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Trauma-informed practice and violence against women and girls

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Trauma-informed practice and violence against women and girls

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Multiple dates available

Registration links: https://forms.towerhamlets.gov.uk/service/Learning_and_Development_Application (if non-Council staff) / Council staff can register via the Learning Hub here: https://learninghub.towerhamlets.gov.uk/course/view.php?id=883

Duration: 2.5 hours

Organised by: Tower Hamlets Council's Violence against women and girls (VAWG) team

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Trauma-informed practice: Learning from experience in violence reduction

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Trauma-informed practice: Learning from experience in violence reduction

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Purpose

This document aims to share practice among violence reduction units (VRUs) and with sector partners for implementing programmes to develop and embed trauma-informed practice (TIP). There are 20 violence reduction units across England and Wales funded to bring together local partners to tackle the drivers of serious violence in their area. VRUs work with partners to develop a whole-systems approach which includes capacity building and delivering a range of early intervention and prevention programmes to divert children and young people away from involvement in serious violence.

The document is not a prescriptive or comprehensive list of requirements for implementation, nor is it formal 'guidance'. TIP is often described as a 'journey without a destination' as it requires constant reflection and adaptation by practitioners and services to meet the needs of individuals, their specific histories, experiences and awareness of the wider circumstances which may contribute to their (re-)traumatisation. As such this document can only reflect what we have learned so far, and will likely need to be updated, reflected upon and adapted to suit different locations, organisations and services' needs. Its aim is to help VRUs and partners learn from each other's findings, ideas, and challenges.

In addition, the Home Office has funded research specifically into TIP, both by the Early Intervention Foundation (EIF - now merged with 'What works for Children's Social Care' to form 'Foundations') and the Youth Endowment Fund (YEF). These evidence-based sources are invaluable and authoritative, and this document is intended to complement rather than duplicate information already covered.

If you are not already familiar with TIP, we recommend first looking at some of the pieces listed in the Resources section at the end of the document to enhance your understanding. Although a basic summary is included, the purpose of this document is not to define TIP, but rather draw practical lessons from its implementation by VRUs.

We would also like to thank those who have provided feedback on this document as it was being developed. In particular, Dr Kirsten Asmussen from Foundations, Hannah Wilson and Ediane Santana de Lima from Dartington Service Design Lab and colleagues from the YEF.

Methodology

The Home Office Trauma-Informed Policy Team (Leo Schwartz and Holly Sperling) within the serious violence reduction unit reviewed reports from VRUs alongside information gained through quarterly meetings. In these meetings we asked questions around programme delivery, looking for:

innovative or unusual intervention methods

how the model has been implemented

challenges faced at any stage in setup, implementation, or delivery, and mitigations that were used to counter these

lessons learned that can be applied to future trauma-informed programmes

risk / issue management, including identification and pre-issue mitigations

We also acquired programme knowledge and expertise from wider partners delivering TIP across Government and in different sectors and settings. Discussions during conferences have also informed our thinking, particularly the Trauma-Informed Policing Conference (1-2 November 2022) with VRUs, the National Police Chiefs' Council, College of Policing, Office for Health Improvement and Disparities (OHID) and key sector partners including the Welsh ACE Support Hub and Scottish VRU.

This document is not produced in conjunction with the Youth Endowment Fund and is more focused on specific learnings from current VRU programmes rather than academic research. However, we encourage practitioners to keep up to date with the latest evidence and research through the YEF's online Toolkit (see Resources section).

Intervention summary

Trauma-informed practice (TIP) is based on the understanding that trauma exposure can significantly impact both individuals' development and life chances as well as the ability to feel safe or develop trusting relationships, and can also affect communities. TIP requires practitioners, organisations and systems to look beyond presenting behaviour and ask 'what happened to this person?' rather than 'what is wrong with this person?'.

