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  • Dr Chris Moore

Applying the 4 Rs of Trauma-Informed Approaches in the return to school

The Substance Abuse and Mental Health Services Administration (SAMHSA) recommend four key assumptions for a trauma-informed approach. This blog attempts to apply these “four Rs” to the imminent return to school as the COVID-19 restrictions are eased. No matter when this return occurs, I feel these are useful principles to keep in mind as schools support this challenging transition.

Realise

This first assumption is about realising the widespread impact of trauma and the potential pathways to recovery.

Bessel Van Der Kolk explains how “after trauma, the world is experienced with a different nervous system…every new encounter or event is contaminated by the past”. The key message about trauma is that it changes the brain. It changes how we perceive others, the world and even ourselves. It disrupts our capacity to plan and think and strengthens neural pathways devoted to reaction and survival. Therefore, we need to realise the implications of trauma on a child’s ability to tolerate and cope with stress.

SAMHSA define trauma as “an event, series of events or a set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening”; events which have a lasting adverse effect on an individual’s functioning and well-being. The pandemic has fundamentally changed children’s lives and in some cases it has opened up multiple avenues for toxic stress. The thought of leaving the house or coming into physical contact with others suddenly became anxiety-provoking. Comforting and regulating routines have been truncated or abandoned. Relatives or family friends have suffered ill health or tragically lost their lives. Parents employed as keyworkers have continued placing themselves at risk when leaving the house each morning.

For some children who have previously been at risk of neglect and abuse, the time out of school and limited access to family and community support has only heightened their experience of adversity. For others, they have experienced a more gradual onset of stress and distress; for example, the loss of employment or increased financial hardship may have resulted in family conflict, domestic violence and substance misuse.

Dr Bruce Perry outlines how “what may be traumatically stressful for one person may be trivial for another…the context, timing and response of others matters profoundly”. Every child will have experienced the pandemic differently, based on individual risk and protective factors. There may be children who have typically been perceived as resilient but have struggled greatly with a cumulative set of stressors in recent months. Meanwhile, other children who have experienced great hardship in the past have coped relatively well with the lockdown. There will be children for whom school itself was stressful and traumatising and the thought of returning may fill them with dread.

Therefore, in order to realise the true extent of the pandemic’s impact, we need to be proactive and gather as much rich information as possible. How are we asking children and young people what the lockdown has been like? We can request their stories, drawings and video messages about the past few months. Schools could consider using email, zoom meetings or online surveys as a means of eliciting the views of parents and discussing how they feel their child will best be supported upon the return to school. This is also the time for honest discussion about what previously made the school environment so anxiety-provoking or unfulfilling for some children and how we can try to reset the situation and sell them on a return after such a relaxing and enjoyable period at home. Professionals such as social workers, psychologists and community workers, who may have had contact with families during the lockdown, can also provide insight and make suggestions for supporting the transition.

Recognise

This second R is about recognising the signs and symptoms of trauma. Jen Alexander provides a great overview of research on the various effects of trauma on different developmental domains and how these may manifest within the school environment. Some examples are given below.

- Behavioural: Decreased capacity for impulse control; hyperactivity; preference for control; disrupted eating and sleeping patterns.

- Emotional: Increased hypervigilance for potential threats; higher levels of distress and reactivity; difficulties with understanding; expressing and regulating feelings.

- Relational: Lacking trust in others; reluctance to engage in relationships; preoccupation with connection to an adult; difficulties with asking for help and resolving conflicts.

- Cognitive: Difficulties with processing and remembering information; limited attention and concentration; problems with planning and organising a response to a learning task.

- Self-Esteem: Lower self-esteem; lack of confidence and belief in one’s skills and strengths; higher levels of guilt and shame.

It’s important to note that the above examples are by no means exhaustive, nor are they always associated with trauma. Any period of stress and uncertainty can elicit some of these characteristics. And if attendance at school has previously resulted in emotional dysregulation, then we may see similar signs. The important message is that all behaviour is communicating something. Something which a child may find hard to control, talk about, reflect upon or indicate before they react a point of crisis. When we keep an open mind about behaviour as a result of stress, then there is more of an onus on us to recognise how we can actively reduce stress for the child.

