Trauma-Informed Practice: Policy context
Suzanne Cheng, Rachel Dickinson, Tony France, Dr Kristine Hickle, Lynn Miles, Sarah Morgan, Sarah Naish and Charlie Taylor
Monday, September 23, 2019
Adversity and trauma
By Lynn Miles, lecturer in education at Teesside University
Research suggests that by the age of 18, half of our children will have faced one adverse childhood experience and 10 per cent will have suffered four or more. These experiences include physical, emotional and sexual abuse, neglect, living in a household where there is addiction, mental illness or domestic violence, financial hardship or familial imprisonment.
Trauma is one of the possible outcomes of exposure to adversity. It occurs when a person perceives an event or set of circumstances as extremely frightening, harmful or threatening - either physically, emotionally or both. Some experiences can be so overwhelming for children and young people that they create a sense of terror and helplessness in the short-term, which can be triggered without warning later in life. If this trauma is not processed, ideally within a genuine, empathetic relationship, the trajectory of a child's future is likely to be significantly altered.
Such experiences impact children and young people's neurological, social, emotional, sensorial, physiological, moral and cognitive development. They have a harmful effect on relationships, school experiences, behaviour, self-image, world view, physical and mental health, mortality and life chances.
In addition, when children experience adversity that is extreme, severe and long-lasting without adequate support from a care-giving adult, the stress response system - fight, flight or freeze - becomes over-activated and recalibrated. This is known as "toxic stress" and over time it gradually wears down the body and brain.
Impact on behaviour
For practitioners to be effective when working with children and young people who have been traumatised, they first need to fully understand the impact that trauma has and how it manifests in their behaviour.
Traumatised children's behaviour often makes no sense to adults and can seemingly come out of nowhere, but when triggered a child's biological instinct to survive kicks in and their reaction is their maladaptive way to ensure this happens.
These children have been hurt and are in pain, so rather than punish their behaviours we need to treat them with love, forgiveness, empathy and non-judgmentally; empowering them through voice and choice and truly seeing, hearing and valuing them. This can be done in three ways: creating safe environments, building trusting relationships and supporting and teaching emotional regulation skills.
We need to ask a child "what's happened to you?", rather than "what's wrong with you?", be curious about their behaviour and not take it personally, offer unconditional positive regard, take the time to identify and meet their unmet needs, respond rather than react and equip them with the life skills they have not yet had an opportunity to develop - then we can begin to help them heal.
Helping children to heal from trauma is a lengthy process. A consistent, compassionate adult, showing they care and taking time to communicate in a way that is predictable, clear, developmentally appropriate, respectful and kind can change a child's life. These relationships can reshape the child's brain and alter their life course for the better.
Trauma-informed practice with children
By Rachel Dickinson, president of ADCS 2019/20
Lots of children and young people have been exposed to repeated and extended trauma in their short lives - from bereavement, neglect and family breakdown to being affected by serious and scary incidents such as the terrorist attack at Manchester Arena a couple of years ago. These events leave lasting effects; once the initial threat or harm has passed children can exhibit "survival behaviours" to cope with new stressors. Children are more susceptible to stress as a result of traumatic experiences. In the longer-term unaddressed trauma reduces resilience, adds to developmental delays, may impact on the ability to form trusting relationships and increase the likelihood of engaging in risk taking behaviours, from running away to substance misuse.
In recent weeks, new education policies and priorities have been revealed. Apparently there is support for behaviour policies based on zero tolerance and the use of sanctions despite the knowledge this will penalise vulnerable learners. Fixed-term and permanent exclusions have been rising since 2013/14 and learners receiving support from social care, those who are eligible for free school meals or children with special education needs and disabilities are significantly more likely to be excluded than their peers.
The ink is barely dry on the findings of Edward Timpson's review of exclusions yet the narrative from central government has hardened and worryingly may even include the use of reasonable force in classrooms.
I find my thoughts turning with increasing frequency to the disconnect between this apparent new policy direction and the relationship-based approaches used in wider children's services.
We teach children that making academic mistakes in school is a valuable part of the learning process yet behavioural errors are somehow worthy of punishment. The benefits of all schools adopting trauma informed and restorative ways of working, showing empathy and building trusting relationships between learners, their families and teaching or pastoral staff are myriad.
We need to think differently and more inclusively for the benefit of children and their futures. Adopting restorative approaches and being alert to the impact of trauma on a child's wellbeing and development isn't a quick fix nor is it simply warm words. It requires cultural and organisational change, a real investment in staff development and the most precious resource of all, time.
