Responding to Traumatic Incidents in Schools

1
Responding to Traumatic Incidents in Schools

• Nick Durbin
• Joint Programme Director Senior
  Educational Psychologist
• University of Nottingham Warrington BC
• Doctorate in Applied Educational Psychology

2
Aims of Session

• Develop awareness and knowledge of the
  psychosocial impact of traumatic incidents on
  children and schools
• Examine current theory and the evidence base for
  practice
• Explore what is known to support those affected
  by traumatic incidents in schools
• Develop your understanding of how educational
  psychologists work as a part of a team to plan
  for, and support those affected by traumatic
  incidents

3
Overview of the Session

• Definitions and Impact of Trauma
• Rationale for Support and Intervention
• Levels of Response and Support
• EP practice and Involvement

4
Educational PsychologyLevels of Involvement
Community
Organisation
Group
Indl
5
What is a Traumatic Incident?

• An incident charged with profound emotion may
  involve serious injury or death
• Incident generating a high level of immediate or
  delayed emotional reaction
• Incident involving serious threat or extremely
  unusual circumstances
• Incident attracting unusual attention from the
  community or media
• Surpassing an individual, group or organisations
  normal coping mechanisms

6
Case Study 1 A School Visit Bus Crash

• Issues?
• Contacts?
• Actions?

• Bush crash close to school
• 70 Y6 pupils some with serious injury
• Taken to 2 Hospitals
• 10 adult staff and helpers also on trip some with
  injury
• 140 concerned parents
• 200 other pupils at school
• 20 staff and governors
• 3 emergency services
• Local authority managers contact EPs ask them to
  respond

7
Rationale for Critical Incident Support

• Understand the Impact of Trauma
• Individuals
• Organisations
• Plan for Peoples Reactions and Needs
• Manage an Organisation and Community Response
• Wise before an Event rather than after it (Yule
  and Gold, 1993)

8
Aims of the Critical Incident Support

• Attempt to Minimise Impact
• Ensure Appropriate Support
• Co-ordinate Responses
• Support Normal Processes

9
Case Study 1 A School Visit Bus Crash

• Bush crash close to school
• 70 Y6 pupils some with serious injury
• Taken to 2 Hospitals
• 10 adult staff and helpers also on trip some with
  injury
• 140 concerned parents
• 200 pupils at school
• 20 staff and governors
• 3 emergency services
• Local authority managers and services

10
Trauma Some Considerations

• Theory
• definitions
• signs and symptoms
• Impact and Intervention
• individual
• groups
• organisation and community
• Evidence
• research
• practice

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Traumatic Incidents Impact and Intervention
Community
Organisation
Group
Individual
12
Common Reactions to Trauma

• Feelings of denial
• Distress
• Guilt
• Anger
• Helplessness
• Re-experiencing events
• Avoidance
• Arousal (high or low)

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Common reactions (continued)

• Flashbacks and intrusive memories
• Headaches
• Difficulty concentrating
• Feeling guilty it was my fault
• Feeling detached from others

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Common reactions (contd)

• Numbness
• Anxiety
• Feeling on edge and Hyper-vigilant
• Depression
• Irritability and anger
• Sleep disturbance, nightmares

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Peoples Reactions and Needs

• Reactions vary depend
• Age
• Experience
• Personality
• Nature of the incident
• Degree of involvement

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Definitions of Post Trauma Stress

• The development of certain characteristic
  symptoms following a psychologically distressing
  event which is outside the range of normal human
  experience (APA, DSM 1987)

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Post Traumatic Stress

• And
• The normal reactions of normal people to events
  which, for them, are unusual or abnormal
  (Parkinson, 1993)

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Post traumatic Stress Disorder

• Occurs when symptoms of PTS emerge later, persist
  or intensify long after the event. i.e. more than
  six weeks - and disrupt normal living
• Involves three aspectsRe-experiencing, Avoidance
  and Arousal
• (DSM IV, 1993)

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DSM IV Symptom Criteria
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Trauma, PTS and PTSD

• Dose Symptoms
• The vast majority of people exposed to serious
  traumatic events do not develop PTSD (McNally,
  2003)