There are many factors within the school environment which may trigger or exacerbate these signs. Louise Bomber talks about “The Big Ask” and cites numerous challenges throughout the school day for children whose attachment and sense of safety has been disrupted by trauma and loss. These can include arriving to school and separating from parents, following the lead of others, sharing the attention of an adult or peer, transitioning between difficult activities/environments and coping with less structured periods of the school day. By recognising how we can change or mitigate the stress associated with these “Big Asks”, we are ultimately enhancing the child’s well-being and their ability to cope with stress.

Jen Alexander describes how “if we are drowning in our own dysregulation, our own stress, and burnout and compassion fatigue have set in, we lose our capacity to help students…”. It’s important that we recognise the signs of secondary stress or emotional contagion in the adults around the child. We may see changes in their behaviour or well-being which indicate that they are struggling. Are school staff appearing tired, run down or more susceptible to illness? Are they becoming more disorganised or taking on too many responsibilities at once? Are parents getting in touch more often and at times outside of school hours? Are they taking longer to respond to contact from school? During the pandemic, I’ve been struck by how many professionals and parents are reinforcing the message that “it’s ok to not be ok”. This is really a perspective that we need to enshrine in all of our work with children and young people with complex needs. This second R can also be about recognising when things are tough for us and how we need to look after ourselves better.

Respond

This third assumption is that we respond in a way which is in keeping with our knowledge of trauma. There is no one-size-fits-all approach, given the differences between individual experiences of stress and trauma. Therefore, I’m going to reference the four essentials recommended by Jen Alexander as a blueprint for any trauma-sensitive school.

The first is helping the children to feel safe. With the new social distancing and hygiene routines associated with COVID-19, physical safety will be paramount. How do we communicate that the school building and classrooms are safe? Some children may cope well with verbal explanations and practice with new rules, routines and safety plans. Others may need more advanced and visualised communication, through positive signage, visual scheduling, Social Stories or virtual tours/maps. We will need to practice how to ask for help and agree with the child on what works for them (e.g. some may prefer to use a discreet “I need help” card). It will be important to identify the safe spaces where a child can have a break or spend time talking to a preferred adult; as well as explaining when and how these spaces can be accessed.

Jen Alexander also differentiates between “physical safety” and “felt safety”. What kind of messages and scripts are we giving when welcoming children back to school and explaining the “new normal”? Using clear and factual language will help both children and their parents to feel safer about the transitions – perhaps focusing on what is staying the same, what has to change and what this change will look like. Giving staff the opportunity to discuss and troubleshoot different situations and agree on consistent plans of action will help them to feel safer in what will undoubtedly be a more stressful role at first.

The second essential is helping children feel connected. Relationships are the key to healing trauma. Some children may need a designated “Key Adult” who facilitates a welcoming routine in the morning and checks in with the child throughout the day. But all staff can provide connection. Dr Bruce Perry talks about “therapeutic encounters” – small doses of positive interaction. This can involve chatting with the child about their day, asking about their interests or sharing a joke; but it can be as simple as a nod or a smile. All non-teaching staff can provide these doses during interactions at the foyer, in the corridor, in the dinner hall or out in the playground. If some children display anxiety about losing the attention of a member of staff or working independently, there can be explicit communication about how you’re thinking about them and when you’ll be back after a temporary separation. Peer relations will also need to be targeted; some children may have spent a great deal of time during the lockdown with siblings or in virtual contact with their friends, while others have been more isolated. Even though physical distancing will be the norm for some time to come, a strong initial focus on play and practical/outdoor activities will ensure that social connection endures.

Tapping into a young person’s experience and eliciting their voice is crucial to instilling connection. We need to show curiosity in their personal interests and celebrate their strengths on a regular basis. On his Optimus Education Blog, Gareth Morewood has described the benefits of a “student passport”. This can include sections such as “What I need you to know”, “What I find hard”, “How you can help me” and “How I can help myself”. This approach enables collaboration with the young person, promotes greater understanding and empathy for their perspective and allows for the passport to be changed over time as progress is made and new situations arise.