There are four key assumptions that underpin TIP, known as the 4 'R's. An individual, programme, organisation, or system that is trauma-informed realises the impact that trauma can have; recognises the signs and symptoms of trauma (in both beneficiaries and professionals); responds to trauma by integrating knowledge of trauma into policies, procedures and practices; and seeks to actively prevent re-traumatisation by avoiding practices that could trigger painful and traumatic memories. In addition, there are six principles which inform TIP: Safety, Trust, Choice, Collaboration, Empowerment and Cultural Consideration (of individuals' demographic characteristics).

The purpose of this document is not to define TIP, and several of the resources below set out comprehensive definitions, particularly those by Substance Abuse and Mental Health Services Administration (SAMHSA) (who developed the original definition), OHID, EIF and the Welsh ACE Support Hub.

Trauma-informed training

Trauma-informed (TI) training is only one element in the provision of trauma-informed practice (TIP) and should work alongside other components such as reflective practice, increasing access to therapeutic interventions and developing organisational policies. It is the most common TIP activity delivered by VRUs, and often the first stage of implementing TIP more broadly.

TI Training aims to improve practitioners' knowledge, understanding and response to trauma. This might include:

understanding the impact of trauma

recognising the signs of trauma

skills related to interacting and responding to those who may have experienced trauma

avoiding practices which might lead to re-traumatisation

understanding the impact of vicarious or secondary trauma on practitioners (see Training content below)

The 2022 independent evaluation of VRUs found that the TI training delivered by VRUs was highly valued by partners, an example of good practice, and contributed to sustainably supporting a public health approach and effective multi-agency working. Partners considered TIP to be 'highly effective in supporting (frontline) professionals to understand their role in the response to violence and upskill them to respond effectively' (Violence reduction units, year ending March 2022 evaluation report, 3.2, February 2023).

On the basis of the research the Home Office commissioned from the EIF, 'Understanding the potential of trauma-informed training in violence reduction units', we suggest the strongest models of TI training are likely to:

integrate into broader efforts to implement trauma-informed practice, including systems and support mechanisms (such as support for staff wellbeing)

include training for senior staff as well as frontline practitioners (as this can increase buy-in and sustainability)

include content which clearly connects changes in knowledge to changes in practice (See Hampshire and West Midlands case studies below)

include follow-up activities or refresher training to reinforce learning

have a strong element of co-design: given the ambition to improve interactions and build trusting relationships between professionals and young people, involving both in the design of training content is likely to increase its ability to meet this objective

have well-developed quality assurance processes to ensure training is of a consistent quality: this is particularly important for 'train the trainer' courses (see 'Train the trainer' section below).

Trauma-informed practice

According to EIF's report, TIP has the potential to contribute most to the wider system of support when it is delivered alongside well-evidenced interventions that have shown positive impact on young people's outcomes.

From a broader systems perspective, VRUs should consider carefully how their trauma-informed programmes work alongside or integrate with other evidence-based interventions they are commissioning / delivering (such as focused deterrence, therapeutic interventions like CBT, or A&E navigator programmes as well as how the approach contributes to their role in supporting multi-agency working and systems leadership.

Trauma-informed practice is distinct from trauma-specific therapies such as trauma-focused cognitive behavioural therapy (TF-CBT) as it doesn't seek to 'treat' trauma, rather to recognise it, create the conditions that will support healing more broadly and work in a way that prevents re-traumatisation (see Limitations of trauma-informed practice section).

Beyond training, the EIF has identified several components that VRUs may wish to consider when designing programmes, or thinking about how to implement TIP beyond increasing knowledge and awareness. One-off training alone (without changes to policies or practice) is unlikely to result in significant outcomes for end beneficiaries. Table 1 below sets out several different TIP components identified in children's social care settings. However, TIP goes beyond these and should also be considered from the perspective of organisational values and culture.

