requested to complete online questionnaires twice, with a six-month gap between the measures.Results: The results from linear regression analyses indicated that perceived partner responsiveness had a positive effect on PTSD recovery, whereas dyadic coping had the opposite effect: higher levels of dyadic coping were associated with an increase in posttraumatic stress symptoms over time. Additional examination of the subscales indicated that heightened communication between clients and partners regarding stress was related with increased posttraumatic stress symptoms.Conclusions: These findings underscore the importance and complexity of effective and supportive communication between patients with PTSD and their partners. While existing literature supports both perceived partner responsiveness and dyadic coping as beneficial, this study indicates that only perceived partner responsiveness positively impacted PTSD recovery.
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Affiliation(s)
- Eline M. Meuleman
- Psychotraumacentrum Zuid-Nederland, 's-Hertogenbosch, the Netherlands
| | - Johan C. Karremans
- Behavioural Science Institute, Radboud University, Nijmegen, the Netherlands
| | - Elisa van Ee
- Psychotraumacentrum Zuid-Nederland, 's-Hertogenbosch, the Netherlands
- Behavioural Science Institute, Radboud University, Nijmegen, the Netherlands
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2
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Brewerton TD. Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span. J Eat Disord 2022; 10:162. [PMID: 36372878 PMCID: PMC9661783 DOI: 10.1186/s40337-022-00696-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality. METHODS In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable. RESULTS At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide. CONCLUSIONS The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.
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Affiliation(s)
- Timothy D Brewerton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.
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3
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Berg L, Brendler-Lindquist M, de Montgomery E, Mittendorfer-Rutz E, Hjern A. Parental Posttraumatic Stress and School Performance in Refugee Children. J Trauma Stress 2022; 35:138-147. [PMID: 34275166 DOI: 10.1002/jts.22708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/08/2022]
Abstract
Refugee children in the Nordic countries have been reported to perform poorly in school and carry a high burden of familial posttraumatic stress. The present study aimed to investigate the impact of maternal and paternal posttraumatic stress on the school performance of refugee children. We used national register data on school grades at age 15-16 along with demographic and migration indicators during 2011-2017 in a population of 18,831 children in refugee families in Stockholm County, Sweden. Parental posttraumatic stress was identified in regional data from three levels of care, including a tertiary treatment center for victims of torture and war. Multivariable linear and logistic regression models were fitted to analyze (a) mean grade point averages as Z scores and (b) eligibility for upper secondary school. In fully adjusted models, children exposed to paternal posttraumatic stress had a lower mean grade point average, SD = -0.14, 95% CI [-0.22, -0.07], and higher odds of not being eligible for upper secondary education, OR = 1.37, 95% CI [1.14, 1.65]. Maternal posttraumatic stress had a similar crude effect on school performance, SD = -0.15, 95% CI [-0.22, -0.07], OR = 1.25, 95% CI [1.00, 1.55], which was attenuated after adjusting for single-parent households and the use of child psychiatric services. The effects were similar for boys and girls as well as for different levels of care. Parental posttraumatic stress had a small negative effect on school performance in refugee children, adding to the intergenerational consequences of psychological trauma.
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Affiliation(s)
- Lisa Berg
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.,Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Stockholm, Sweden
| | | | - Edith de Montgomery
- Department of Public Health, Danish Institute for Migration, Ethnicity, and Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Anders Hjern
- Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Stockholm, Sweden.,Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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4
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Mooren T, van Ee E, Hein I, Bala J. Combatting intergenerational effects of psychotrauma with multifamily therapy. Front Psychiatry 2022; 13:867305. [PMID: 36819942 PMCID: PMC9929345 DOI: 10.3389/fpsyt.2022.867305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 12/29/2022] [Indexed: 02/04/2023] Open
Abstract
There is growing evidence that parental trauma is associated with psychosocial disorders, externalizing and internalizing problems, and higher sensitivity to posttraumatic stress disorder (PTSD) in children. Recent research findings suggest multidimensional relational, psychological, and neurobiological interrelated pathways of intergenerational influence. Moreover, the intergenerational effects of parental trauma need to be understood within a broader systemic context, as a part of family adaptation. This article explores research findings and clinical practice to enhance our understanding of intergenerational processes and presents directions for therapeutic interventions. A trauma-focused multi-family therapy, aiming to restrict the relational consequences of parental trauma and strengthen family resilience, is described. The proposition is that to facilitate and improve the quality of parent-child interaction in response to psychotrauma, fostering emotion regulation capacities and mentalization is crucial. These efforts offered through family group interventions may benefit various families coping with adversity in culturally diverse societies.