Trauma's impact on offending
By Charlie Taylor, chair, Youth Justice Board (YJB)
In 2017, Her Majesty's Inspectorate of Probation (HMIP) conducted a thematic inspection of public protection work undertaken by YOTs, partly focusing on trauma histories. Of the 115 cases examined, three quarters of children had been through emotional trauma or other deeply distressing experiences. HMIP recommended that "all YOTs should be able to identify and respond effectively to emotional trauma and deliver simple interventions".
Trauma-informed practice asks what has happened to you. It focuses on developing trusting relationships, considers developmental need and assists practitioners to deliver the right intervention at the right time, based on the child's cognitive, social and emotional ability. It can involve multi-agency case formulation guided by a clinical psychologist. This approach helps to make sense of why past events have influenced current behaviour and to guide future responses.
In 2013, Enhanced Case Management (ECM), underpinned by the Trauma Recovery Model, was developed in Wales by the YJB, Welsh Government and Forensic Adolescent Consultation and Treatment Service. An initial independent evaluation of ECM, published in 2017 found 43 per cent of children had not reoffended by the end of the trial - previously all had shown prolific offending behaviour - and the severity of offending for a further 14 per cent of children had reduced. The study concluded that "the ECM approach is helping to create changes in practice and, in turn, improvements in young people's lives". Another ECM pilot has begun in the South West of England and there is a commitment to develop a system-wide approach to trauma-informed practice in Wales.
Youth offending teams (YOTs) are at various stages of embedding trauma-informed approaches. A recent YJB survey of YOTs in England and Wales, found significant evidence of the delivery of trauma-informed training, ranging from awareness of adverse childhood experiences (ACEs) to explanation of the Trauma Recovery Model. Several of the developments in England are supported by funding from NHS England, through a project which is testing how to enhance pathways for children with complex needs.
The Framework for Integrated Care (SECURE STAIRS) is being delivered collaboratively by the NHS, Youth Custody Service and Department for Education in 19 secure settings across England. SECURE is an acronym outlining key components of a trauma informed therapeutic environment and recognising that day-to-day staff and relationships are the primary agents of change. STAIRS describes the approach to creating change through formulation (the child's story), collaboratively developed for all children and young people. Interventions, interactions and all departmental plans are developed from this collaborative approach.
Trauma-informed practice has the potential to benefit children with entrenched offending behaviour - improving their quality of life, relationships with agencies and ultimately reducing the rate and severity of reoffending. Progress is set to accelerate over the next few years as evaluations are published and approaches are developed.
Supporting children in care
By Sarah Naish, Centre of Excellence in Child Trauma
Children that have suffered abuse or neglect will not behave like normal children. Having been shaped by experiences of trauma whilst developing, their behaviour functions from a place of fear. This can manifest itself as violence or rudeness and lead to these children being labelled as "naughty" or "bad". When they act out, their "surface" behaviour is responded to through common parenting techniques such as placing them in time-out, which increases anxiety and fear. It is useful to think about post-traumatic stress disorder (PTSD) as a point of comparison. You wouldn't expect someone suffering from PTSD to be able to ignore stimuli replicating their trauma and you certainly wouldn't make the situation worse. This is what many care institutions currently do to children.
Key to helping children who have suffered abuse is to understand the impact that trauma has had on their brains. Having had their brain development disrupted, these children find themselves with a constant predisposition for a fight, flight, freeze or defensive-rage response. This is compounded by the fact that the source of fear is usually adults - the very people working hard to protect and reassure them. Imagine if you are scared of spiders, you are not bothered whether it is a good or trustworthy spider, your heart pounds and your brain runs very fast looking for the nearest escape route. This is how a traumatised child feels, so it is our duty to help them feel safe and lower anxiety though consistency, empathy and responding to them at their emotional age, rather than their chronological one.
There needs to be more support for parents and guardians and it is proven that policy changes have impact. Since its inception in 2015, the Adoption Support Fund (ASF) has provided much needed support for over 38,000 families. Its purpose is to provide the money to local authorities for essential therapeutic services for adoptive and special guardianship families. The fund has changed the lives of both parents and children by providing access to therapy, training and trauma education, and it is pivotal it is retained beyond 2020.
There needs to be an overhaul in the national understanding of trauma if we are to help children who have had the worst start to life. Taking the ASF as an example, whilst a great initiative, its implementation is littered with examples of a lack of understanding of child trauma such as excluding foster parents from the scheme and not allowing voluntary adoption agencies to apply for support directly. Children are currently being damaged because of a fundamental misunderstanding of how they should be properly cared for. We need to see the government and care services recognise this and start supporting our children therapeutically.