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Normal Features of Grieving
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Stages of Response and Recovery

• Shock
• Denial
• Emotional Impact
• Working Through
• Acceptance
• Normal reactions
• Pre- trauma Stability
• Post trauma Stability
• Traumatic Incident

7
8
9
1
6
2
5
3
4
Adapted from Queensland Dept of Education
23
Some common needs

• Information,
• acknowledgement
• opportunity to talk
• formal and informal rituals
• recognition
• routines and normality
• return and reintegration

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Evidence based treatment for Individuals with PTSD

• NICE (2006) guidance suggests the importance
• Psychological first aid
• Watchful waiting
• Trauma focused CBT
• Eye Movement Desensitisation Reprocessing
  (Shapiro,1993)
• CBT has slightly better evidence base in children
  than EMDR (Wolpert,M et al, 2006)

25
Psychological treatments for adults

• Interventions need to be focused on trauma and
  structured
• Trauma focused CBT
• Helps confront traumatic memories with less fear
• Modify misinterpretations which overestimate
  threat
• Develop skills to cope with stress.
• Eye movement desensitisation and reprocessing
• PTSD sufferer is asked to recall an important
  aspect of the traumatic event
• Wilst following repetitive side to side
  movements, sounds or taps as the image is being
  focused on
• (NICE, 2005 PTSD guidance)

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In children and young people

• Diagnosis is the same as adults
• Symptoms may differ in younger children may
  include re-enacting, repetitive play, emotional
  and behavioural difficulties.
• Intervention of choice is currently trauma
  focused CBT
• Need for better evidence base and audit of all
  interventions
• (NICE PTSD guidance 2005)

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Traumatic Incidents Impact and Intervention
Community
Organisation
Group
Indl
28
Case Study 2 Death in the Playground

• 12 noon Pupil aged 7 years
• Suddenly falls and hits head in the playground
• Pupils alert staff who give first aid
• Ambulance is called
• Parent informed
• Ambulance arrives but pupil has died before
  arrival at hospital

• Issues?
• Contacts?
• Actions?

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Levels of Support (Hindmarch, 1999)
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Impact of Traumatic Incident
1
2
3
4
5
1. Primary Victims 2. Secondary Victims 3, 4,
5.Tertiary Victims
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Group Reactions and Needs

• Reactions can vary depend
• Previous Experience
• Group Dynamics
• Nature of the incident
• Degree of involvement
• Closeness to incident

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Critical Incident Debriefing

• A structured group process that aims to reduce
  the impact of PTS and enhance coping mechanisms
• Confidential and supportive service offered
  staff, parents and pupils affected by an an
  incident
• In which group shares experiences, thoughts and
  feelings about an incident
• Usually takes 2-3 hours ( but can vary depending
  on size of the group)

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Critical Incident Debriefing (continued)

• For Adults and Children
• Initial session with follow up
• Between 3-14 days after incident
• Two trained facilitators (lead and support)
• Priority given to those who witnessed or were
  closely involved in some other way
• Children groups need informed parental consent

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Definition

• a group meeting or discussion, employing both
  crisis intervention and educational processes,
  targeted towards mitigating or resolving
  psychological distress associated with a critical
  or traumatic event
• (Mitchell and Everly, 1996)

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Psychological Debriefing

• Introduction
• Facts
• Before, during and after
• Thoughts
• Feelings
• Normalisation - psycho-education
• Future
• (Dyregrov, 2003)

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Aims of Debriefing

• Integrate cognitive and emotional memory
• Connecting past - present - future
• Psycho-education
• Normalisation

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Critical incident stress Debriefing Process
Cognitive
Introduction
Re-entry
Facts
Teaching
Thoughts
Symptoms
Reactions
Emotional
(Mitchell and Everly, 1996)
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Objectives of CISD

• Ventilation of impressions, reactions and
  feelings
• Promotion of clear understanding of precipitating
  events and subsequent reactions
• Decrease in individual and group tension and the
  sense abnormality
• Mobilisation of coping resources
• Preparation for future symptoms and
  identification of avenues for further assistance
  (Hodgkinson and Stewart, 1993)