Another essential ingredient of a trauma-sensitive school is to support emotional regulation. Perhaps the first step in this ingredient is teaching children about emotions using a relatable method. Dr Dan Siegel’s famous hand model of the upstairs and downstairs brain and “flipping your lid” is one example. Jen Alexander provides the concept of the “River of Feelings”, where children can visualise and draw a river and try to pinpoint when their emotions are too much, not enough or just right. Staff also have a role in recognising emotions during one of their many therapeutic doses. Louise Bomber’s technique of “wondering aloud” enables us to communicate our willingness to explore a child’s inner experience without judgement. Teaching the whole class about the brain has the added benefit of creating a more empathetic and tolerant peer group, who can then support those who find it more difficult to understand and regulate their feelings. Dr Bruce Perry explains how “students who begin to understand the brain begin to recognise why differences among peers exist and why those differences do not have to be feared”.

We should prioritise prevention rather than reacting to emotional crises and expecting strategies or resources to work when the child is already dysregulated. We can schedule activities on a whole-class or whole-school basis, with initiatives like the Daily Mile, breathing techniques or exercise routines. But it will be important to give children a range of choices and identify activities which are personally comforting and relaxing (e.g. colouring, listening to music, indulging in specialist interests). Some will need their own schedule of calm breaks and more comprehensive preparation and support for daily transitions. We also need to consider making the school environment more regulating, through an emphasis on structure, predictability and reduction of sensory-based stressors.

Finally, we also want to support learning and help the children achieve at their full potential. Safety, connection and regulation are the bedrock of learning. Whether a child has experienced higher levels of stress during the pandemic or a traumatic incident such as bereavement or domestic violence, we will need to have the three essentials above in place before we can consider learning. But even then, we can still differentiate the curriculum to make it more accessible. Given the time out of school and the differences in access to or completion of home learning, we may need to revisit previous concepts and topics before thinking of starting new ones. Metacognitive questions and prompts - which ask the child where/when they saw a similar question, what they need to do first/next and how they arrived at an answer – may help to understand their strengths and areas for further reinforcement far more than generic testing. And let’s not discount some of the amazing practical learning experiences which children have been engaging in with parents – we have a lot to learn from what has worked at home and how this can be continued or adapted for school.

Working memory demands can be reduced through simplification and repetition of instructions and making concrete links between new tasks and previous learning or real-life examples. We can also support the speed and efficiency of children’s processing through extra time, minimising the need to transcribe written information and breaking down tasks into small steps. Setting clear goals and ensuring that time-limited tasks have an achievable goal will help to mitigate difficulties with concentration and organisation. The use of concrete manipulatives may be limited at first, given the hygiene restrictions, so can may be more opportunity for learning through ICT, story, song, dancing and other physical activities which regulate as well as educate.

Resist

This final R is about resisting re-traumatisation. In any approach which seeks to apply knowledge of the impact of adversity and trauma, a preventative and systemic approach will have the most positive effect on children and the adults supporting them. As Alexander Den Heijer famously said, “when a flower doesn’t bloom, you fix the environment in which it grows; not the flower”.

Behaviour policies are too often predicated on zero tolerance, seclusion and a quick application of sanctions. I feel we need to establish or strengthen relational policies, which prioritise safe, nurturing, regulating and socially engaging experiences. Professor Andy McDonnell explains how behaviour support/management plans can place too much emphasis on the target of specific behaviours rather than promoting general well-being. Behaviour underpinned by stress and trauma may be triggered by a variety of factors in the school environment and even inadvertently through the responses of staff. A stress support plan involves a more collaborative approach, where we agree with the young person on proactive strategies for reducing stress. This may include a sensory diet and a “planned escape” to a comforting place with motivating activities.

