Helping children by healing parents

Adverse Childhood Experiences Dr Sheena Webb, Consultant Clinical Psychologist & Service Manager Family Drug and Alcohol Court Team, Tavistock & Portman NHS Trust Suffolk Through a Childs Eyes 02.10.19 Adverse Childhood Experiences Study Looked at 10 types of childhood adversity ACE scores and found a high correlation with a huge range of

adult outcomes. Filetti et al (2002) Source: ACEs were associated with Risking& damagingbehaviours

Over eating Over drinking Smoking Drug abuse Risky sexual behaviour Risky reproductive behaviour Intimate partner violence Diminished life chances

Lower academic attainment Impaired work performance Unemployment Financial difficulties Imprisonment Poor health Addiction Anxiety, depression, eating disorders, posttraumatic stress disorder, psychosis Suicide and self-harm Ischemic heart disease Stroke Liver disease Chronic obstructive airways disease Asthma

Diabetes Sexually transmitted diseases Reduced life expectancy BUTthe ACE study is not the only evidence that trauma is associated with adverse outcomes Freud The etiology of Hysteria 1896 Papers dating back to the 70s describing long terms effects of trauma both psychological and physical Studies with other chronically traumatised groups E.g. Veterans, victims of DV e.g. PTSD rather than Combat exposure associated with physical health outcomes such as

arthritis, musculoskeletal, hypertension. (OToole & Catts, 2008) Prevalence of trauma in treatment seeking population Of all adults receiving any form of health care, 11% reported emotional abuse, 30% physical abuse and 20% sexual abuse. In one study 58% of people in inpatient substance misuse unit had PTSD symptoms within a range requiring treatment. Between 35% and 53% of people with a severe mental illness report childhood physical or sexual abuse. And in vulnerable groups juvenile offenders have been exposed to traumatic

victimisation and 11-50% have PTSD. Abuse and family of origin problems are consistent predictors of DV perpetration & victimisation in men and women and PTSD is associated with repeat victimisation. History of trauma associated with negative parenting behaviours and repeatedly having children removed through care proceedings, e.g. Broadhurst et al (2016) Diagnosis Effect of non-consensual sexual intercourse before the age of 16 years expressed as Odds Ratios

Depression 5.07 Phobia 12.12 OCD 7.01 PTSD 8.23

Eating Disorder 6.53 Psychosis 10.14 jonas s, et al. (2011) sexual abuse and psychiatric disorder in england: results from the 2007 adult psychiatric morbidity survey. psychological medicine; 41: 709-20. bebbington et al (2011) childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in england the british journal of psychiatry 199, 2937. Cluster B Personality Disorders

No Maltreatment % Childhood Maltreatment & SA % AOR * Antisocial 3.5% 19.9% (5.10)

Borderline 3.1% 21.1%. (5.25) Narcistic 5.0% 20.3%. (3.76)

Histrionic 1.0% 6.3% (4.83) All 10.2% 42.4% (5.17)

turner et al (2017) the relationship between childhood sexual abuse and mental health outcomes among males: results from a nationally representative united states sample child abuse & neglect 66: 6472 * adjusted for demographics and household disfunction The impact of trauma Traumatic events are common; 50-69% of people experience at least one trauma in their lifetime. Of those experiencing a traumatic event only about a quarter will go on to develop Post-Traumatic Stress Disorder.

Post-Traumatic Stress Disorder is not the only mental health outcome related to trauma exposure. 59% of Men and 44% of women with PTSD met criteria for 3 or more other psychiatric diagnoses. Interpersonal traumas increase the risk of PTSD and other problems. Exposure to sustained and repeated trauma results in more complicated presentations. Complex trauma People with repeated experience of trauma display: Core PTSD symptoms: re-experiencing, avoidance, hyper-arousal AND Problems with self-regulation: Emotional, relationships, dissociation, distorted beliefs, somatic FEAR vs SHAME

OUT OF THE BLUE vs PREDICTABLE SPECIFIC vs GENERALISED ADULT vs CHILD RESTORATION OF HEALTHY vs CREATION OF HEALTHY Beyond PTSD Putnam and Trickett (e.g. Trickett et al 2011) Followed 84 girls (mean age=11) who reported incest for 20 years. Compared with matched group. Higher rates of: cognitive deficits, depression, dissociative symptoms, troubled sexual development, high rates of obesity, and self-mutilation. They dropped out of high school at a higher ratehad more major illnesses and healthcare utilisationabnormalities in stress hormone responsesearlier onset of puberty, and accumulated a host of different, seemingly unrelated, psychiatric diagnoses.