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Issues of debriefing with Children (Wraith, 2000)

• Involvement of parents
• Developmental issues in child
• Role of peer group
• Modalities of expression and conversation
• Level of engagement
• Self disclosure, confidentiality, coping skills
• Secondary traumatisation/retraumisation
• Importance of trained leadership, psychological
  first aid linked to debriefing

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Issues of debriefing

• In a comparative study of adolescents Stallard
  and Law (1993) conclude
• psychological debriefings can be very effective
  in reducing intrusive thoughts, possibly by
  validating the persons experience of trauma,
  allowing re-interpretation of their attribution
  and providing a forum in which emotions can be
  discharged (p.663)

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Debriefing

• Questions have been raised as to efficacy of
  single session debriefing in preventing PTSD in
  individuals
• Needs to be part of group and overall management
  response and package of care
• Careful consideration of elements of debriefing
• Purpose
• Timing and Duration
• Group membership
• Training of facilitators
• Follow up

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Criticisms of CISD and its impact on PTSD

• Evidence base for CISD and other interventions
  are inconclusive
• A meta analysis by Van Emmerick et al (2002)
  adult CISD studies found no evidence of
  prevention of PTSD
• But some evidence of perceived helpfulness and
  satisfaction
• But CISD has other purposes too
• contributing to psychological first aid and part
  of a planned response
• reduction of distress and psycho-education
• Ethical and research issues
• Normalising rather than pathologising
• Research with bereaved and traumatised groups
  notoriously difficult

43
Methodological criticisms of the critics of
debriefing

• Analyse single session debriefing
• Use self selection and groups not adequately
  matched
• Actual debriefing used not defined
• Timing of intervention variable
• Intervention insufficient
• Training of facilitators not clear
• Not part of Critical Incident Stress Management
  (Dyregrov, 2003)

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Context for debriefing

• Needs to be part of overall crisis intervention
  or plan
• Not given too early
• Or without follow-up
• Assessment of group and individuals
• Trained personnel
• Focus cognitive and education
• Not too long or too short

• (Hodgkinson and Stewart, 1993)

45
Case Study 3 Young Person Missing and Suspected
Murder

• Issues?
• Impact?
• Actions?

• Young Person Aged 17 missing
• Concerned friends tell teacher who reports this
  to police
• Frequent news stories and bulletins over months
• Body found and confirmed it is the young person
• Suspected Murder
• Family members arrested then released

46
Traumatic IncidentsImpact and Intervention
Community
Organisation
Group
Indl
47
Impact on Organisations

• Incidents can directly or indirectly affect a
  school and organisation
• Can be an onsite, offsite or multi-site
• May directly/indirectly affect school staff
  including senior managers
• May generate a lot of media interest
• May generate reaction in parents
• May generate over zealous helping, callers and
  visitors
• Plans and responses need to be flexible and Wise
  before the event

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Impact of trauma in Organisations

• Brings out the Best and Worst in people
• Magnify difficulties or strengthens existing
  relationships
• Close ranks in group versus out group
• Competing pressure to stop or carry on
• Opportunity to share and support

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Impact of Trauma School as an Organisation
(Attneave, C cited in Hindmarch, C (1999))
9

• Pre- trauma Context
• Crisis
• Retribalisation
• Polarisation
• Mobilisation
• Depression
• Breakthrough
• Exhaustion/Elation
• Post-trauma Context

1
2
3
4
8
5
7
6
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Managing an incident in school

• Action within Hours
• Obtain and Collate Information
• Convene Critical Incident Management team
• Create Incident room and phone line
• Contact Families affected
• Make arrangements for informing other parents
• Inform school staff
• Inform Pupils
• Inform Local Authority and Communications
  Department
• (Managing the response to critical incidents in
  schools (Cheshire CC Guidance, 1995)

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Managing an Incident in School

• Develop a plan for handling the feelings and
  reactions of people
• Prepare a more detailed media statement in
  association with Communications Dept
• Prepare further information for parents, pupils
  and staff
• Contact Critical Incident Support Team (CIST)
• Consider and arrange where appropriate debriefing
  for staff, parents and the pupils involved
• (Managing the response to critical incidents in
  schools( Cheshire CC Guidance, 1995)

52
Case Study 4 Child found in a swimming pool

• Issues?
• Impact?
• Actions?