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Affiliation(s)
- Trudy Mooren
- ARQ National Psychotrauma Centre, Diemen, Netherlands.,Department of Clinical Psychology, Faculty of Social Sciences, Utrecht University, Utrecht, Netherlands
| | - Elisa van Ee
- Psychotraumacentrum Zuid-Nederland, Reinier van Arkel, 's-Hertogenbosch, Netherlands.,Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
| | - Irma Hein
- Department of Child and Youth Psychiatry, Amsterdam Academic Medical Center, Amsterdam, Netherlands
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5
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Maternal secure base scripts predict child attachment security in an at-risk sample. Infant Behav Dev 2021; 66:101658. [PMID: 34768047 DOI: 10.1016/j.infbeh.2021.101658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/23/2022]
Abstract
Accumulating evidence indicates that individuals possess attachment, or secure base, scripts based on experiences with attachment figures, and these attachment scripts predict important outcomes such as caregiving behaviors and offspring social-emotional adjustment. However, less is known about the association between parents' secure base scripts and child attachment security within at-risk samples, i.e., those known to be at greater risk for insecurity. The current study examined the relation between maternal secure base script representations and child attachment security by extending the use of the Attachment Script Assessment (ASA; Waters & Rodrigues-Doolabh, 2004) to an at-risk sample. One-hundred mother-child pairs from a larger longitudinal study participated; the larger study focused on psychosocial risks related to parenting in a primarily low-income sample. In the present study, overall ASA script scores were first compared with two independent middle-class samples, one from a U.S. study, the other an international study. Scores and statistical patterns were comparable across all samples, indicating that the ASA was successful in tapping into maternal secure base script knowledge in our at-risk sample. The relation between maternal script scores and children's Attachment Q-Set (AQS; Waters, 1995) security scores were examined at ages 1 and 2 years. Dependency scores from the AQS were also included to establish discriminant validity for the script scores. Results indicated that maternal script knowledge predicted child security, while showing no relation to dependency scores. Findings indicate that the ASA can be an important and viable measure for assessing attachment representations in at-risk samples of caregivers.
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Schestag L, Mehner‐Gentner J, Stein L, Rossi H, Fischmann T, Leuzinger‐Bohleber M, Fritzemeyer K. Ghosts in the nursery in exile—Supporting parenting in exile during the COVID‐19 pandemic. INTERNATIONAL JOURNAL OF APPLIED PSYCHOANALYTIC STUDIES 2021. [PMCID: PMC8239545 DOI: 10.1002/aps.1702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The early prevention project “Strong together!” supports refugee parents and their young children (0–4 years) in Berlin, Germany. It aims to mitigate the transmission of trauma to the generation born in exile. For refugee families who have only recently arrived in Germany, the COVID‐19 pandemic poses a particularly great challenge. Not only are they confronted with numerous challenges in respect to re‐building their lives in Germany after fleeing war and persecution, but are also vulnerable to conscious and unconscious anxieties, fantasies, and conflicts evoked by the pandemic and the threat it poses to their lives. This was observed in the context of the mother–child groups of “Strong together!”. Many expressed great insecurity, heightened levels of anxiety, re‐experiencing of traumatic scenes, and over‐strictly self‐isolating themselves and their children, even attraction to fundamentalist ideologies. In this paper, some of the empirical and clinical findings of “Strong together!” are summarized and reflected on within a framework of psychoanalytic trauma theory.
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Affiliation(s)
- Lena Schestag
- International Psychoanalytic University Berlin Germany
| | | | - Lea Stein
- International Psychoanalytic University Berlin Germany
- Kindergesundheitshaus e.V. Berlin Germany
| | - Hildegard Rossi
- Kindergesundheitshaus e.V. Berlin Germany
- Vivantes Klinikum Neukölln Berlin Germany
| | | | - Marianne Leuzinger‐Bohleber
- IDeA (Individual Development and Adaptive Education of Children at Risk) Center Frankfurt/Main Germany
- University Medicine, Mainz Mainz Germany
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7
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Khan F, Eskander N, Limbana T, Salman Z, Siddiqui PA, Hussaini S. Refugee and Migrant Children’s Mental Healthcare: Serving the Voiceless, Invisible, and the Vulnerable Global Citizens. Cureus 2020; 12:e9944. [PMID: 32968603 PMCID: PMC7505673 DOI: 10.7759/cureus.9944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Millions of children are on the run worldwide, with many unaccompanied children and adolescents undertaking risky journeys to flee war, adverse circumstances, and political persecution. The grueling journey and multiple stressors faced by the refugee children, both accompanied and unaccompanied during the pre-migration, migration, and in the country of destination, increase their risk for psychiatric disorders and other medical conditions. Unaccompanied refugee migrant children have higher prevalence of mental health disorders than accompanied refugee peers. Long after reaching the host country, the refugee, migrant, and asylum-seeking juveniles continue to face adversities in the form of acculturation. In assessing medical fitness and healthcare mediations for refugees and migrant children, special consideration should be given to certain areas such as their distinct history, whether they are with their family or separated or unaccompanied, and whether they have been peddled or have been left behind.