Alsoafter three years, the abused girls displayed emotional numbing in response to distressing events. Escape when theres no escape The helpless person escapes from her situation not by action in the real world but rather by altering her state of consciousness. Herman, p.42 AND the more you dissociate, the less traumatised you look to others AND individual themselves will quite comfortably tell you they have dealt with their past and they are fine now. BUT constrictive symptoms, though they may represent an attempt to defend against overwhelming emotional states, exact a high price for whatever protection they afford. They

narrow and deplete the quality of life and ultimately perpetuate the effects of the traumatic event. P.47 From Judith Herman, Trauma and Recovery 1996 Being traumatised means continuing to organise your life as if the trauma were still going on unchanged and immutable as every new encounter or event is contaminated by the past Van der Kolk, The body keeps the score, 2015, p.53 The body keeps the score The body speaks clearly to those who know how to listen.

Nonverbal expressions visibly reveal what words cannot describe: the speechless terror of trauma and the legacy of early or forgotten dynamics with attachment figures Ogden, Sensorimotor Psychotherapy, 2015. Body and mind overwhelmed by threat Affects the balance between defensive systems (fight/flight & freeze/faint) and social engagement system Narrows our window of tolerance Easily triggered into hyper- and hypo- arousal Unbearable states of mind cause us to dissociate and fragment self-states

Latent vulnerability Maltreated children develop psych problems earlier, more severe, more comorbid, more chronic less responsive to traditional treatments Not damage but childrens neuro/cognition calibrates to abusive environment - adaptive These adaptations have a role in pathogenesis of mental health problems in context of other environmental stressors Threat processing, reward processing, emotional regulation and executive control FMRI evidence McCrory et al (2017) J Child Psychology & Psychiatry 58:4 The diagnostic gap PTSD does not account for the range of symptoms seen

in multiply traumatised children and adolescents. Labelled with a range of affective and behavioural diagnoses each of these diagnoses captures an aspect of the traumatised childs experience, but frequently does not represent the whole picture (NCTSNet 2003). Leads to inappropriate or incomplete treatment. But also to a complete misunderstanding from the system around the YP as to why they are struggling in the way that they are.

Because their responses can be so challenging this can elicit negative responses from those who might offer help. The life cycle of complex trauma Disorganised/ traumatised traumatised infant infant Maltreating Maltreating parent parent Adult

Adult with with complex complex needs needs Childhood emotional & behaviour behaviour problems problems Adolescent offending/selfharm/risk harm/risk

Interventions Health Visiting/ Visiting/ Early Early Years/Social Services Family Family Courts/Social Courts/Social Services Services

Criminal Criminal Justice/ Justice/ Drug Drug and and alcohol/Crisis/ alcohol/Crisis/ Homeless Homeless EBD/Social EBD/Social Services/LAC/ Services/LAC/

CAMHS YOT/Leaving YOT/Leaving Care/A&E/ Youth Services Services Trauma informed practice & ACEs Dr Sheena Webb Strategies that survivors develop for self-protection combined with the post traumatic stress symptoms of hyperarousal and avoidance, make a survivors entrance into a service setting seem fraught with danger Elliot et al (2005) Trauma informed or trauma denied, p.463

Conditioned to react Childhood experience Frustrating behaviour Being co-erced, forced, frightened into doing things. Avoidance, not turning up, not engaging, withdrawing. Being neglected, dismissed, unheard, unseen. Not seeking or accepting help,

not talking, not sharing information. Being lied to, being told to lie, not being believed. Being betrayed by trusted adults Being made to feel inferior, powerless, disempowered. Being hurt, harmed, wounded, put at risk. Lying. Not trusting anyone, being hostile and angry. Not taking responsibility for own actions.

