Trauma-Informed Practice: Policy context

However, consistent themes emerge from academic literature, which, helps to describe what trauma-informed practice looks like. NPC in its guide to trauma-informed approaches suggests five principles for developing trauma-informed care. These are:

1. Recognise and respond to trauma – understand the extent of trauma among the group of children you support and ensure services do not inadvertently retraumatise them.
2. Provide safe environments – collaborating with users of services can minimise the risk of them being retraumatised. Trauma-informed care avoids putting people in situations that reminds them of previous trauma.
3. Take a strengths-based approach – successful services build on what people are capable of doing so they feel empowered to support their own recovery. Trauma-informed practice involves understanding the connection between a person’s experiences and the difficulties they face.
4. Build empowering relationships – trauma can be triggered by misuses of power so power-based relationships between the professional and service user can trigger distress responses in survivors, so give young people a say over how services are delivered.
5. Equality of access – At the heart of trauma-informed care is a recognition of the needs of each individual. Everyone deserves equal access to good quality treatment which takes account of the unique context of their life.

The NPC guide explains that for an organisation to deliver trauma-informed care it needs to apply to all aspects of the design and delivery and be underpinned by a culture of thoughtfulness across the organisation. It says leaders “need to provide committed and effective leadership to initiate and sustain such a significant operational and cultural change, supported by appropriate governance”.

Some organisations have had success in appointing “trauma champions” tasked with the day-to-day delivery of trauma-informed services. Such a model has been implemented by youth homelessness charity St Basils (see practice example).

• Read more in CYP Now's special report on trauma-informed practice

Crucial to the success of implementing an organisation-wide approach is providing training in trauma-informed practice for all staff (see Islington Council practice example). They need to understand the benefits of working in a trauma-informed way with support and supervision provided to enable this to flourish.

Another key part of the approach is to promote a culture that supports staff wellbeing, including careful supervision, manageable workloads and leadership that “fosters a culture of trust”.

Trauma and the pandemic

The coronavirus pandemic has had a significant impact on children and young people’s lives. It has increased the experience of trauma for many, and compromised the support which children and young people receive from friends, family and public services.

The UK Trauma Council, a coalition of leaders from a range of organisations across the children’s sector, has warned that without “a specific focus and sustained energy from governments” young people’s needs will go unmet with potentially long-term negative consequences (see research evidence).

“The focus should now be on understanding the impact of trauma on children’s development and wellbeing, and responding appropriately,” the council states in its briefing paper Beyond the pandemic: Strategic priorities for responding to childhood trauma.

“Trauma…can have lasting consequences for the child or young person’s development, including psychological, behavioural and emotional problems. These can occur into and throughout adulthood, presenting related challenges in many aspects of their life.”

The council has developed four recommendations to address childhood trauma in both the short and long term that it says policymakers should prioritise in their response to the pandemic. This includes prioritising trauma recovery in national and local strategies, investing in specialist mental health provision and ensuring staff are trained to deliver the most appropriate evidence-based interventions while the wider workforce is able to recognise and respond appropriately to children showing signs of trauma, and shifting towards a prevention focused model of care.

The council emphasises the need for “sustained impetus” to ensure children can call on consistent and effective response post the pandemic. The extent of the need is likely to be seen across the age ranges – 42 per cent of nursery staff in a recent survey conducted by the Anna Freud Centre said pre-school children’s behaviour and mental health had been affected by the pandemic (see graphics) while numerous studies have shown lockdowns and school closures have had a detrimental effect on many children and young people.

Here, five experts from across the sector discuss how the pandemic will impact children’s trauma and the practice response.

Covid is another traumatic life event children will need support to overcome

By John Simmonds, director of policy, research and development, CoramBaaf

There is now considerable evidence about the impact of traumatic experiences resulting from maltreatment on the short- and long-term development of children. Trauma can work against children’s subjective capacity to trust others, to feel safe and to have hope for the future. It can impact on their relationship with their parents or other carers and the wider group of people that typically form the social world of most children. Adaptability, problem solving resilience and resourcefulness are core features to individual development over time, but trauma can interfere with this developmental process with severe consequences.