• Child aged 6 with learning difficulties
• Enters swimming through an unlocked door and pool
  is unsupervised
• Staff supervising other children getting changed
• Child found face down in pool but is resuscitated
  by school nurse
• Sent to hospital but is discharged later that day

53
Traumatic Incidents Impact and Intervention
Community
Organisation
Group
Indl
54
Core Components of Critical Incident Stress
Management

• Pre-incident education/mental prepardness
• On scene crisis intervention support
• Demobilization
• Defusing
• Critical Incident Stress Debriefing
• Additional support for families and children
• Follow up services and appropriate
• (adapted from Mitchell Everly, 2000)

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Case study 5 Meningitis Death

• Suspected meningitis death of Child aged 5
• A member of school staff ill also with suspected
  meningitis
• Community and parents very upset and concerned
• Parents keeping children away from school despite
  advice to the contrary

• Issues?
• Impact?
• Actions?

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EP involvement in Strategic Development

• Involvement in development and revision of
  policy, procedures and guidance for schools
• Training and development activities provided for
  Staff in LA, Schools and other settings to ensure
  they are aware of issues related to bereavement
  and loss, psychological impact of trauma and
  effective management
• Coordination and Liaison with other agencies e.g.
  Health Protection Agency

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Authority and Community Wide Involvement and
Support

• Emergency Planning
• Team Development and Co-ordination
• Simulation and practice
• Links and Liaison with other services
• Training and Development
• Support and Response
• (See Pousada, 2006 for example)

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Crisis Support to Schools

• Crisis support to schools is still valid and
  needed
• Psychological debriefing useful aid to cognitive
  restructuring and normalisation
• Group work and coaching can lead to self help and
  dispel misunderstandings
• Work on planning and response is highly valued by
  schools
• (adapted from McCaffrey, 2004)

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Critical Incident Support Three Teams with
Links and Roles

• Immediate Aftermath
• - Local Authority Managers and Officers
• Short-term
• Multi-Disciplinary Critical Incident Support Team
• Medium-term
• Other Specialist Support Services
• including Occupational Health, CAMHS and
  bereavement services
• Long-term
• Critical Incident promotion, planning and
  preparing
• Local authority and other services

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EP involvement in Multi-Agency CIST working

• Involvement in responding and supporting
• Co-ordinated Multi-Agency Critical Incident
  Support Team involving
• Including educational psychologists, Child health
  and social care professionals
• Trained and developed for role
• Involvement in Coordination, Training, Planning
  and Working with
• Emergency Planning Officer
• Health Protection Agency (HPA)
• Public Relations and Communications Teams
• Children and Social services
• Emergency services
• (see Pousada, 2006, for example)

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EP Position in the Chain of Command
Incident
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Case Study 1 A School Visit Bus Crash

• Issues
• Impact?
• Actions?

• Bush crash close to school
• 70 Y6 pupils some with serious injury
• Taken to 2 Hospitals
• 10 adult staff and helpers also on trip some with
  injury
• 140 concerned parents
• 200 pupils at school
• 20 staff and governors
• 3 emergency services
• Local authority managers and services

63
Case Study 1 The Incident

• The Incident
• The Hours following
• The rest of the day/night
• The next day
• The day after that
• The rest of the week

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Case Study 1 The Response

• Information and support for
• Pupils
• Family
• Parents Group
• Staff
• Media
• Others (inc Governors, LEA etc)

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Case Study 1 Team and EP Response

• The Call
• The Reactions
• The Response
• Issues, Actions and Contacts
• Evaluation and Learning points

66
Support Needs

• Support needs
• In The Immediate Aftermath
• The Short Term ( up to 4weeks)
• The Medium Term ( 1 month to year)
• The Long Term ( 1year on and beyond)

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Some feedback

• The Critical Incident Team were a tower of
  strength to us all. They handled the whole
  incident in a very supportive and caring way
  without being intrusive. I feel that they were
  excellent in very way and do not lack in any
  area

