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Dr Ian Barron, University of Dundee

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Dr Ian Barron, University of Dundee Scotland s Secure Estate (ESS; Good Shepherd; Kibble; St Mary s) David Mitchell, Rossie, Young People s Trust – PowerPoint PPT presentation

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Title: 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
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