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8
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Mevissen L, Ooms-Evers M, Serra M, de Jongh A, Didden R. Feasibility and potential effectiveness of an intensive trauma-focused treatment programme for families with PTSD and mild intellectual disability. Eur J Psychotraumatol 2020; 11:1777809. [PMID: 33029319 PMCID: PMC7473050 DOI: 10.1080/20008198.2020.1777809] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Persons with mild intellectual disabilities or borderline intellectual functioning (MID-BIF; IQ 50-85) have a higher risk of being exposed to traumatic events and developing posttraumatic stress disorder (PTSD). EMDR therapy has shown to be applicable, safe and potentially effective for the treatment of PTSD in individuals with MID-BIF. However, in traumatized multi-problem families with MID-BIF and (impending) out of home placement of children, standard PTSD treatment in an outpatient setting may not be appropriate. OBJECTIVE To evaluate the feasibility and potential effectiveness of KINGS-ID, a six-week clinical trauma-focused treatment programme consisting of intensive EMDR therapy with parents and children, and parental skills training followed by two weeks of parent support at home. METHOD Six families (nine parents of whom six had MID-BIF) and 10 children (all having MID-BIF) participated in the KINGS-ID programme. Seven parents and seven children had PTSD. Data were collected within a single case study design. For each family member data were collected during baseline (three measurements), treatment (seven weekly measurements), posttreatment (three measurements) and at follow-up (three measurements). RESULTS None of the family members dropped out. Within the first two treatment weeks all but one child and one parent no longer met PTSD symptom criteria. In both children and parents, trauma-related symptoms and daily life impairment significantly decreased following treatment and in parents a significant decrease in symptoms of general psychopathology and parental stress was found. Results were maintained at six-month follow-up. CONCLUSIONS The findings of the current study are promising given that the treatment programme seems to offer new perspectives for traumatized multi-problem families with MID-BIF.
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Affiliation(s)
| | | | | | - Ad de Jongh
- Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands.,Research Department, PSYTREC, Bilthoven, The Netherlands.,School of Health Sciences, Salford University, Manchester, UK.,Institute of Health and Society, University of Worcester, Worcester, UK.,School of Psychology, Queen's University, Belfast, Northern Ireland
| | - Robert Didden
- Trajectum, Zwolle, The Netherlands.,Behavioural Science Institute (BSI), Radboud University, Nijmegen, The Netherlands
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9
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Reflective Functioning of Refugee Mothers with Children Born of Conflict-Related Sexual Violence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082873. [PMID: 32326331 PMCID: PMC7216145 DOI: 10.3390/ijerph17082873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 12/03/2022]
Abstract
The ability of a parent to step back from their own experiences in order to understand those of their child, reflective functioning (RF), can be impacted by myriad factors. We explored RF among refugee mothers in the context of having a child born of sexual violence (CBSV). A sample of 10 mothers now residing in the Netherlands, both with (n = 5) and without (n = 5) a CBSV, were interviewed, seeking to explore parents’ representations of their children, themselves as parents, and their relationship with their children. After deriving a score of RF, interview narratives were qualitatively analyzed using thematic analysis. An ordinary level of reflective functioning was identified in this sample overall (average score 4.5); which was reduced in the group with CBSV (average score 3.0). Trends within the qualitative analyses indicated that emotion regulation and ambivalence as well as parenting challenges are factors that affect RF capabilities for mothers with CBSV. Wider findings show that the asylum process and mental well-being also impinge on RF capabilities. Experiences of having a CBSV as well as those pertaining to being a refugee appear to interact and impact reflective functioning for some mothers. Further investigation would add weight to this pilot data.
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10
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Eruyar S, Maltby J, Vostanis P. How do Syrian refugee children in Turkey perceive relational factors in the context of their mental health? Clin Child Psychol Psychiatry 2020; 25:260-272. [PMID: 31648532 DOI: 10.1177/1359104519882758] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although there has been increasing attention on the impact of risk and resilience factors on refugee children's mental health, there has been limited evidence on the role of parental factors to inform interventions, and this predominantly relies on adult reports. The aim was to investigate the relationship between perceived parenting styles and attachment relationships and child mental health, as reported by 322 Syrian refugee minors aged between 8 and 17 years in Turkey. Child-rated scales included the Children Revised Impact of Event Scale-8 (CRIES-8), Strengths and Difficulties Questionnaire (SDQ), Security Scale and Egna Minnen Betraffande Uppfostran for Children (EMBU-C), and were used as measures of post-traumatic stress disorder (PTSD), general mental health problems, attachment relationships and perceived parenting styles, respectively. Children with secure maternal and paternal attachment perceived their parents as less rejecting, while children with secure paternal attachment also reported their parents as emotionally warmer. Attachment relationships significantly contributed in predicting PTSD after controlling for age and gender, while conduct problems were predicted by lack of emotional warmth, rejection and over-protection by both parents, in addition to insecure attachment relationships. Refugee children's views are essential in establishing their needs and planning interventions. These should address both the impact of trauma and current family relationships.