Along with our existing understanding of the causes and consequences of trauma we must now add the impact of Covid. We are aware that the pandemic is affecting a significant part of the population aside from the direct effects of the infection itself, with the impact on the wellbeing and mental health of children and young people now clearly identified as one of its most serious underlying consequences.

Let’s start with first principles by addressing what “should” happen in healthy development. Babies are born with powerful biological systems that enable survival and promote development. As well as these internal processes, there is a significant degree of dependence on other human beings to instinctively facilitate survival and further development – typically parents but other family members too. Babies signal their needs by crying or physical movement and over time this will be further facilitated by language. Development over childhood sees most individuals evolve to a high degree of independence.

For every individual, their development will include the ways in which they come to adapt, to learn and problem solve. These developments will become embedded in the routines of daily living and the confidence and predictability that this brings. But there are always the unpredictable and unknowns that accompany this. Memory, environmental awareness and prediction play a part in assessing the unknowns. For some people these “ordinary” challenges will be escalated where the degree of threat is significant and immediate protective actions need to be taken. This can be thought of as flight (from the event), fright (at the event) or fight. The purpose of these actions, whether physical or psychological, is to ensure survival.

While actions may be appropriate in the here and now, the risks lay in the lessons that the body and mind take often with a heightened sensitivity to the potential of a threat and the escalation of the response to threat. The original traumatic experience actively lives on in the mind and body even though the threat no longer exists. The phone rings, there is a knock on the door, the family member is 10 minutes late, what is that smell?

The impact of trauma can result in significant harm to development. There is now considerable evidence about the impact of trauma resulting from maltreatment on the short- and long-term development of children. They can trap these children in their subjective capacity to trust others, to feel safe and to have hope for the future. This can impact on their relationship with their parents or other carers and a wider group of people that typically form the relational world of most children. Adaptability, problem solving, resilience and resources are core features to individual development over time but traumatic, instinctive memory and defensive responses will interfere with this development with severe consequences.

Trauma covers a wide range of stress-related factors. These can be brought on by single, one off events such as the Grenfell Tower fire, the Manchester Arena bombing, or incidents of youth violence. There are also multi-incident trauma issues that result from repeated traumatic events such as domestic violence or child maltreatment – such as physical, sexual and emotional abuse or neglect. Now we can add the impact of Covid, a significant new challenge to the emotional wellbeing of a generation of children and young people.

The immediate and longer-term impact of these issues are often serious, although that will vary depending on individual circumstance and resilience and the availability of personal support networks as well as professional services.

As government grapples with how best to achieve a population-wide recovery, that must include specific services to children and young people as well as those who are at the core of caring for them on a day-to-day basis – parents and wider family and friends. Some children will need ready access to trauma informed professionals – health, education and social care. Understanding and treating trauma has moved significantly up the agenda in recent years. Sadly, Covid has made this an even more pressing priority.

Pandemic has overwhelmed children’s mental health – a trauma-informed response can aid their recovery

By Anna Feuchtwang, chief executive of NCB and member of the UK Trauma Council

Reports that referrals to the Maudsley Hospital’s child and adolescent mental health unit had risen by 42 per cent between February and November last year, provided a stark reminder of the impact that the pandemic is having on many children’s mental health.

The isolation and anxiety brought on by the virus have affected the happiness and emotional wellbeing of many children and young people in the country. In our recent research into the effect of the pandemic, young people described the corrosive mix of boredom and stress they experienced during lockdown.

But for some the experiences of the last year will have been so extreme that it has overwhelmed their ability to cope. For them, the pandemic has crossed the line from being a challenge to their mental health, to being a traumatic event that can feel impossible to shake off. Or, it will have triggered a response building on previous traumatic experiences.

For a start, there are the children who have been bereaved as a result of Covid-19 and other causes, whose grief has been made unbearably painful by social restrictions, leaving them unable to spend time with dying loved ones, or attend funerals.

We have also seen many families burdened with additional financial pressures as unemployment soars, with millions more placed on furlough. The shattering knock-on effects on family life may be reflected in the rising numbers of domestic abuse offences in England and Wales. And the Council for Disabled Children recently reminded us of the plight of some children with complex needs who have been effectively ‘incarcerated’ for a year.

