This document discusses childhood trauma and its treatment within an integrated residential and educational environment. It defines different types of trauma including acute, chronic, and complex trauma. Symptoms of complex trauma are then outlined. Statistics on childhood trauma within the general population and looked after children are provided. The document emphasizes that effective trauma-informed assessment and treatment can help children recover from traumatic experiences. Core components of trauma interventions are described, including safety, self-regulation, relationship building, and future focus. The benefits of a therapeutic learning environment for traumatized children are explored. Overall it promotes an integrated approach addressing children's emotional and academic needs to facilitate recovery from trauma.

3. Childhood Trauma:
Understanding the core components of
change and recovery within an integrated
residential and educational environment
Community Care Live
20th May 2014
Richard Cross & Linda Moss

4. “Effective treatment can and will make a
significant impact on children’s lives”.
”
“A good safeguard to ensure we do no ‘harm’ is for all those working with complex trauma is to have a solid
foundation in child development, and treatment of attachment and trauma disorders”

5. What is Trauma: Types and potential
diagnosis ?

6. “It’s like you’re on autopilot and someone else is
controlling the switches” (Dodd,2009)
• A trauma response involves “intense fear, helplessness,
or horror” (with children, they may have disorganized or
agitated behavior) – Being ‘overwhelmed beyond ones
limits / capacity. Trauma can be understood to mean a
profound emotional shock (Oxford Dictionary, 1992)
• A “trauma” response requires a psychological (and often
physical) response to a dangerous event – “leading to
disorders of Vigilance and Defense” (Cantor, 2005)
• “Symptoms” are understood not as pathology but
primarily as attempts to cope and survive; what seem to
be symptoms may more accurately be solutions…..

7. Categorisation of Trauma:
• Acute trauma (Type 1) is a single traumatic event that
is limited in time
• Chronic trauma (Type 2) refers to the experience of
multiple traumatic events
• Complex trauma describes both exposure to chronic
trauma—usually caused by adults entrusted with the
child’s care—and the impact of such exposure on the
child (Herman, 1992)
When trauma is associated with the failure of those who should
be protecting and nurturing the child, it has profound and far-
reaching effects on nearly every aspect of the child’s life……
For ‘Looked After Children’ this is especially evident

8. Types of Trauma experienced by children in care -
may be acute, chronic, single event or repeated
• Neglect and abuse – physical, sexual, emotional.
• Witnessing of domestic abuse.
• Multiple placements and rejection repeating the
sense of Traumatic loss.
• All of above involve unstable care and disruption of
primary attachments --- care systems should focus on
creating stability.
• Community violence – bullying, rape, witnessing
violence.

9. SYMPTOMS RELATED TO COMPLEX TRAUMA
Traumatic events overwhelm a child’s capacity to cope and elicit
feelings of terror, powerlessness, and out-of-control
physiological arousal
• Anxiety and Depression (Panic attacks or depressed mood)
• Cognitive Distortions: “Its all my fault”, “I am bad” etc
• Post-traumatic Stress: re-experiencing events (Flashbacks)
Avoidance (people, situations – sights, smells, sounds etc),
numbing (reduced emotional reactivity) and hypo- and hyper-
arousal, sleep disturbance
• Dissociation: de-personalisation, de-realisation and
disengagement e.g. appearing ‘spaced out’
Please refer to literature reviews for an exhaustive list
of trauma symptoms in relationships (Briere, 2004)

10. The Reality
The Tip of the iceberg?

11. Extent of Trauma in the population?
Estimated prevalence in society:
• General population: 34-53% report childhood abuse or sexual
abuse.
• People in treatment for substance abuse: 30-59% of females
with PTSD, & 11-38% of males (Najavits, 2014).
• 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.
• *Dissociation may mediate the ‘cycle of violence’ – research
indicates pathological dissociation in adolescent offenders 14.3
– 28.3 % (Moskowitz, 2004)
* James Gilligan (1996) Shame is the primary or ultimate cause of all violence & Prologue to Violence
(2007) book by Abby Stein (Child abuse, dissociation and crime)

12. *Statistics for Looked after Children
April 2014
• There were over 92,000 looked after children in the whole
UK in 2013.
• Over half of looked after children in England and Wales
became looked after because of abuse or neglect in
2012/13
• This is why trauma informed therapeutic care is essential for
those affected
*Cawson, P., Wattam, C., Brooker, S. and Kelly, G. (2000) Child Maltreatment in the United Kingdom: a study of
prevalence of child abuse and neglect. London: NSPCC.

