Breaking the cycle of trauma and adversity in the lives of Scottish children.

Understanding the impacts of trauma and adversity on children’s lives

Written by: Sharon Doherty NHS Education for Scotland Trauma Team Psychology@nes.scot.nhs.uk; Suzy O’Connor NHS Education for Scotland Early Intervention Team Psychology@nes.scot.nhs.uk; Gail Nowek Education Scotland Gail.Nowek@educationscotland.gsi.gov.uk

It is unlikely to come as a surprise to teachers that children who experience adverse childhood experiences (ACEs) find it difficult to learn(1). Educators have long recognised this. What is perhaps surprising is just how prevalent childhood trauma and adversity is, and the extent to which adverse experiences shape a child’s social, emotional and cognitive development and, potentially, their health and quality of life over the course of a lifetime.

“Adverse childhood experiences are experiences that have the potential to cause a child to experience traumatic stress, such as emotional, physical or sexual abuse or toxic stress, such as having a parent in prison, parental mental illness, parental separation, parental substance misuse, witnessing domestic abuse or physical or emotional neglect”

Recent research from Public Health Wales provides some stark examples. This research showed that 14% of adults in Wales had suffered 4 or more adverse experiences as children(2) and that, compared to children who had experienced no ACEs, children who had experienced 4 or more ACEs were, in adulthood; 20 times more likely to go to prison, 16 times more likely to use cocaine or heroin and 4 times more likely to be a high-risk drinker than those with no ACES. Girls with 4 or more ACEs were 4 times more likely to have had their first child before they were 18(3).

That’s not all; those with a history of 4 or more ACES were 5 times more likely to suffer with poor mental well-being(4),  4 times more likely to develop type 2 diabetes, 3 times more likely to develop respiratory and heart disease(5) and were found to be at increased risk of premature death(6). “Figures like these are powerful because they are clear in their message. Exposure to adversity and trauma in early life can significantly affect a child’s life chances, and, because children grow in to adults who shape the next generation, potentially the life chances of their children”.

Mobilising responses to children affected by trauma and adversity

While these messages are sobering, they are likely to confirm what many who work directly with children or adults already know. They nonetheless create an imperative to act and reinforce the importance of continuing to build on the work that is already underway in Scotland to prevent childhood trauma and adversity, and to address its impact in children and in adults.

There is presently significant will to do this - preventing and responding to adversity and trauma is a key focus across a range of Scottish Government strategies, including the current mental health strategy(7). Scottish educators are also working to break the cycle by developing approaches which recognise and respond to the needs of children and young people in ways that nurture and support(8).

These efforts are well-founded. Recent research emphasises that “adversity is not destiny” in that “continuous access to a trusted adult in childhood reduces the impact of ACEs on mental well-being and health-harming behaviours such as smoking and drinking in adulthood”(9). Previous research has also highlighted the benefits of school connectedness, and attachment to key adults such as teachers, in improving attention, attainment and the behaviour of children and young people, and in reducing the risk of youth offending(10,11,12). The importance of “one good teacher” was also echoed by Mullholland and Seith(13) in a recent Times Educational Supplement article.

- “A compassionate teacher that takes an interest in you could be enough… it could be protective enough” (Mulholland and Seth)

“Transforming Psychological Trauma -  a Knowledge and Skills Framework for the Scottish Workforce”(14) was published in 2017 and articulates the different evidence-based ways that workers, from all sectors of the workforce, can respond to people affected by trauma within the context of their own job role.

The framework specifies four practice levels: trauma informed, trauma skilled, trauma enhanced and trauma specialist. The aspiration is that all workers will develop a trauma-informed level of understanding whilst workers who have regular contact with children or adults who may be affected by trauma (even if this is not known about) would be expected to develop a trauma skilled level of understanding and skills. Trauma-enhanced workers have a specific remit to provide supports and/or interventions and trauma specialists a remit for those with complex difficulties.

The trauma skilled level is of particular relevance to teachers. A key emphasis of this practice level is that workers and managers understand the value of trauma-informed approaches and environments, the importance of considering the question “what is happening to you?” rather than, “what’s wrong with you?” and the importance of providing children with access to safe, consistent, empowering and trustworthy relationships. Safe, collaborative, supportive and empowering workplaces are also central to the success of trauma-informed approaches as these support workers to relate to others in a trauma-skilled way and enable workers to cope with adversity and trauma in their own lives.

“Considering asking yourself the question “what’s happening to you?” rather than “what’s wrong with you?”

How do these ideas fit with work already underway within Education in Scotland?

Whilst the language used to talk about trauma and adversity can be different in education and health, many of the central ideas and principles are the same or overlap(15).

Scotland’s educational policy context has long emphasised the importance of schools’ supporting the wellbeing of children and young people and to promoting positive relationships(16,17,18).  Health and wellbeing is also a core area and a responsibility for all within the Curriculum for Excellence.

Whilst the emphasis on adversity is welcomed by many educators, many are still unsure about how best to help. However, in developing systems which recognise and respond to a child’s developmental needs within the school environment, and which recognise the importance of secure relationships and attachment in the lives of children, Scottish schools are already making a difference to the lives of children affected by trauma and adversity. The whole school nurturing approach brings these ideas and understandings together within a single approach which includes trauma informed practice(19).