Impact of working with trauma
By Dr Kristine Hickle, senior lecturer in social work and social care, University of Sussex
Practitioners working with traumatised children have the privilege of bearing witness to their experiences and seeing children heal. Despite the hope and possibility in this work, it can also have a lasting negative impact, particularly when practitioners emotionally investing in children's lives are working in contexts that require them to carry high caseloads and where there is insufficient recognition of the work's impact on them. This negative impact is often referred to as vicarious (or secondary) trauma. It can be experienced following a single incidence of witnessing someone else's trauma or an accumulation of working with many traumatised people over time. Symptoms can be similar to PTSD and include changes in a practitioner's overall sense of themselves, feeling unsafe and a loss of trust in others - both professionally and personally.
Practitioners can experience symptoms that are very similar to the traumatised children and families they interact with; they might feel on edge, hypervigilant and always ready for unexpected circumstances to arise. They could also feel a sense of depersonalisation, making connecting with children difficult. They might find themselves engaging in more polarised thinking, a sense of cynicism or even grandiosity, and avoid interactions. Vicarious trauma can also disrupt their worldview, leading them to see the world as dangerous and experience feelings of hopelessness, depression and/or anxiety.
In order to combat the impact of vicarious trauma, practitioners need to begin with an honest self-assessment. They should consider how work impacts their professional and personal life - can they engage in activities that promote self-care, establish healthy boundaries around time at work, including mental/emotional energy spent thinking about work?
Prioritising their own mental health is important - this might include seeking help for their own traumatic experiences; practicing self-compassion; establishing boundaries around time spent on/at work; and develop self-care techniques to draw upon including physical exercise, sleep, mindfulness practices and social activities.
Practitioners also need to be able to talk about the impact the work is having on them in professional contexts. This requires courage but also necessitates an organisational commitment to providing time, space and support so that practitioners can share honestly in forums such as supervision. They need opportunities to debrief after difficult interactions with traumatised service users, and need organisations to accept their stress as legitimate, and that the work will not affect everyone the same way.
It is important to remember that supporting others through their journey of healing can lead to personal growth, positively changed perspectives and a strengthened belief in the resilience and goodness of humanity. Practitioners are best able to see these positive changes in their own lives when they feel equipped with a full range of tools to support themselves in this fulfilling but challenging work, working in environments that engage with them in trauma-informed ways, promoting safety, trust, collaboration, choice and empowerment for both service users and practitioners alike.
Relationship-based work and trauma-informed practice
By Suzanne Cheng, Practice Development Manager, Social Care Institute for Excellence
There has been a recent drive towards relationship-based practice models in children's social work. Trauma-informed practice is one such example of relationship-based approaches that are providing organisations with the opportunity to work with families and to build true connections between practitioners and people who use services. The current system doesn't always allow for a human understanding of what's going on in people's lives, partly because of processes and pressures in those systems.
At SCIE we recently ran an online webinar for social workers on why relationship-based work isn't a new phenomenon - and how social workers are increasingly understanding the need for this type of approach. But what is perhaps not always focussed on is how relationships need to exist at the core of service design and delivery; and indeed the importance of relationships permeating through the whole system.
So, one example of relationship-based work is the role that trauma and lingering traumatic stress plays in young people's lives. According to researchers, a greater understanding of trauma and its effects on war veterans has improved our understanding of trauma in the civilian world; and with children and families who have experienced abuse, neglect, and other traumatic events. It's important for professionals to consider the role that trauma and long-term traumatic stress can play in young people's lives; and to address this.
What I find particularly encouraging about trauma-informed practice is the focus on human connections. Other relationship-based approaches, such as motivational interviewing, strengths-based approaches and restorative practice all have a human element. However, what really inspires me about trauma-informed approaches is the opportunity to understand how past trauma can affect anyone; and, from there, how there is hope for a better future for some children and young people. Past trauma and its burden can massively affect who we are in the present, but it doesn't have to be the story of our future. Being able to work in a therapeutic way with families can start their healing journey and it also has to potential to change their current coping strategies, as long as these are supported by services that are compassionate.