Table 1: common components of trauma-informed care within children's social care

Workforce development

Training of all staff on the impact of abuse or trauma

Measuring staff knowledge / practice

Strategies / procedures to address / stress (secondary trauma) among staff

Knowledge / skills in accessing evidence-based services

Defined leadership position for trauma services

Trauma-specific services

Use of standardised trauma screening / assessment measures *

Availability of evidence-based trauma-specific practices

Trauma history is always included in case / service plan

Organisational environments and practices

Within agency collaboration / service coordination

Outside agency collaboration / service coordination

Positive, safe physical environment

Reduce risk of retraumatisation

Strengths-based / promote positive development

Written policies that include trauma

(Adapted from Bunting et al., 2019)

Table 1 above, reproduced from EIF's report 'Trauma-informed care: understanding the use of trauma-informed approaches within children's social care', January 2022).

* Caution should be used regarding trauma screening tools (such as the ACE-Q) and these should not be used in place of comprehensive assessments, to triage or determine individuals' access to support services.

The YEF, in designing its TIP grant round (co-funded with the Home Office) identified the elements of TIP as follows:

1. Organisational learning: staff training and development which increase the awareness and knowledge of staff on the impact of trauma to support their own traumatic stress and adapt how they work with young people.

2. Organisational policies: changes to policies and ways of working that incorporate trauma, collaboration and information sharing within and across organisations, and support the development of safe, inclusive and positive environments.

3. Organisational processes: implementing trauma-focused referrals and planning such as access to trauma-specific services and the incorporation of trauma history in case/service plans.

Case study: Hampshire - trauma-informed practitioners

This pilot was the first of its kind in the UK and involved expert trauma-informed practitioners (TIPs) patrolling alongside Response and Patrol Teams in a live policing environment ti help them embed trauma-informed policing. This pilot, which operated in Hampshire and Isle of Wight Constabulary from Sept 2021 to March 2022, showed early indications of making a positive difference. The TIPs' approach continues to receive significant national interest and has now been commissioned until 2025, evaluated by Liverpool John Moore's University.

TIPs spend time getting to know the police teams and vice versa. They understand the challenges faced by Police and get a feel for Policing, going on patrol with officers, reviewing body worn video footage and safeguarding forms, observing people being booked into custody, and observing stop and search. The TIPs promote the use of Reflective Practice, providing an opportunity to de-brief incidents that Police and TIPs attend, and encouraging professional curiosity of the story behind the presenting behaviour. TIPs will produce de-personalised case studies to show-case the value of trauma-informed policing.

The TIPs help police recognise someone stuck in fight or flight mode and teach basic grounding techniques to help bring them back to the present moment. This can help overcome barriers in accessing support services often experienced by those affected by trauma. This consistent, trauma-informed way of working seeks to increase the likelihood of generating reachable/teachable moments and build feelings of safety and trust.

TIPs support includes the use of language and how powerful this can be. For example, using the appropriate language on a safeguarding form helps other professionals such as Social Workers in the Multi Agency Safeguarding Hub, and enables more appropriate support to be provided as a result. For instance, terms such as 'refused to engage with support...' can be replaced with 'felt unable to accept support at this time because...'.

At the start of the TIPs pilot, the main impact of the TIPs was presumed to be on the ways officers respond to incidents and individuals. This did happen, with officers reporting increased awareness and sensitivity to the impact of trauma and the ways in which this can be mitigated in their responses and interactions. However, officer feedback also captured the project's impact on officers' general wellbeing and understanding of the impact of the work on themselves, with this becoming a key outcome.

Limitations of trauma-informed practice

Practitioners should be clear that TIP is not a replacement for specialist mental health services or intended to enable practitioners to 'treat' trauma or anyone with serious or diagnosed mental health conditions. Rather it should create the conditions for healing by encouraging appropriate referrals to specialist services, removing barriers to accessing support (including by developing trusted relationships), preventing re-traumatisation of the individual, recognising the impact of vicarious trauma on front-line staff and driving closer working and shared understanding between services.

