What are the affects?
What can we do to help?
What if we do nothing?

Why Study Childhood Trauma?

Numerous studies link trauma and criminal behaviour.

Mann (1995) - Found 74% of a small sample of adolescents offenders held with secure conditions were experiencing symptoms consistent with PTSD.

Dissociation is a common component of the complex trauma response (van der Kolk et al., 1996) Boswell (1995) - Amongst those committing the most serious of crimes, over 90% experienced childhood trauma in the form of abuse and / or loss and frequently both. Burgess et al (1987) - found a link between sexual abuse and the occurrence of drug abuse, juvenile delinquency and criminal behaviour a few years later.

Steiner et al found 32% of incarcerated juvenile delinquents met the criteria for current PTSD, and - For 5% of the sample the symptoms of PTSD resulted from the violence they perpetrated on others. Dissociation may mediate the cycle of violence. research indicates pathological dissociation in adolescent offenders 14.3 – 28.3 % (Markowitz, 2004)

What inference might we make from the following research on the needs of looked after children?

• 45% were assessed as having a mental disorder
•38% had clinically significant conduct disorders
•16% were assessed as having emotional disorders –anxiety and depression
•10% were rated as hyperactive

The Truth?

These mental health indicators are symptoms relating to complex trauma and dissociative disorders (Terr, 1991; Putman, 1993).

All truth passes through three stages.

First, it is ridiculed. Second, it’s violently opposed. Third, it’s accepted as self-evident. (Schopenhauer, 2006)

For many centuries various theorists and clinicians have postulated about the psychological and emotional distress observed in children and some began to attribute some of the causes to early childhood experiences of neglect and trauma. This notion and sense of truth. could be viewed as going through a process of being ridiculed and violently opposed, but recent there appears to have been an tidal change in that society is more able overcome the defensive reactions to such notions to begin to develop appropriate support and services for survivors e.g. Scottish National Strategy for Survivors of sexual abuse.

The 5 Symptoms Of Post Traumatic Stress Disorder (PTSD) In Children

Re-experiencing the trauma in various ways Numbing of responsiveness and avoidance of reminders of the trauma Hyper-arousal Development of NEW fears that weren’t present before the trauma Development of aggressive behaviour that wasn’t present before the trauma Trauma Symptoms and Conduct Disorder Aggression, Impulsivity, Impaired, empathy, Anger, Disregard for the future, Substance abuse, Risk-seeking behaviour, Reactivity

Do you only see the behaviour?

Trauma, Attachment and Dissociation.

The three strands of understanding which are needed to inform effective evidence based approaches for children referred to residential care?

“Human beings of all ages are found to be at their happiest and to be able to deploy their talents to best advantage when they are confident that, standing behind them, there are one or more trusted persons who will come to their aid should difficulties arise”. John Bowlby (1973, p 359)

Another quote:

“Maintenance of proximity to caregivers increases the likelihood that the infant will be sheltered from exposure to the elements, defended against attacks”

Grand Central - The Brain

Genes provide, blueprints and basic frame work of the brain, The Environment provides the shaping and finishing, They work in tandem, with genes providing the building blocks, and the environment acting like an on-the-job foreman, providing instructions for the final construction Sounds, sights, smell, touch like little carpenters - all can quickly change the architecture. Ronald Kotulak (1993)

“The Dyadic Dance”

The caregiver modulates the infants non-optimal states by calming the infant when arousal is too high and stimulating it when arousal is low. He or she is constantly attuned to and responding to the infants cues (Schore,2001)

This is the dyadic dance. The adult is the interactive regulator of arousal Modes of self-regulation Interactive regulation: involves the ability to utilise relationships to mitigate breaches in the window of tolerance and to either stimulate or calm oneself

Auto-regulation: is the ability to self regulate, independent of other people. It is the ability to calm oneself down when arousal arises to the upper limits of the window of tolerance or to stimulate oneself when arousal drops to the lower limits (Ogden, 2002)

Childhood Attachment Strategies

Secure attachment: infant shows clear preference for interactive regulation, but after being re-regulated by caregiver, is then able to self-regulate for short periods Anxious attachment (also referred to as Insecure - ambivalent): the infant anxiously seeks proximity to the caregiver, cannot auto-regulate without the caregiver and is not self soothed by reunion.

Avoidant attachment (also referred to as Insecure - avoidant): infant shows clear preference for self regulation, often actively avoiding interactive regulation and preferring books and toys to caregiver Disorganised attachment: infant has difficulty with both interactive and auto-regulation, exhibiting proximity-seeking coupled with freezing, distancing or avoidant behaviour

Disorganized Attachment

Secure attachment contributes to lifelong abilities to regulate emotional states. Even “anxious” and “avoidant” attachment styles allow for predictable ways of regulating arousal, using either interactive or auto-regulatory strategies.