HOW TO RESPOND TO CHILDREN'S TRAUMA
By Tony France, director, Headsight Services
Many of the most vulnerable young people I have worked with over the last 30 years are either within or have experience of the UK care system. These children and young people present particular challenges in terms of trauma; most notably that much of their acute distress and neglect was experienced pre-verbally. What this means is that it happened at a time before they had any level of narrative or language to make sense of, describe or communicate what was happening to them. Effectively, what happens is that there is no ‘story' to what happened so the memory is stored in the body and mind with no context to the experience. This is then compounded by the fact that subsequent behaviours relating to that trauma are often interpreted as difficult, challenging and unpredictable, leading to numerous and repeated breakdowns in family, foster and residential placements which, in turn, replays and re traumatises the young person.
In many ways working with looked-after young people is a process of working with live trauma processing in addition to the historic. Early trauma often presents through ADHD type behaviours, sensory processing difficulties, fine motor and co-ordination challenges and some behaviours commonly associated with autistic spectrum conditions, while the live trauma can lead to aggression, rage, self-harming, substance misuse and dissociation.
However, the core approach to creating an alliance between the child and practitioner is not sophisticated. Using our knowledge and insight into trauma and incorporating that into the relationship means that we work from a principle approach that starts to address the difficulties in the same sequence that they occurred.
Start with activities that can help calm the brain stem and mid-brain areas. Remembering that much of this early trauma is stored in the body, we must engage through trauma releasing exercises and by spending time together oriented around movement. In the first instance this can simply be walk and talk sessions while exploring what other activities might suit them.
Over time we and they begin to experience windows of tolerance where the basic concepts of relationship with self and others can start to be explored. And so we begin the process of providing the relationship that heals.
Why we need trauma-informed schools
By Sarah Morgan, specialist adviser, Shropshire Academy and Learning Trust
For children whose minds, bodies and lived experiences are flooded by the pervasive impact of trauma, schools across the UK are in desperate need of access to intense and therapeutically-informed teacher training.
Schools and initial teacher training providers have an urgent need to review and develop their teacher training and professional development programmes so they move towards the principles of trauma-responsive teaching.
Socially and academically, many schools across the country are desperate to access enhanced training and support to reduce the recent rise in exclusion. Training that will not only build upon their internal capacity, but ultimately empower teachers to further develop their relational skills to positively include the most vulnerable children on their school roll.
Latest Department for Education figures show that in the 2017/18 academic year, the rate of fixed-term exclusions increased for a fourth year running, with 41 schools in England during this period giving a fixed-term exclusion to at least one in five pupils. The data shows that higher rates of exclusion are seen in areas of higher deprivation, where children are attending schools physically and emotionally impoverished and often under-nourished.
Despite a recent and positive rise in discussion about trauma-responsive teaching, it remains clear that we have an education system that continues to marginalise, stigmatise and exclude the most disadvantaged in society, whilst actively discriminating against the very children who require the highest level of psychological understanding, inclusion and support. Academic achievement, data driven targets and league tables are not a priority for emotionally distressed children. These children are wired for survival at the most primitive human level. Their survival-based feelings persistently alarm the amygdala, causing fear-based responses within the confines of a prescriptive curriculum and a crowded classroom.
This is the very dynamic that schools need training and support to understand. It is within this relational interaction that neither punishment, sanction, rejection or reward-based options are congruent or effective.
Exclusion perpetuates the child's feelings of non-acceptance, isolation and shame, and only serves to reinforce their core inner belief that they are unworthy of the teachers time, care and understanding. It also reinforces the child's inner most belief that adults are unable to keep them safe from harm, and that teachers or support staff are unable to emotionally ‘hold' the child's big feelings of trauma, pain, anger and distress.
Too many teenagers are being pushed away from the school gates and into the hands of criminal gangs. It is within these newly found ‘relationships' that children seek an alternative sense of identity, human connection and the relational belonging that they are looking for.
Trauma-responsive strategies are nurturing and therapeutic. They are always based upon the premise of positive human connection and supportive relationships. They are not an add on, but are a whole-school and culturally responsive approach to the increasing needs of so many vulnerable children with in our schools and communities.
- Timpson review of school exclusion, DfE, May 2019
- Trauma-Focused Cognitive Behavioural Therapy Review, Early Intervention Foundation, May 2019
- Mental Health and Behaviour in Schools, Department for Education, November 2018
- A Trauma-informed Health and Care Approach for responding to Child Sexual Abuse and Exploitation, Department of Health and Social Care, May 2018
- Trauma-informed youth justice briefing, Youth Justice Board, September 2017
- Adversity and Trauma-Informed Practice, practitioners guide, YoungMinds