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Responding to Traumatic Incidents in Schools

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Responding to Traumatic Incidents in Schools Nick Durbin Joint Programme Director Senior Educational Psychologist University of Nottingham Warrington BC – PowerPoint PPT presentation

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Title: 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 Psychology Levels 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

11
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)

13
Common reactions (continued)
  • Flashbacks and intrusive memories
  • Headaches
  • Difficulty concentrating
  • Feeling guilty it was my fault
  • Feeling detached from others

14
Common reactions (contd)
  • Numbness
  • Anxiety
  • Feeling on edge and Hyper-vigilant
  • Depression
  • Irritability and anger
  • Sleep disturbance, nightmares

15
Peoples Reactions and Needs
  • Reactions vary depend
  • Age
  • Experience
  • Personality
  • Nature of the incident
  • Degree of involvement

16
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)

17
Post Traumatic Stress
  • And
  • The normal reactions of normal people to events
    which, for them, are unusual or abnormal
    (Parkinson, 1993)

18
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)

19
DSM IV Symptom Criteria
Re-experiencing (one required) Avoidance (three required) Arousal (two required)
Distressing memories Distressing images Distressing thoughts Distressing dreams Feeling it is recurring Illusions Hallucinations Flashbacks Distress on exposure to trauma triggers Physiological reactivity on exposure to trauma triggers Thoughts Feelings Conversations Activities People Places Inability to recall aspects of the event Reduced interest in usual activities Feeling detached or estranged from others Restricted range of affect Sense of foreshortened future Difficulty with sleeping Panic Irritability Difficulty with concentrating Hyper-vigilance Exaggerated startle response
20
Trauma, PTS and PTSD
  • Dose Symptoms
  • The vast majority of people exposed to serious
    traumatic events do not develop PTSD (McNally,
    2003)

21
Normal Features of Grieving
Phase Symptom Tasks Methods
1.Denial Shock, disbelief, Sense of unreality Accept reality of loss Facing loss by e.g. ritual, talking about it
2. Pain Distress Anger, guilt, worthlessness searching Key task to experience pain of grief Weeping, raging, talking about loss
3 Realisation Depression, apathy, fantasy if only Adjust to life without deceased Resolving practical issues Making sense
4. Resolution Hindmarch (1999) Readiness to engage in new activities relationships Re-invest emotional energy in new relationships Looking to new activities and people exploring new options
22
Stages of Response and Recovery
  1. Shock
  2. Denial
  3. Emotional Impact
  4. Working Through
  5. Acceptance
  6. Normal reactions
  7. Pre- trauma Stability
  8. Post trauma Stability
  9. 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

24
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)

26
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)

27
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?

29
Levels of Support (Hindmarch, 1999)
Level 1 Someone there First Hours
Level 2 A Listening Ear First Days
Level 3 Structured Group Support First weeks
Level 4 Counselling or Therapy First Months
30
Impact of Traumatic Incident
1
2
3
4
5
1. Primary Victims 2. Secondary Victims 3, 4,
5.Tertiary Victims
31
Group Reactions and Needs
  • Reactions can vary depend
  • Previous Experience
  • Group Dynamics
  • Nature of the incident
  • Degree of involvement
  • Closeness to incident

32
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)

33
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

34
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)

35
Psychological Debriefing
  • Introduction
  • Facts
  • Before, during and after
  • Thoughts
  • Feelings
  • Normalisation - psycho-education
  • Future
  • (Dyregrov, 2003)

36
Aims of Debriefing
  • Integrate cognitive and emotional memory
  • Connecting past - present - future
  • Psycho-education
  • Normalisation

37
Critical incident stress Debriefing Process
Cognitive
Introduction
Re-entry
Facts
Teaching
Thoughts
Symptoms
Reactions
Emotional
(Mitchell and Everly, 1996)
38
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)

39
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

40
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)

41
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

42
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)

44
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 Incidents Impact 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

48
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

49
Impact of Trauma School as an Organisation
(Attneave, C cited in Hindmarch, C (1999))
9
  1. Pre- trauma Context
  2. Crisis
  3. Retribalisation
  4. Polarisation
  5. Mobilisation
  6. Depression
  7. Breakthrough
  8. Exhaustion/Elation
  9. Post-trauma Context

1
2
3
4
8
5
7
6
50
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)

51
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)

55
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?

56
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

57
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)

58
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)

59
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

60
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)

61
EP Position in the Chain of Command
Incident
62
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

64
Case Study 1 The Response
  • Information and support for
  • Pupils
  • Family
  • Parents Group
  • Staff
  • Media
  • Others (inc Governors, LEA etc)

65
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)

67
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 Psychology Levels 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)

71
Responding to Traumatic Incidents in Schools
  • Questions
  • Comments

72
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
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