Engaging in dangerous and dramatic behaviours. Broadening our view of trauma treatment Feeling safe in my body and my mind Learning how to respond to difficult feelings in my mind and body and stay in balance Learning to step back and reflect on myself, my actions and my goals Processing and making meaning of my traumatic memories Learning how to relate to others

Learning to live in and enjoy the present, and being myself Heavily paraphrased from: Core components of Complex Trauma Treatment in Cook et al, 2017, Psychiatric Annals. What is Trauma Informed Practice? Culture shift not a manualised model A lens for reflection on practice Core principle of Do No Harm Form of safety governance like a sharps policy, or infection control

A re-conceptualisation of pathogenesis and recovery A way of understanding and working with non-engagement Something that is already inherent in many peoples practice It is both nothing new and completely revolutionary What does it mean to be trauma informed? DO NO HARM TRAUMA AWARENESS EMPHASIS ON SAFETY REBUILDING CONTROL STRENGTHS BASED Prevent new trauma

Prevent secondary traumatisation Promote engagement Avoid retraumatising Promote healing CLIENTS JOURNEY THROUGH SERVICES What that might look like?

Anticipating anxiety transparency, information giving Changing waiting areas privacy, warmth, safety History taking eliciting and receiving traumatic information Reports language, distribution, redaction Engagement attunement, reliability, boundaries Working with wider family confidentiality, disclosure, contact with abusers Continuity keyworker change, service boundaries Supervision & support for staff secondary trauma

NCTSN advice for Residential Settings managers For youth with complex trauma, standard rules and protective measures such as seclusions, restraints, and other behavioral management strategies may be perceived as threats and authority figures as potential perpetrators. Administrators should limit residential policies that may trigger trauma responses for youth with complex trauma. In order to help youth internalize a sense of control in the face of outside stressors, residential policies should attempt to shift from the use of external controls, such as restraints, time-outs, PRNs, and redirection, to the use of self-regulation and problem-solving skills.

And for residential staff Its about trauma. Understand behaviour through a trauma lens. Maintain a nonjudgmental attitude about youths behaviors. Consider the way in which behaviors can serve as survival mechanisms that developed in the context of dangerous or otherwise unsafe environments. Its about the relationship, but relationships take time. Be patient. Mis-attunements will happen; its what you do about them that matters. Seek opportunities for therapeutic repair, which is healing for the child, but also beneficial to your own learning process. Its not about you. Strive to make interactions with youth responsive, not reactive. When youth are triggered they are responding to events from the past, so dont take things personally. Instead, invoke your curiosity and trauma lens to

understand what happened. Emerging evidence base Women randomly assigned to an integrated programme based on Hermans model of recovery were significantly less likely to be incarcerated at 6 months follow up (29 vs 48%) and were more likely to be participating in voluntary aftercare (25 vs 4%). Covington (2005). Those who completed trauma work in an Family Drug Court were more likely to be returned with their children. Powell et al (2012) Domestic Violence Shelter: Increase in self-efficacy, safety empowerment. Sullivan et al (2017) Child Welfare System: Positive impact on child wellbeing,

behaviour, maltreatment and multi-agency effectiveness. Barto et al (2019) Psychological barriers Our belief that being professional means holding back ourselves/our emotions A feeling that being this attuned would be a breach of boundaries Being too busy and stressed Top down/time-pressured processes that feel more

pressing Our emotional reaction to the client/own biases/judgements Preoccupation with risk Guiding principles for implementation Empowerment of staff Recognising and building on existing strengths Creating a context for healing Everyone has a role Each interaction has the power to heal or harm Little things matter Trauma awareness between colleagues Helpful references Filetti, V. (2002) Turning Gold to Lead.

Van der Kolk (2014) The Body Keeps the Score. Penguin. Cook, A., Blaustein, M., Spinazzola, J. & van der Kolk, B. (2003) Complex Trauma in Children and Adolescents. White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force. Elliott et al (2005) Trauma-Informed or Trauma-Denied: principles and implementation of trauma informed services for women. Journal of Community Psychology, 33(4). Barto et al (2019) The impact of a stateworde trauma-informed child welfare initiative on childrens permanency and maltreatment outcomes. Child Abuse and Neglect, 81, 149-160.

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