Although Nurture Groups were originally developed to help children and young people known to be affected by adversity and trauma to recreate missed early experiences (through the creation of safe environments, safe relationships, a focus on wellbeing, on learning which is developmentally-focussed, on behaviour as communication and on supporting transitions), a whole school nurturing approach now applies these principles at a whole school level to support all children. In Scotland, a national framework has been developed to support schools to self-evaluate and implement a nurturing approach.

 “At the heart of a nurturing approach is a focus on wellbeing and relationships and a drive to support the growth and development of children and young people particularly those who may have experienced early adversity or trauma. Education Scotland (2016).”

What is the role for specialist supports and interventions?

Whilst the Transforming Psychological Trauma Framework emphasises the contribution all workers can make, the framework also recognises the need for specialist services. It articulates the importance of workers being able to recognise when specialist support and interventions are needed and the importance of bridging between the supports which schools and specialist services provide.

What training is available to support these aspirations?

The Transforming Psychological Trauma framework was developed to support workforce development through high quality training. It is not expected that any one organisation will provide all training – rather that training will come from a range of training providers. To support organisations to identify high quality training relevant to their needs, NHS Education for Scotland will be publishing a Trauma Training Plan in the Autumn. 

In this context, the table below details relevant training which is currently provided by Education Scotland and NHS Education for Scotland and which is accessible to workers in educational settings. Child-specific NES training is particularly relevant for workers who have a remit to provide targeted 1:1 or group input to children, young people and their parents (e.g., early years’ workers, school nurses, guidance teachers, nurture teachers) and is designed to enhance existing work with children, young people and their families. It is envisaged that NES training will span trauma-skilled and trauma- enhanced practice levels and thus complement and build upon existing Nurture provision within schools.

References

1.    Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., DeRosa, R., Hubbard, R., Kagan, R., Lautaud, J., Mallah, K., Olafson, E. & van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 390-398.
2.    Ashton, K., Bellis, M. A., Davies, A.R., Hardcastle, K. and Hughes, K. (2016). Adverse Childhood Experiences and their association with chronic disease and health service use in the Welsh adult population. Public Health Wales. http://www.wales.nhs.uk/sitesp...
3.    Bellis, M.A., Ashton, K., Hughes, K. Ford, K., Bishop, J. and Paranjothy, S. (2015). Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population. Public Health Wales. http://www.wales.nhs.uk/sitesp...
4.    Ashton, K., Bellis, M. A., Hardcastle, K., Hughes, K., Mably, S. and Evans, M. (2015). Adverse Childhood Experiences and their association with mental well-being in the Welsh adult population. Public Health Wales. http://www.wales.nhs.uk/sitesp...
5.    Bellis, M.A., Ashton, K., Hughes, K. Ford, K., Bishop, J. and Paranjothy, S. (2015). Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population. Public Health Wales. http://www.wales.nhs.uk/sitesp...
6.    Brown, D.W., Anda, R.F., Tiemeier, H., Felitti, V.J., Edwards, V.J., Croft, J.B., Giles, W.H (2009). Adverse childhood experiences and the risk of premature mortality. American Journal of Preventative Medicine. Nov;37(5):389-96. doi: 10.1016/j.amepre.2009.06.021.
7.    Mental Health Strategy 2017-2027. Scottish Government. http://www.gov.scot/Publicatio...
8.    Applying Nurture as a whole school approach: A framework to support the self-evaluation of nurturing approaches in school and early learning and childcare settings. Education Scotland 2016
9.    Bellis, M. A., Hardcastle, K., Ford, K., Hughes, K., Ashton, K., Quigg, Z and Butler, N. (2017). Does continuous trusted adult support in childhood impart life-course resilience against adverse childhood experiences – a retrospective study on adult health-harming behaviours and mental well-being. BMC Psychiatry (2017) 17:110, DOI 10.1186/s12888-017-1260-z.
10.    Bergin, C. and Bergin, D. (2009). ‘Attachment in the classroom’, Educational Psychology Review, 21:141–170
11.    Smith, D.J. (2006). School experience and delinquency at ages 13-16. Edinburgh Study of Youth transitions and crime research digest, No.13
12.    Frisby, B. N., and Martin, M. M. (2010). Instructor–student and student–student rapport in the classroom. Communication Education, 59 (2), 146-164.
13.    Mulholland H & Seith E (23rd June, 2018). Long Read: Are schools coping with trauma? https://www.tes.com/news/long-...
14.    Transforming Psychological Trauma – A Knowledge and Skills Framework for the Scottish Workforce (2017). NHS Education for Scotland & Scottish Government. http://www.nes.scot.nhs.uk/edu...
15.    Nurture, Trauma informed and Adverse Childhood Experiences: making the links between these approaches (2018). https://education.gov.scot/improvement/Documents/inc83-making-the-links-nurture-ACES-and-trauma.pdf. Education Scotland
16.    Developing a positive whole school ethos and culture: Relationships, learning and behavior. Scottish Government (2018).
17.    Included, Engaged and Involved Part 2: A positive approach to preventing and managing exclusion. Scottish Government (2017).
18.    A Guide to Getting it Right For Every Child. Scottish Government (2012).
19.    Applying Nurture as a whole school approach: A framework to support the self-evaluation of nurturing approaches in school and early learning and childcare settings. Education Scotland (2016).
20.    Education Scotland currently provides a suite of resources to support nurturing approaches in schools. Further information can be found at:  https://education.gov.scot/imp...
https://education.gov.scot/imp...
21.    Opening Doors: Trauma Informed Practice for the Workforce. http://www.nes.scot.nhs.uk/edu...