A Practical Guide to Helping Children and Young People Who Experience Trauma

A Practical Guide

Panos Vostanis

• Publisher: Routledge
• Year: 2017
• Print ISBN:
  9781138043503
• eBook ISBN:
  9781351699945
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This will be a concise and practical resource for a range of carers and practitioners working with children who experienced trauma. It will highlight their characteristics in contrast with those for children living in stability, and will describe specific techniques and strategies to help them in different environments and situations. The aim will be to equip practitioners with a range of approaches for these groups of vulnerable children, which are appropriate to sensitively meet their needs and make a difference to their emotional well-being. Key features: case studies; work-sheets; and, evidence-based interventions. It is authored by Dr Panos Vostanis, Professor of Child Psychiatry, University of Leicester; Consultant Child Psychiatrist, Leicestershire Child Mental Health Service.

Chapter 1
Impact of trauma on children

Psychological trauma

Psychological trauma can be acute or chronic; it can be the case of a single event (such as an accident or natural disaster) or it can occur through a chain of multiple and interrelated incidents – often referred to as complex trauma, like abuse in the context of domestic violence and family breakdown. All traumatic events will cause distress in children, and a high proportion of traumatic events wili lead to child mental health problems. Trauma has a cumulative effect, that is, the more exposed a child is to similar events, the more vulnerable to or at risk of suffering from ill mental health the child will be. The mechanisms can be direct, such as from experiencing and witnessing violence, or they can be indirect, through lack of safety or impaired parenting capacity. Trauma impacts on most aspects of a child's life, hence the relevance of this text to all carers and professionals in contact with children and young people (hereafter mostly referred to in the text as simply 'children', although both terms will be used intermittently).

Some children are particularly vulnerable

The interplay between different types of trauma and exposure over a number of years means that certain young groups are particularly vulnerable to experiencing psychological trauma, and these groups will thus form the focus of this handbook. It, however, needs to be acknowledged that these often overlap. Young groups who are particularly vulnerable include:

• children and young people in public care (fostering, kinship care or in residential homes)
• children who have been adopted
• homeless children and families – usually victims of domestic violence
• single homeless young people
• asylum-seeking and refugee children (and their parents)
• unaccompanied minors
• juvenile offenders.

Child development from a trauma perspective

It is always useful to have a good understanding of different theories when working with any child, as this will provide a framework to formulate their difficulties before tailoring an intervention. In the case of traumatised children this is even more important, as there may be limited or fragmented information on their early life, their presentations can be perplexing and their environmental adversities may be pretty overwhelming. Such theories to take into consideration, and that are not mutually exclusive in planning interventions, are broadly driven by:

• cognitive and social approaches, like Piaget's cognitive stages, Vygotsky's complex thinking patterns, Erikson's psychosocial development, Kohlberg's moral development, and social empathy (theory of mind)
• emotion-focused or psychodynamic, from Freud's early psychosexual stages, Vaillant's defence mechanisms or Winnicott's object relations theories
• attachment-based, mainly from Bowlby's pioneering work, and followed by the definition of attachment styles from Ainsworth and Main.

Exercise

Consider this child's needs from different developmental perspectives. How is her emotional, cognitive and social development likely to differ from a child of the same chronological age who has not had similar traumatic experiences?

Lucy is seven years of age. Along with her three younger siblings, from birth she suffered severe abuse and neglect. The children were left unattended, starving and dirty for days. Lucy tried to look after her siblings as well as she could, and she missed most of her first year at school. Her mother was either out or exhausted in bed from drug use. Several partners came and went over the years. The neighbours called social services on several occasions, who tried to help Lucy's mum with family and practical support and respite care. These measures only worked for short periods, however. When two toddlers from the home were found wandering in the street, all four children were removed to foster care. Unfortunately for Lucy, she had to be placed separately from her siblings. She has been in this placement for 18 months, and she is likely to remain there in the long term.

Lucy does not cause any trouble at home. She sits quietly for hours and plays with toys but cannot yet follow games rules, no matter how much she is prompted. Sometimes she looks sad during the sleep or sobs in her sleep. She seems pleased to see her siblings once a fortnight, but she does not know what to do with them. At school, her reading and writing have come along, but she drifts between children in the playground and has no friends.

Case scenario

Now revisit Lucy's case from those developmental perspectives. How can your previous formulation inform ways of helping Lucy at this stage of her life?

• Emotional development: Lucy seems to hold back and not express or process her emotions. This is not surprising; after all this is how she survived over the years. If she cried or protested, she was probably told off or hit. Both her carers and teachers need to model a different and more nurturing approach, while remaining mindful of Lucy's history and appreciating that it will take some time before she spontaneously expresses her feelings. They may need to spell those out as if she were a younger child. Life story work could help Lucy make sense of her experiences. Whether she needs more specialist psychotherapeutic input will depend on the above steps and her responses.

