Developmental Trauma in Scotland’s Secure Care Estate: Assessment and Intervention

1. Developmental Trauma in Scotland’s Secure Care Estate: Assessment and Intervention Dr Ian Barron, University of Dundee Scotland’s Secure Estate(ESS; Good Shepherd; Kibble; St Mary’s) David Mitchell, Rossie, Young People’s Trust Dr Ricky Greenwald, Child Trauma Institute Dr Bill Yule, AtleDyregrov and Patrick Smith, Children and War Foundation. David Cotterell- A Scottish Government funded project

2. Aims (Phase 1& 2) • Shift focus - symptom management (attempting to control violence, anger and drugs use) to healing the underlying trauma which (i) drives the behaviour and (ii) results in YP being unresponsive to behavioural programmes • Introduce trauma-specific screening and evaluation (i) Develop a developmental trauma framework to case files analysis (PTSD – DSM IV and developmental trauma lens – Bessel Van der Kolk) (i) Trauma history interview (Dr Greenwald’s Treating Problem Behaviour script) (iii) Standardisedmeasures (CRIES-13; MFQ; TGIC; ADES; SDQ). • Introduce and evaluate trauma-specific intervention • Training for trauma-sensitive milieu

3. Neurobiology: TM “The body keeps the score” – embodied trauma response (van der Kolk) • Burnt in under severe threat & extreme emotion • Triggered by – sensory fragments similar to original trauma, e.g. talking about T; seeing similar face, hearing voice, smell of aftershave, taste … • Re-experienced (not re-remembered) in same vividness; body sensations, horror, terror, helplessness as original event; as if ‘happening again’ • Activated - re-traumatizes; timeless and immutable; sense of it always in the present; life through trauma lens of terror/helplessness; highly accurate (sensory) • Generalised response - Amygdale: smart smoke alarm “any bang becomes a bomb” (Myers, 2009)

4. Young People - Rossie Young People’s Trust(Barron and Mitchell, 2013) • N=17; 14-18yrs; 11 female/6 male; Scottish Caucasian; relative & absolute poverty; poor quality housing/homeless (n=2); parental prostitution (n=5); drug dealing (n=3); substance misusing (n=11); schedule 1 offenders access to home (n=3), mother sectioned under the mental health act (n=1) • In free fall , e.g. 40 absconding, 20 break ins, 7 assaults, 3 suicide attempts ….. short period of time.

5. Case file analysis • Trauma invisible in medical files • Physical rather than mental health focus • Symptoms rather than diagnosis • No connection to embodied symptoms & YP trauma • ‘Scatter Gun’ of professional involvement • Wide range of ‘types’ of professions recorded per YP • Up to 31 different types of professional – frequent changes • Omission of survivor organization/expertise

6. Extensive abuse histories not set within trauma lens • Multiple ‘types’ of harm/trauma: 10 different types categorized: sexual abuse (n=12); physical abuse (n=15); physical assault (n=17); experiencing domestic violence (n=12); witnessing domestic violence (n=8); neglect (n=10); emotional abuse (n=7); hospitalisations (n=9); sudden traumatic losses (n=17); and frequent placement change (n=17). • Few coherent chronologies (n=4) - despite repeated child death recommendations

7. Lack of Social Justice for YP vs. multiple legal proceedings • Despite extensive abuse only 1YP experienced justice through the Scottish Legal system for harms done to them (perpetrator imprisoned) Vs. • YP experienced multiple child protection case conferences, children’s panels, review meetings, supervision meetings, care plan meetings, police stations, over-night custody and charged with various and numerous offences.

8. PTSD unrecognised & triggers not connected to historical abuse • Descriptive behaviours, e.g. hostility, self-harm, drug taking etc. NOT set within trauma lens • Omission YP internal intrusive/sensory experiences • Few PTSD assessments (n=3; TSSC) & no diagnosis as YP “unpredictable” invalidating result?? • N=8 files recognised daily events as behavioural triggers – not connected to historical abuse, e.g. derogatory comments to young people, worries about stability of mother’s residence

9. Developmental trauma symptoms apparent but not ‘connected up’ and seen as consequences of trauma • Extensive behavioural difficulties • Multiple charges • Severely disrupted educational histories • Families relationships characterized by violent chaotic disorder; Violent peer relationships • Lack of future hope frequent • Negative behaviours/emotions for all (Emotional dys-regulation) • Disturbed cognitions rarely reported • Re-victimisation statements common • Dissociation (n=2) - no evidence professionals making connection between substance misuse/self-harm • Depression rarely named (n=3) - symptoms reported

10. Conclusions: file analysis • PTSD & developmental trauma symptoms pervasive with YP in secure care • Professional reports indicate lack of understanding of the impact of trauma on YPs presenting behavioural difficulties • Post-placement decision-making equally characterized by omission of trauma lens • No trauma-specific programmes • Substantial need across health and welfare services (whole system) working with children, who have been neglected and abused, to understand: (i) the nature of children’s traumatic experience (ii) how to apply this understanding to placement decisions, support and trauma-specific interventions for YP (iii) take cognisance of this during exit planning.