The mental health burdens brought on by the pandemic come on top of an already precarious situation. Research by University College London’s Centre for Longitudinal Studies in partnership with NCB, provides evidence of widespread and severe mental health difficulties among the UK’s ‘Generation Z’ even before the Covid-19 pandemic struck. The virus is likely to have made things worse, a trend reflected in stark statistics from Childline, which conducted counselling sessions with nearly 21,000 children and young people with suicidal thoughts between April 2020 and January this year.

The long-term impact of the added trauma brought on by the pandemic is only starting to be understood; but for some the experiences of the last year will have been so extreme that there may be a risk of them suffering a range of poor outcomes later in life – including increased risk of heart disease, diabetes, obesity, depression, substance abuse, smoking, poor academic achievement, time out of work and early death.

The good news is that, with the right support, it is possible to limit the damage and help children recover from trauma. Providing access to trauma-informed care should be a national and local priority, so that practitioners are alert to the different ways in which the symptoms of trauma can come to light.

This means properly funding specialist help within local mental health services, but also supporting the broad range of professionals working with children and young people to respond confidently and constructively when a child presents with a traumatic response.

Trauma-informed practice should be a central element of our work to meet the mental health challenges that have overwhelmed many children during the pandemic.

Children’s services must deploy trauma-informed responses to pandemic

By Jenny Coles is ADCS president and director of children’s services in Hertfordshire

Due to its unfamiliarity and unpredictability, the pandemic is clearly a stressful and traumatic event. Although the full impact of our shared Covid-19 experience on both individuals and society remains to be seen, we know that far greater numbers of children and young people will have been exposed to repeated and extended trauma, including bereavement and family breakdown, by the time this is all over. Many more will have felt scared or confused by how radically their lives can change with little or no notice.

Vaccines alone won’t help us fully recover from this experience. Beyond the economy, emotional health and mental wellbeing must be firmly on the national recovery agenda. People of all ages will need reliable, long-term support to come to terms with losses and a future that is different than they imagined.

In the wake of previous epidemics, higher prevalences of psychological problems such as post-traumatic stress disorder, psychological distress, depression and anxiety were recorded amongst the general population. This certainly chimes with the outcome of recent research and health surveys, plus children and young people regularly cite emotional health as one of their top concerns at this time.

Covid-19 has clearly intensified the challenges many children and families face and its impact is now evident at the front door of children’s early help and social care, in the rising number of benefit claims, increased homelessness, hunger and greater demand for mental health support.

There are lessons for us to draw from disaster recovery too. Here the need for targeted support to mitigate longer term effects on children’s wellbeing and development is underlined as well as a universal component emphasising wellness and resilience, typically via schools. A public health style approach to recovery could accelerate the use of trauma informed and restorative ways of working via the incorporation of these principles into policy and practice across the spectrum of public services. It is easy to see the benefits of building strong, trusting relationships between learners, their families and school staff, for example. The clear line of sight school leaders now have into their pupil’s family life is a strong foundation for this shift coupled with the strengthened relationships between schools, local authorities plus the voluntary and community sectors.

The pandemic has impacted on almost every aspect of our work with children, young people and families. The longer it persists, the greater the risk of physical, mental and emotional fatigue and exposure to secondary trauma on our staff and communities. There are many challenges as well as opportunities for us as employers too. A trauma informed response acknowledges difficult experiences and focuses on what is needed for recovery. It will require a commitment to cultural and organisational change as well as investment at both a local and national level.

Using trauma-informed approaches in everyday practice can help staff support children

By Sue Penna, creative director, Rock Pool CIC

Data collated by the Department for Education’s State of the Nation 2020: children and young people’s wellbeing research report presents a surprisingly positive response to the wellbeing and happiness of children despite media coverage suggesting children are going to suffer from mental health problems, isolation and behaviour disturbances.

Too often discourse has centred around medicalising and criminalising children and young people rather the taking a trauma-informed view that can “normalise” and “simplify” their experience and so make it manageable within families and communities without expert intervention. However, what we do know is that this is not an equal opportunities pandemic: children already living in a household where there are challenges will be disproportionality affected by this virus through lack of schooling, limited IT and connectivity, hunger, poverty insecure housing, and exploitation by gangs and abusers. We need to focus on engaging these children and families to prevent the potential for a huge social divide in the future.

