Dr Ian Barron, University of Dundee

1
Developmental Trauma in Scotlands Secure Care
Estate Assessment and Intervention

• Dr Ian Barron, University of Dundee
• Scotlands Secure Estate (ESS Good Shepherd
  Kibble St Marys)
• David Mitchell, Rossie, Young Peoples Trust
• Dr Ricky Greenwald, Child Trauma Institute
• Dr Bill Yule, Atle Dyregrov 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 Greenwalds
  Treating Problem
• Behaviour script)
• (iii) Standardised measures (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 Peoples
Trust(Barron and Mitchell, 2013)

• N17 14-18yrs 11 female/6 male Scottish
  Caucasian relative absolute poverty poor
  quality housing/homeless (n2) parental
  prostitution (n5) drug dealing (n3) substance
  misusing (n11) schedule 1 offenders access to
  home (n3), mother sectioned under the mental
  health act (n1)
• 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 (n12) physical
  abuse (n15) physical assault (n17)
  experiencing domestic violence (n12) witnessing
  domestic violence (n8) neglect (n10)
  emotional abuse (n7) hospitalisations (n9)
  sudden traumatic losses (n17) and frequent
  placement change (n17).
• Few coherent chronologies (n4) - despite
  repeated child death recommendations

7
Lack of Social Justice for YP vs. multiple legal
proceedings

• Despite extensive abuse only 1 YP experienced
  justice through the Scottish Legal system for
  harms done to them (perpetrator imprisoned)
• Vs.
• YP experienced multiple child protection case
  conferences, childrens 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 (n3 TSSC) no diagnosis
  as YP unpredictable invalidating result??
• N8 files recognised daily events as behavioural
  triggers not connected to historical abuse,
  e.g. derogatory comments to young people, worries
  about stability of mothers 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 (n2) - no evidence professionals
  making connection between substance
  misuse/self-harm
• Depression rarely named (n3) - 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 childrens 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 Greenwalds 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 Atle Dyregrov
• Psycho-education - Intrusion, Hyper-arousal and
  Avoidance
• Delivered in pairs, three fours
• 7-8 session (vs 5 session)

16
Evaluation of TRT (RCT)

• YP (N17)
• Intervention / control
• Presenters PSDO team (n3) - 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 T treatment (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 - Childrens 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_at_dundee.ac.uk