13. Potential Misdiagnosis's if accurate symptoms not accurately
understood:
• Reactive Attachment Disorder
• Attention Deficit Hyperactivity Disorder
• Oppositional Defiant Disorder
• Conduct Disorder
These diagnoses generally do not capture the full extent of
the developmental impact of trauma. Many children with
these diagnoses have a complex trauma history.

14. Social Care Systems
-are vulnerable to exhibiting parallel processes associated
with traumatised systems

15. Social care systems are failing to support care:
• Repetitive mandate – do more with less – focus becomes on ‘market’
and not the reality e.g. notice periods of contracts for traumatized and
attachment disordered children (28 days notice), clear need to develop
trauma informed outcomes,
• Training of staff, foster carers, residential staff: not just theory but
helpful models to assist practice.
• Policy changes may be sudden and unexpected and regulators need
to ensure these don’t destabilise care environments: proactive and not
reactive responses
• Adversarial relationships with funders & regulators if you don’t go
along with the ‘market forces’ --- “would it be acceptable for a LA to
choose the cheapest accident and emergency care bed for a child… I
propose children and young people have been injured and need
trauma informed care to help them recover”.

16. Assessment
Without clear understanding of the child’s internal reality one
may not be seeing the real child or young person

17. Children and young people whom move to foster care or residential care
carry with them into these environments inside their experiences and
history.... Its not on the outside and difficult sometimes to see....

18. Stages of Screening for difficulties
Screening (Completed by Adult carers)
1. Strengths and Difficulties Questionnaire (Goodman 2001)
2. Relationship Problems Questionnaire (Minnis et al 2007)
Detailed assessment (completed by Adult Carers)
3. Development and Well Being Assessment (Goodman et
al, 2000)
Focused Assessments – Child clinical assessment
4. Children: Play based Child Clinical Assessment (Story
completions, projective approaches, etc)
5. Adolescents 14 years + = Trauma Symptom Child
Checklist, A-DES (Armstrong, 1997), Clinical interview

19. Five Rivers (Residential Care) Assessment
framework indicates:
• Very high level of emotional and behavioural difficulty
(82% at risk of a potential psychiatric diagnosis). Age
range 11-17
• Attachment data indicates improvement over time in
particular after 12 months in placement which would
be expected to develop resilience protecting against
mental health problems
• We are currently undertaking a parallel research
programme throughout our foster care service

20. SDQ Scores in residential care
Average is the figure showing 8% at the top of the diagram – so in residential care in Five Rivers we have 52% of our placements exhibiting
disturbance levels found only within the top 5% in the population, 76% of our placements are in the top 10% of difficulties in the population

21. Where have we got to....
1. There is a clear need to consider the impact of trauma on children
and young people in the looked after system and to develop a clear
understanding of the presenting needs which need to be addressed
by services
2. Without effective interventions many children and young people
who have been injured through repeated psychological traumatic
experiences will not recover
3. There is a clear need to have trauma informed assessment
(attachment, trauma and dissociation) to help provide the right
supports for both the child and carers (Cross, 2012)

22. Attachment and Trauma

23. CRITICAL LINK: Trauma affects attachment
• The earlier the maltreatment, the greater the impact
on attachment. Cannot consider one without other.
• Attachment is the basis for child’s safety, emotions,
learning, identity, coping, etc.
• Insecure attachments create significant risk for child,
and likelihood of multiple disabilities across lifespan.
• Conversely, if trauma or adversity occurs after child
has attached well to primary caregivers, less impact

24. Interventions
What can we do to help?

25. Assessment and interventions:
Must be ethical, effective and increasingly efficient –
children don’t have long in a ‘plastic’ state
• Helping children and young people maximise their potential
• Key factors: motivation to engage; younger children; likely to show larger changes;
intensity of intervention important
• Avoids ‘under treatment’ and ‘over treatment’
• Global effects - “Positive ripple effects through the child’s life”
• Provides an opportunity to design services based on aggregated needs
25