The five guiding principles of a trauma-informed approach are: safety, trustworthiness, choice, collaboration and empowerment. Ensuring that the physical and emotional safety of an individual is addressed is the first important step to providing trauma-informed care.

A trauma-informed approach has potential to support children and young people that have been adversely affected by the pandemic; focusing on the psychological safety of the client and the trustworthiness of the practitioner is one of the main conduits to helping those that are traumatised.

Reassuring children that you understand why they are behaving the way they are and that it is because something has happened to them rather than they are a bad child is paramount in re-establishing and maintaining relationships.

One of the most useful approaches is using psychoeducation to inform individuals about the evidence behind their experiences. Talking to children and young people about the body responses they are experiencing when they are struggling to manage their emotions can enable them to take some control of their bodily sensations back – teaching grounding and relaxation techniques can also help a child find a way to feel a sense of personal safety.

Many practitioners are, as part of their own best practice, using a trauma-informed approach without identifying it as such. Trauma-informed working is not a set of techniques we learn but is a way of “being” with the children we work with, of making a genuine authentic relationship with them and working out how to give support without retraumatising them.

To ensure the trauma-informed approach succeeds, what is crucial is the support to frontline staff to keep them psychologically safe and informed. If we don’t support the staff, we can’t support the children.

• Sue Penna is author of The Recovery Toolkit
  
  

Childcare staff need support to meet pre-schoolers’ trauma needs

By Michela Biseo, deputy head of the Early Years Programme (Clinical), The Anna Freud Centre

The Anna Freud Centre has released the findings of a new survey, Their Challenges Are Our Challenges, revealing that a high proportion of nursery staff have experienced working with children facing extremely complex backgrounds and challenging emotional and behavioural needs. Many admitted that they had found these needs difficult to manage.

Nursery workers and early years staff have been at the forefront in the pandemic, providing vital childcare for parents and carers juggling work and home schooling. They have had to adapt rapidly to a world of “bubbles”, while attempting to reassure parents, carers and children that their settings are safe and welcoming.

This enormous challenge requires staff to contain their own anxieties in order to retain a comforting, familiar and creative space that families feel they can settle back into. These new findings confirm that early years workers often support children who are extremely vulnerable, and that nursery workers may not always know how best to work with such complexities as abuse, loss or neglect.

The impact of the pandemic on families has undoubtedly added to these stresses. Staff see increased anxiety around strangers than they would usually expect in this age group. Mask wearing has proved frightening to some children and can impair the usual “getting to know each other”. While children seem to have become accustomed to a world of masked adults, we don’t know the longer term impact this will have. Many babies and young children will also be struggling to understand why people in their lives have disappeared – following, for example, the death of a grandparent.

Nursery heads have responded to the crisis by striving to offer high-quality, child-centred care while negotiating new ways of working and supporting staff wellbeing. However, it is clear that many of the parents and carers accessing nurseries are themselves showing high levels of distress, which manifests itself in increased concerns around children’s safety, feeding issues and renewed struggles around separation and independence. Nurseries continue to operate in this highly demanding environment.

Through our clinical work, we know that psychologically informed training on how to find clear meaning in the behaviours and interactions which professionals face in their work can be immensely helpful. We explore how these behaviours can be redirected through talking and other playful activities. Families that require more help can be more easily identified and signposted to support. One of the ways we have trialled this is to deliver “infant mental health reflective practice” groups to staff. In this way, issues that can feel overwhelming can be brought to a regular confidential space for reflection and discussion.

The aim is to empower the practitioners to have time to consider their own feelings about the children in their care, in a way which helps them to feel less anxious at work, more curious, and ready to explore the difficulties they face. This provides them with support, enables them to feel more skilled, and they learn from one another. This is an important starting point in helping adults – including early years professionals – to “hear” the powerful messages that children send us through their behaviour, listen and interpret these calmly, and act on them. It is through the strong and safe relationship between adult and child that we see this really happen.

Read more in CYP Now's special report on trauma-informed practice