68
Educational PsychologyLevels of Involvement
Community
Organisation
Group
Indl
69
Aims of the Session (Revisited)

• Develop your awareness and knowledge of the
  psychosocial impact of traumatic incidents on
  children and schools
• Examine current theory and the evidence base for
  practice
• Explore what is known to help support those
  affected by traumatic incidents in schools
• Develop your understanding of how Educational
  Psychologists work with other professionals to
  support those affected by traumatic incidents

70
Remember ..

• The normal reactions of normal people to events
  which, for them, are unusual and abnormal
  (Parkinson, 1993)

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Responding to Traumatic Incidents in Schools

• Questions
• Comments

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Responding to Traumatic Incidents in Schools

• I hope that you now feel Wise before the Event
  (or is it Exam!)
• Good Luck!!

73
References

• American Psychiatric Association (1993)
  Diagnostic and Statistical Manual of Mental
  Disorders Washington APA Carroll,D., Frew, D.,
  Futcher,A., Ladkin,M., Morey,Y., price,T.
  Smith, A. (1997) The educational psychology
  crisis intervention service. Educational
  Psychology in Practice, 13, 2, 112-114
• Dyregrov, A. (2003) Psychological Debriefing A
  leaders guide for small group crisis
  intervention USA Chevron Publishing
• Everly, G.S., Mitchell, J.T. (1999) Critical
  incident stress management(CISM) A new era and
  standard of care in crisis intervention.

74
References (Continued)

• Hindmarch, C (1999) On the Death of a Child.
• Hodgkinson, P.E. and Stewart, M(1998) Coping with
  Catastrophe. London Routledge
• OHara, D.M., Taylor, R., Simpson, K.,(1994)
  Critical incident stress debriefing bereavement
  support in schools - developing a role for an LEA
  educational psychology service. Educational
  Psychology in Practice, 10, 1, 27-34
• Mallon, F., Best, C., (1995) Trauma in School A
  psychological service response Educational
  Psychology in Practice, 10, 4, 231-237

75
References (continued)

• Mitchell, J.T., and Everly, G.S. (2000)Critical
  Incident Stress management and critical Incident
  stress debriefings evolutions, effects and
  outcomes. In Raphael, B., and Wilson, J.P.(2000)
  (Eds) Psychological Debriefing Cambridge
  Cambridge University Press
• National Institute of Clinical Excellence (2005)
  Post-Traumatic Stress Disorder Guidance
• Parkinson, F. (1993) Post trauma stress. London
  Sheldon Press
• Parkinson, F (1997) Critical incident stress
  debriefing. London Sheldon press
• Resnick, P.A. (2001) Stress and Trauma East
  Sussex Psychology Press

76
References (Continued)

• McCaffrey, T (2004) Responding to Crises in
  Schools A consultancy model for supporting
  schools in Crisis educational and child
  psychology 2004, 21, 3, 109 -120
• McNally., R.J., Bryant, R.A., Ehlers, A. (2003)
  Does early psychological intervention promote
  recovery from post traumatic stress?
  Psychological science in the Public interest 4,
  2, 45-96
• Pousada, S.(2006) Applying Psychology in Local
  Authority Emergency Planning Processes
  Educational Psychology in Practice, 22, 3,
  199-214
• Shapiro, F. (2001) Eye movement
  Desensensitization and Reprocessinig. New York
  Guilford Press

77
References (continued)

• Van Emmerik, A.P.A., Kamphuis, K.H., Hulsbosch,
  A.M. Emmelkamp, P.M.G.(2002) Single session
  debriefing after psychological trauma a
  meta-analysis Lancet, 360, 766-771
• Wolpert, M., et al (2006) Drawing on the Evidence
  London EBPU
• Wraith, R. (2000) Children and debriefing
  theory, interventions and outcomes. In Raphael,
  B., and Wilson, J.P.(2000) (Eds) Psychological
  Debriefing Cambridge Cambridge University Press
• Yule, W.,and Gold, A.(1993) Wise before the
  event. London Calouste Gulbenkian Foundation