26. Targeted interventionsAssessment
- Care Planning
recommending
best ways to
help
Interventions
- ‘What works’
- NICE
- Difference
between
specific
treatments
and theoretical
orientation
OutcomeMeasures
- Are we
attaining the
desired
outcome?
- What needs
to be done
differently?
26

27. Case Study – child in residential care for
stabilisation:
• Young person: 16 placement moves in 3 years including placement under
Mental Health Act 1983
• Chronic self harming and attempts to take own life
• Anger and crisis ‘outbursts’ (property, self and others)
• Absconding
• Fragmented schooling due to placement breakdowns - lots of ability
• No previous accurate assessment to help young person e.g. trauma
symptoms but no detail to empower and help young person to
understand through psycho-education
• Child was able to share their sense of: anxiety, depression, dissociation,
anger, helplessness and PTS in their residential home
27

28. Outcomes are attainable (16 months) elements from
Trauma Symptom Child Checklist (Briere, 1998)
0
1
2
3
4
5
Anger
Depression
PTS
Anxiety
28

29. Focused treatment and integrated care can make a
difference…..
• Young person has been able to relate well enough to cope in a long term
stable foster care placement for over 1 year
• Attaining in school
• No absconding
• Pro-social peer group
• Patterns of past behaviour connected to trauma symptoms not displayed (eg.
no suicidal ideation)
• Resources = saving in terms of step down from intensive care over 1 year is
over £216,000 to help more children and young people.
29

30. Core Components of Trauma Interventions
1. Safety : The installation and enhancement of internal and environmental safety (Safety),
2. Attainment of Self Regulation: Enhanced Capacity to modulate arousal (Emotional Management),
reduction in Hyper and Hypo arousal.
3. Traumatic Experiences Integration: Remembrance and mourning of traumatic loss etc (Loss),
careful consideration is needed if child is dissociative symptoms before using approaches such as
EMDR.
4. *Relational Rapport: This is crucial in terms of creating core therapeutic environment for change and
creating effective models of attachment, social empathy and capacity for physical and emotional
intimacy (Future),
5. Positive Future Focus / Locus of control: Empowerment and future orientation, enhancement of
self-esteem.
*Acceptance (doesn’t mean you agree with behaviour), Flexibility (need to be responsive to needs), - Curiosity (“I wonder if
we put all the lights on when you feel ungrounded if it would help?”), - Containment (the young person needs to know YOU
can manage and support them – need to be clear of limits), Expected to be mistrusted and tested again and again and again,
Always tell the truth

31. Theory into Practise
Hyper-arousal (aggression, impulsive behaviour, children viewed as high risk,
emotional and behavioural problems – ‘Fight or flight’ response)
Window
Of
Tolerance
Hypo-arousal (dissociation, depression, self harm etc)

32. Creating a Therapeutic Learning
Environment in our Schools and
Residential Care

33. What do we know?
• On going trauma due to separation
•Insecure attachments lead to a profound effect on a
child’s emotional intelligence
•Dissociation = disruptions in the integration of memories,
perception, and identity into a coherent sense of self;
amnesia
•Secure attachment produce oxytocin and opioids….
promote good neural growth
•Stress(abuse/neglect) produces toxins that slow down
brain development
•90% brain develops in the first five years

34. However…………..
Trauma has an impact on Cognition
Traumatised children can have
problems focusing on and
completing tasks, or planning for
and anticipating future events.
Some exhibit learning difficulties
and problems with language
development

35. The Good News!
Neuroscience has proven that a positive attachment figure-
Foster Carer, Teaching Assistant, Therapist, Lunchtime supervisor,
Virtual Head,
Can ENCOURAGE new neural pathways!

36. Positive Care=synaptic pruning
and good neural pathways= Good Learning
Behaviours and Abilities
 Creativity
 Problem solving
 Reasoning and reflection
 Self Awareness
 Kindness
 Empathy and Concern

37. Five Rivers Schools
Provides a therapeutic educational framework that promotes
emotional growth and academic success.
Aims:
• To live life to the full – as a counter to the messages given to
children who have been abused and neglected
• Learn to love learning – and you can achieve
• Laugh a lot – being the best medicine – improving resilience and
solution finding, engagement with others, motivation