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Affiliation(s)
- Seyda Eruyar
- Faculty of Social Sciences and Humanities, Necmettin Erbakan University, Turkey
| | - John Maltby
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, UK
| | - Panos Vostanis
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, UK
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11
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Punamäki RL, Qouta SR, Diab SY. The role of maternal attachment in mental health and dyadic relationships in war trauma. Heliyon 2019; 5:e02867. [PMID: 31890934 PMCID: PMC6926227 DOI: 10.1016/j.heliyon.2019.e02867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/01/2019] [Accepted: 11/12/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Infant care is a demanding task in dangerous war conditions, but research on the wellbeing of mother-infant dyads is mainly available in peaceful conditions. Knowledge on protective versus risking processes is especially vital for tailoring effective help, and the present study proposes the maternal attachment style to play an important role in dangerous war conditions. OBJECTIVE The study analyses, first, how various traumatic war events, such as losses, horrors and life-threat, are associated with maternal mental health and dyadic mother-infant interaction quality, indicated by maternal emotional availability (EA). Second, it tests a hypothesis that maternal insecure attachment risks and secure attachment protects good mental health and optimal EA from negative impacts of traumatic war events. METHOD The prospective three-wave study involved 502 Palestinian mothers, who were pregnant during the 2014 War on Gaza, and participated at delivery (T1), and when the infant was seven (T2; N = 392) and eighteen (T3; N = 386) months. Mothers reported about war events at T1 and T2 (death and losses, witnessing horrors and life-threat), and posttraumatic stress disorder (PTSD) and depression symptoms at T2 and T3. Dyadic interaction quality was assessed by mother-perceived emotional availability (EA) scale at T2 and T3, and attachment styles by mothers' self-reports at T3. RESULTS Death and losses, witnessing horrors, and life-threat were all associated with a high level of maternal PTSD, but only at T2, whereas death and losses were associated with her depressive symptoms both at T2 and T3. Witnessing horrors was associated with a low close and positive and a high distant and negative emotional availability at T2 and T3. As hypothesized, maternal avoidant attachment was associated with a low level of close and positive EA in general, and especially when the dyads were exposed to a high level of traumatic war events, thus indicating a risking function. Against the hypothesis, secure attachment did not show any protective function on emotional availability, while, unexpectedly, maternal preoccupied attachment was associated with close and positive emotional availability, when dyads were exposed to a high level of traumatic war events. CONCLUSION Mothering in conditions of war and military violence is an overwhelmingly demanding task, and mother-infant dyads need legal, social, and psychological assistance. Knowledge and reflection of unique responses and meanings of different attachment styles would be fruitful in tailoring effective help.
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Affiliation(s)
- Raija-Leena Punamäki
- Tampere University, Faculty of Social Sciences, Department of Psychology, Finland
| | - Samir R. Qouta
- Doha Institute For Graduate Studies, Qatar
- Islamic University Gaza, Department of Education and Psychology, Gaza, Palestine
| | - Safwat Y. Diab
- Tampere University, Faculty of Social Sciences, Department of Psychology, Finland
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12
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Hodes M. New developments in the mental health of refugee children and adolescents. EVIDENCE-BASED MENTAL HEALTH 2019; 22:72-76. [PMID: 30944095 PMCID: PMC10270370 DOI: 10.1136/ebmental-2018-300065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/31/2019] [Accepted: 02/13/2019] [Indexed: 12/22/2022]
Abstract
The increase in refugees globally since 2010 and the arrival of many into Europe since 2015, around 50% of whom are under 18 years, have been the stimulus to greater investigation and publications regarding their mental health. This clinical review summarises selected themes in the field as described in the published literature since 2016. The themes include refugee statistics, premigration and postmigration experiences, psychopathology focusing on parent-child relationships, unaccompanied refugee minors and associations between resettlement, acculturation and mental health. Some important reviews and studies are discussed that address service and treatment provision. While there has been a recent increase in research in this field, more is needed into the course of psychopathology, protective factors and the promotion of integration into resettlement countries, as well as models of service delivery and treatment effectiveness.
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Affiliation(s)
- Matthew Hodes
- Department of Medicine, Centre for Psychiatry, Imperial College London, London, UK
- Westminster Child and Adolescent Mental Health Service, Central and North West London NHS Foundation Trust, London, UK
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