A more relational approach to discipline should also be taken. Dan Siegel and Tina-Payne Bryson’s memorable concept of “Connect and Redirect” still allows room to talk about changing behaviour and the consequences for specific actions. But it accepts that we do so when the child is not at crisis point and after we first listen to and empathise with their inner experience. Similarly, time-out in isolation can be replaced with Louise Bomber’s strategy of “Time-In”, where the connection with a co-regulating key adult can be maintained even if the young person needs time away from a stressful situation. When it comes to issues of punctuality and attendance, expecting a 100% success rate and immediately invoking sanctions at a time of heightened stress risks further emotional dysregulation and shame. For children who find it hard to attend school, we need to consider how we greet them upon arrival, what they need first in order to relax and how to support them over the course of the day.

Resisting re-traumatisation will depend on how the supporting adults are supported. If we know that parents and caregivers are struggling, they may need a designated means of talking about issues, asking questions and seeking advice. This could be via telephone, email or video calls, if face-to-face meetings prove difficult to establish or maintain. The school newsletter or notice boards in the reception area could signpost parents to external agencies and helplines.

For school staff, scheduling access to psychologists, coaches and other professionals could provide opportunities for individual supervision or solution-focused meetings with a group – sometimes the simple experience of being listened to, accepted and contained will help a member of staff to remain resilient and consider different ways of managing stressful situations. This may be far more useful and relevant than a one-off CPD event, as it allows for more personalised reflection and does not mistakenly suggest that a small number of strategies or resources can be applied universally. Dr Karen Treisman recommends embedding a trauma-informed culture through posters, signs, keyrings, staff book clubs and emailing links to YouTube clips and podcasts.

We also need to ensure that staff are adequately supported within the school system. We can identify members of the senior leadership team who can provide time for checking in and talking through difficult situations, just as pastoral teams offer similar support for young people. Any type of organisational and cultural change requires a consistent vision and mission statement from the top of the system. There could be regular support groups where staff can discuss tricky periods without judgement and learn from their colleagues. It will be important to continually promote self-care and offer avenues for this through school, such as arranging a number of physical, social or relaxation activities which staff can opt into.

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The four assumptions above represent a starting point. Can we ever be truly “trauma-informed” when trauma is such a complex, fluid and individualised phenomenon? We won’t have all the answers when considering how to support those children and young people who will find the return to school challenging and stressful; particularly when the circumstances of the return are by no means familiar. But we can reflect on our own perspectives, ethos and culture when thinking about what we can change to make the experience better for them and what will support us in doing so.

References

· Alexander, J. (2019). Building Trauma-Sensitive Schools: Your guide to creating safe, supportive learning environments for all students. Baltimore: Paul H. Brookes Publishing Co.

· Bomber, L (2011). What about me? Inclusive strategies to support pupils with attachment difficulties make it through the school day. King’s Lynn: Worth Publishing Ltd.

· McDonnell, A (2019). The Reflective Journey: A practitioner’s guide to the Low Arousal approach. Alcester: Studio III.

· Morewood, G. D. (2015). Optimus Education Blog: How to develop student passports – the movie. Viewed 7th May 2020. https://blog.optimus-education.com/how-develop-student-passports-–-movie

· Perry, B.D. & Szalavitz, M. (2017). The boy who was raised as a dog and other stories from a child psychiatrist’s notebook: What traumatized children can teach us about loss, love and healing. New York: Basic Books.

· Siegel, D.J & Bryson, T.P (2012). The Whole-Brain Child: 12 proven strategies to nurture your child’s developing mind. London: Robinson.

· Substance Abuse and Mental Health Service Administration (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Rockville: SAMHSA.

· Treisman, K. (2017). Working with Relational and Developmental Trauma in Children and Adolescents. New York: Routledge.

· Treisman, K. (2018). Some top tips & ideas to keep the momentum alive and embed & breathe life into the concepts/values/content of training. Viewed 9th May 2020. http://www.safehandsthinkingminds.co.uk/wp-content/uploads/2018/09/Some-top-tips-to-further-keep-the-momentum-alive.pdf

· Van Der Kolk, B.A. (2014). The Body Keeps the Score: Brain, Mind and Body in the healing of Trauma. New York: Penguin Books.


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