38. ‘The Warm Duvet of A Therapeutic Society’
(Rex Haigh 2013)
• The natural course of developments demands that pupils’
experience within the school must become more complex.
• Pupils responsibilities are pointed out to them
• Naturally conflicts arise and need to be resolved
• Expect the rough and tumble of love, hate, fear, anger,
frustration, sadness, attack, defence, comfort and all the
ingredients of
relationships

39. Teaching & Learning
• Outstanding Teaching
Adapted Curriculum, Literacy lessons for All, Annual Curriculum Plan,
Adapted timetable, Schemes of work and Schematics
• Learning Free From Anxiety
Adapted Structure for lessons, Adapted lesson planning, nurturing environment, positive relationships, mutual respect, being
valued, relentless care
• Engagement & Progression
Evaluated outcomes, high expectations, personalised learning, multiple learning styles, evaluated lessons
Confident Learners
Assessment for Learning, standardised weekly marking, thorough feedback on work, fine grading for KS 3&4
• Outstanding Learning
Accredited qualifications, positive work experience, progression to post 16 opportunities, achieved of goals and beyond

40. Bob Geldof Was Right……….
‘We don’t like Mondays’!
We do ‘stuff’ together. We go out and about. We have ‘experiential’ learning
*Geocaching *Getting muddy *Reflecting on Beauty around us*Learning
something new *Keeping Safe *Talking to each other *Shouting at each
Other! *Leadership skills *Problem Solving*Orienteering *Being Scared at
trying something new *Bivouacking *Laughing a lot
*Falling over *Exercising *Aching!
*Building fires *Having a good time
*Cooking outdoors *Trusting each other

41. Have our pupils made progress?
Emotional Growth Profiles
Measuring the quality of the interventions
• Interpersonal relationships
• Preparation for the world of work
• Health and well being
• Positive behaviour for learning
• Engagement in School
• ‘On Task’ behaviour

42. Conclusion
• Any model aimed at helping children should aim to reduce symptoms but
also build strengths,
• This also serves as a ‘prevention’ programme against poor outcomes in
adulthood,
• All research shows that programmes aimed at symptom reduction,
improving social competence and emotional management are consistently
more effective !
At Five Rivers we use a phased orientated treatment model ---- Stabilisation,
Processing, Integration are consistently applied throughout all our services.

43. References
- Brown, Jon, O'Donnell, Trish and Erooga, Marcus (2011) Sexual abuse: a public health challenge. London: NSPCC.
- Cawson, P., Wattam, C., Brooker, S. and Kelly, G. (2000) Child Maltreatment in the United Kingdom: a study of prevalence of
child abuse and neglect. London: NSPCC.
• Cantor, C (2005) Evolution and Posttraumatic Stress: Disorders of Viglinace and Defence, Routledge, London
• Cross, R (2012) (2012) "Interpersonal childhood trauma and the use of the therapeutic community in recovery", Therapeutic
Communities: The International Journal of Therapeutic Communities, Vol. 33 Iss: 1, pp.39 – 53
• Ford, T ., Vostanis, P., Meltzer, H., & Goodman, R. (2007). “Psychiatric disorder amongst British children looked after by local
authorities: comparison with children living in private households”. British Journal of Psychiatry, 190. 318-25
• Herman, J.L., (1992) Complex PTSD: A Syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic stress, 5,
337 -391
• Nijenhuis, E.R.S., Vanderlineden, J. And Spinhoven, P (1998) Animal defence as a model for trauma-induced dissociative
reactions, Journal of Traumatic Stress, 11: 243-260
• Newlove-Delgado, T., Murphy, E., Ford, T (2012) Evaluation of a pilot project for mental health screening for children looked after
in an inner London borough. Journal of Children’s Services 7. 213-225
• Goodman, R. (2001) Psychometric properties of the Strengths and Difficulties Questionnaire (SDQ). Journal of the American
Academy of Child and Adolescent Psychiatry, 40, 1337-345.
• Goodman, R., Ford, T., Richards, H., et al (2000) The Development and Well-Being Assessment: description and initial validation
of an integrated assessment of child and adolescent psychopathology. Journal of Child Psychology and Psychiatry, 41, 645-657
• Minnis, H. , Reekie, J., Young, D., O’Connor, T., Ronald, A., Gray, A., et al. (2007) Genetic, environmental and gender
influences on attachment disorder behaviours. British Journal of Psychiatry 180: 495
43

44. info@five –rivers.org
residential@five-rivers.org