• Psychosocial development: Similarly, Lucy cannot spontaneously relate to other children. There is a clanger that the gap with her peers may widen without help, and even lead to secondary problems such as aggression. Here, Lucy will need a mixed approach of supervision, direction and safe experimentation until she can handle relationships on her own. On some occasions she should be treated like a younger child, but her carers must keep prompting her by making social activities more demanding.

• Cognitive development: There are promising signs that Lucy can learn and make up for her lost schooling. She is likely, however, to require a personalised educational plan, tailored strategies and individual teacher time for a while. The key risk is the social side of her school attendance, that is, whether her social deficits can hinder her learning. For this reason, tackling both domains should be a priority.

• Attachment relationships: Lucy is tentative, to say the least, in trusting adults and why should she? Her foster carers need to gradually and patiently bring her into their family by regaining her trust. To do so, they will require their own support and will need to manage their expectations, as Lucy may not be able to give back her affection for a while. Additional measures, such as attending a foster carers group or therapeutic input involving the carers (for example, theraplay), may be necessary if the previous steps have not been enough.

This could highlight the importance of a child's emotions, behaviours, cognitions, attachments and peer relationships and integrate these. We could draw Lucy in the centre of a page, with five bubbles of Lucy in those five domains (emotions, behaviours, cognitions, attachments and peer relationships) around her.

In conclusion, all developmental theories are important, and they are no longer considered mutually exclusive in understanding children who suffered trauma. Their knowledge can help a carer or practitioner to:

• observe and interpret behaviours and needs from different perspectives
• avoid enmeshment and confusion of complex presentations
• choose an intervention that will be best matched to the child's needs and wishes
• remain clear on both the indications and limitations of this intervention.

Factors that make children vulnerable

What children carry from birth and experience onwards will invariably influence how they grow up and function. Although some factors that place them at risk of developing and sustaining mental health problems are obvious, it is worth adopting a more systematic approach to risk factors by considering the following:

• It is important to consider the cumulative effects of risk factors, that is, the more of them that there are and/or the longer they go on for, the more adverse will be their impact.
• While bearing the above in mind, it is important to recognise that risk factors are neither critical nor irreversible.
• One should consider that risk factors are often interrelated, and one can lead to another.
• It is important to think about the fact that risk factors may predispose a child to a problem or precipitate an episode.
• It is important to think about the fact that risk factors can have a direct or indirect effect on a child.

Child vulnerabilities

Risk or vulnerability factors can be related to the child, their family, school and wider community.

Individual factors

• Temperamental traits
• Genetic susceptibility
• Prenatal or perinatal
• Physical ill health

Within the family

• Family conflict
• Domestic violence
• Abuse and neglect
• Negative or inconsistent parenting
• Parental mental illness or drug use

At school and in the community

• Bullying
• Exposure to violence
• Peer pressure
• Lack of social and attainment opportunities
• Being unsafe
• Discrimination
• Social and school exclusion

Protective and resilience factors

Protective and resilience factors constantly try to compensate for adversity and can be a source of hope, even under very difficult circumstances. Protective factors fall under the same domains as risk factors:

Individual

• Ability to learn, process and reflect on new information
• Adaptability
• Self-regulation
• Sense of cultural identity and belonging
• Self-worth and confidence

Family related

• Secure attachment
• Nurturing and affection
• Consistent and firm parenting
• Role models

At school and in the community

• Friendships
• Attainment and sense of achievement
• Support networks
• Community safety

Exercise

Think of a needy and vulnerable child under your care. Try to formulate vulnerability and protective factors under the previous framework.

Case scenario

How would you minimise the risk factors and maximise the protective ones in this difficult situation?

Jonathan is 15 and has just come out of a secure institution, following a violent attack on another young man. His dad told me that he will kick Jonathan out if he gets into any more trouble. As a matter of fact, his dad has kicked him loads of times in the past. Jonathan can hardly read – what's the point of going back to school? He gets a break when he smokes whiff – but he no longer has the money. He likes boxing, although he tends to lose interest. He already hates himself – 'they must have been taking the mickey' in prison when they told him he had a good voice.

Table of contents

• Cover
• Title
• Dedication
• Copyright
• Acknowledgements
• Preface
• Contents
• Chapter 1: Impact of trauma on children
• Chapter 2: Mental health concerns, problems and differences from other children
• Chapter 3: Interventions: Meeting vulnerable children's needs in the context of one's role
• Chapter 4: Children and young people in foster care
• Chapter 5: Young people in residential care
• Chapter 6: Adoptive families
• Chapter 7: Homeless families and victims of domestic violence
• Chapter 8: Homeless single young people
• Chapter 9: Asylum-seeking and refugee children
• Chapter 10: Young offenders
• Chapter 11: Overarching messages
• Bibliography