11. What did the young people say – Trauma history interviews(Ricky Greenwald’s script) events and SUDs 0-10 • 9 T events on average; multiple 10s cumulative Ts not processing - see cases • Multiple T losses: deaths, into care, parent in prison, sibling into care; • Violence endemic: gang, assaults experienced and done • Agency traumas: returned to abusive home; hearings; in custody; into care (esp. 1st time); secure accommodation • No harm conducting Trauma Histories – psycho-education

12. Compared with standardised measures Clinical levels (mostly clusters) of: • PTSD (65%) • Depression (65%) • Dissociation (18%) found in nearly all young people (files) • Clinically significant levels of complicated grief • Underestimated trauma as measures developed around ‘single’ events

13. Evidence-based aspects of intervention - phased approaches (Greenwald, 2014) • Safety first; “safe now”; good attachment • Stabilization – calming and dissociation techniques - improved affect regulation • Core relationship factors – empathic, warm, positive regard, shared understanding & planning • Motivational interviewing (bounce effect) • Trauma-specific therapies – “face T memory & not overwhelmed, brief exposure, viewing distance, broader perspective, internal processing, dual focus, privacy option, coherent structured narrative”

14. Evidence-based trauma-specific interventions (Greenwald, 2014) • Prolonged exposure – old standard, tell story in detail over and over, - ordeal teenagers as revs up anger/guilt • Trauma-focused CBT – write/draw story page by page in a book, piece by piece structure narrative, lot of lab research applied to community MH settings, 8-10 sessions per TM • Narrative Exposure Therapy (KidNET), dev with refugees, tell life story with trauma story embedded, rope timeline - stones/flowers, individual & group (4-6 sessions) • Traumatic Incident Reduction – guided through imagining the T story 1 to 3 per TM • Eye Movement Desensitization Reprocessing – new standard , focus on worst moment during eye movements, brief exposure, associative memory (1-3 sessions?) • Progressive Counting – imagine the movie while therapist counts to 100; T memory sandwiched between positive past and future images – contains associative memory (intensive sessions – couple of days!)

15. Manualised Programme intervention • Group/individual-CBT ‘Teaching Recovery Techniques’ (TRT) • Children and War Foundation - Patrick Smith, Bill Yule & AtleDyregrov • Psycho-education - Intrusion, Hyper-arousal and Avoidance • Delivered in pairs, three & fours • 7-8 session (vs 5 session)

16. Evaluation of TRT (RCT) • YP (N=17) • Intervention / control • Presenters PSDO team (n=3) - deliver behavioural change programmes • Trauma history interview • SUDs; standardized measures (CRIES-13; MFQ; ADES; TGIC; SDQ) • 2 weeks pre/post TRT • Programme fidelity – video analysis • Interviews YP; Staff focus group

17. TRT Findings • Large effect size - reducing SUDs • Small effect size - behavioural change • No statistical difference - standardized measures. • Control group made small gains = secure is containing & stabilizing (emotionally) while there • YP mostly positive about TRT experience & identified specific helpful aspects • Presenters (i) YP selection and grouping important (ii) liaison with care/education staff to enable transfer of YP strategies (iii) further gains after evaluation • Programme fidelity very high • Substantial financial and post-placement gains were achieved for some young people. • Whole staff group evidenced substantial knowledge gains in trauma-sensitive environments

18. Phase 2: Rationale for individualised therapy Treating Problem BehaviorsRicky Greenwald • Some harm inappropriate to disclosure within a group • TRT - assessment of need for in-depth individual T therapy • Short duration placement impeding group delivery • On site individual therapy provides immediate access to treatment within short placements • Individual therapy recognized as standard of care for Ttreatment (NICE) • Evidence suggests TPB phase model enables high levels of engagement & can lead to lasting change, i.e. true healing and transformation • TPB is manualised/replicable & developed/tested with secure care populations • Cost saving - time limited behavioural stabilization to intensive trauma focused treatment

19. TPB Developments • 5 provision across the whole secure care estate in Scotland involved • By April 2015 - 14 TRT practitioners; 24 TPB practitioners • Increased time spent with individual therapy for YP (1st year 5-10% of workers time was increased to 10-30% ; expecting similar increase this year • Therapy more intensive (YP tolerate longer sessions) - treatment 4-6 weeks YP entry • High standard of supervision - monthly review videotaped sessions & expert consultation with Dr Greenwald • Practitioner capacity to adhere to programme implementation fidelity dramatically improved • All staff trained in TPB trauma-sensitive milieu – enhances communication programme/care staff • Writing reports from T-informed lens (report template and exemplars) • Sustainability – trainer of trainers model: 6 accredited TPB ‘trainers’ (Child Trauma Institute); and 10 TRT trainers; international TPB network • Increase quality & no. of professionally trained staff / outsourcing • Eliminate stakeholders requesting less promising interventions – psycho-education

20. TPB/TRT/Writing for recovery Evaluative Research • Field trial • T measures into ‘standard evaluative practice’ for benchmarking programmes, practitioners, provision and longitudinal evaluation • Standardized measures for assessing cumulative trauma - Children’s Report of Post Traumatic Symptoms (CROPS): Parents Report of Post Traumatic Symptoms (PROPS) and the Problem Behaviour Rating Scale • Behavioural tracking (before/during/after) - point/level behaviour systems, incident reports, medical utilisation, school performance, time to discharge, type of discharge to higher/lower level of care • Programme adherence through scripts and video • Qualitative measures – interviews with staff and young people • Placement trajectory costs

21. Thank you • i.g.z.barron@dundee.ac.uk