Disorganized attachment status, on the other hand, interferes with the development of both auto and interactive regulatory abilities Disorganized attachment in children is correlated with maternal behaviour which is characterised as “frightening” or “frightened”. (Liotti, 1999) In studies of abuse and neglected children, disorganized attachment styles have been found in over 80% of maltreated children (Carlson et al, 1985; Ogawa, 1997)

Disorganized attachment is also statistically significant predictor of dissociative symptoms by age 19 and diagnoses of Borderline Personality Disorder and Dissociative Identity Disorder (Lyons - Ruth, 2001)

The Trauma Mechanism

Other mental health problems (Co-morbidity)

e.g. Major Depressive Disorder 48% Physiological response Behavioural re-enactment Developmental impact (Mal)adaptive coping strategies Belief system Trauma

Behavioural Re-enactment

Young people can expose themselves, seemingly compulsively, to situations reminiscent of the original trauma. In behavioural re-enactment of the trauma the characters may play the role of: victim/perpetrator/rescuer.

Three key ways: Harm to Others; Self-destructiveness; Re-victimization. Children seem more vulnerable than adults to compulsive behavioural repetition and loss of conscious memory of the trauma.

Key Concepts

Behaviour is seen as being related to either Hyper-arousal or Hypo-arousal - related to either attachment and / or trauma disorders (Cross, 2005)

Based on sound neurological research about the impact of trauma, attachment and neglect. The use of social milieu and the therapeutic residential care staffs interactions with the child can help regulate the child behaviour (symptoms of trauma)

No child who has experienced trauma is going to heal and learn to use different ways of coping without first feeling secure. For children who have experienced chronic trauma, the importance of environmental interventions can not be overemphasised and is viewed as essential (Shirar, 1996, p 146), in terms of providing the stable and safe place from which therapeutic work can be undertaken (milieu e.g. understanding of parallel processes etc throughout organisation).

Example of structures to help (must be done for all elements of trauma mechanism - hyperarousal etc ):

If the Child Is Experiencing High Arousal we need to show Low Arousal - Common sense that can be difficult in practise A non-confrontational way of managing challenging behaviour A philosophy of care which is based on valuing people an approach that specifically attempts to avoid aversive interventions. An approach that requires staff to focus on their own responses and behaviour and not just locate the problem in the person with the label A collection of strategies that are designed to rapidly reduce aggression

Assumption One

Most people who are challenging are usually extremely hyper-aroused at the time. We should therefore avoid doing anything that will arouse a person who is already upset.

Assumption Two

A large proportion of challenging behaviours are usually preceded by demands and requests, therefore reducing these should help to reduce the frequency and perhaps the intensity of the incidents

Assumption Three

Most communication is predominantly non-verbal, therefore we should be aware of the signals we communicate to people who are upset.

Theoretical

Assumptions

One technique to take away: life space interviews using a technique to increase coping and understanding. The following is a brief overview of an approach initially developed for work with high risk adolescent but has been found to work well with children. Other approaches can be added to this to increase outcomes which I developed as part of a set of therapeutic techniques for working with adolescents. I will be running in future workshops on these in the future e.g. advanced role play strategies.

Using Drawing - with high risk adolescents Simple is best, let young person create own symbols.

Remember safety must be in place first, Young person has developed self-care strategies, remember, at times process might need to return to stabilisation phase.

Conclusion:

Link between trauma and attachment styles in ability to regulate affect, importance of being able to help child learn how to regulate affect

Links between trauma and long term consequences for not only the child but society, Proposal to utilise knowledge and understanding relating to trauma and attachment to create evidenced based approaches to meet the needs of young people for whom residential care has not address such underlying needs (e.g. limited specialised provision in Scotland)

The need total organisation approach to therapeutic residential care

What we need to be aware of..

Residential child care can replicate the toxic traumatic experiences of children who are looked after e.g. multiple placement breakdown, Those responsible for identifying care for children need to understand the high level of skill, support and resilience required by the caregiver to ‘survive’ to enable improved outcomes.

To be able to use the relationship the staff member has with the child is crucial but to do so effectively, the individual needs to be able to work within a therapeutic framework of understanding which contains not only the work but which directs and maintains an understanding of what we do and how we do it for all those who work within the organisation.

Unfortunately to educate on such areas take time and groups and teams can sometimes neglect such areas for short term gain.

Above all it takes time to not only develop a culturally sensitive environment to undertake trauma informed therapy but also the development of an appropriately trained staff group.

If we do nothing…… the Legacy?