While TIP is seen as a promising and innovative approach, practitioners should be aware that currently the evidence base in terms of its impact is under-developed. We hope to close this gap in the near future through the YEF and Home Office co-funded trauma-informed practice grant round and further research being carried out in other sectors. However, practitioners should be aware of the current evidence base, its limitations and where TIP is more or less likely to deliver outcomes for vulnerable children, young people and staff. This understanding should inform your programme design and Theory of Change.

Please refer to the literature review and Theory of Change from the EIFs research on VRUs' TIP delivery to see which elements are currently more or less supported by evidence. The YEF's Toolkit also contains information on common elements thought to be effective as well as information on the current evidence base.

Delivery Considerations

Qualifications, skills and experience

When choosing your delivery provider, careful attention should be paid to background qualifications, skills and experience of those who will be delivering the training. There are a range of different providers that can deliver trauma-informed training, from specialist organisations to voluntary and community sector organisations. Some VRUs also feel they have sufficient expertise within their own networks to deliver training internally. However, when choosing who will deliver your training you may wish to consider:

what level of qualification do they have in a relevant field such as psychology and have they continued to update their knowledge with recent relevant professional development courses?

whether they have an appropriate clinical or professional background so that they could effectively support someone who has had a traumatic experience and might be triggered by the training?

are they an experienced, professional trainer or educator?

are they experienced in delivering training to the specific cohort of professionals you are seeking to work with?

are they experienced in working with the end beneficiaries or the specific cohort you are seeking to benefit (children and young people at risk of involvement in serious violence)? Can they tailor the training and provide relevant examples in relation to this group and for professionals working with them on how implementing the training will work in practice?

if they have relevant lived experience, or will they be able to include elements of lived experience in the training? Are they able to represent the views and experiences of young people, ethnic minorities and those with other protected characteristics who may have particular (traumatic) experiences?

are there multiple trainers who can fulfil key criteria and deliver to the same standard in case one trainer is unable to complete all the delivery?

It may not be possible for one individual to fulfil all these criteria - they might need to be spread across a team of trainers delivering together.

Training content and length

Through the EIF Research, our observation of VRU trainings and reviews of delivery plans, we identified many different topics covered in training. These included:

ACEs and trauma, including what they are, their impact on a person or community, and how trauma affects the brain, physical, neurological and psychological development

recognising the signs of trauma, interacting and responding to those who may have experienced trauma

avoiding re-traumatisation

vicarious trauma and how to build resilience

how to apply the training in practice - what does a trauma-informed approach look, sound and feel like? How do you empower individuals through TI approach? Considering language and vocabulary from a TI perspective, and the importance of building trust

developing trauma-informed organisations, and how to embed a trauma-informed approach long-term

specific forms of trauma - community trauma, racial trauma, trauma specifically affecting the LGBTQ+ community, or those experiencing domestic abuse / violence against women and girls

VRUs have used varying lengths of training (from half a day to three days) and there is no definitive evidence that identifies how much time is needed for participants to significantly increase their knowledge and understanding. However, given the breadth and complexity of the topics above it is unlikely that short courses (for example, a few hours or half a day) will be sufficient. In addition, one-off trainings without follow-up support or consideration of how knowledge gained can be implemented in practice are less likely to achieve the desired outcomes.

Sector-specific considerations

The impact of the training may be different for different workforces. For example, training could be more likely to lead to improved practice within workforces where knowledge and understanding of the impact of trauma has not previously been addressed, rather than those who are already familiar with these concepts. Sectors such as healthcare or social work may be more used to TIP (although not always badged as such) and be closer to embedding its principles within their standard practices than sectors such as policing or education.

Decisions about who to train, where and when, should be determined by the outcomes that the training is designed to achieve. If the primary aim is to develop a common understanding among frontline practitioners working with children and young people at risk of serious youth violence, then including all relevant practitioners is important. In the research conducted by EIF, VRUs strongly emphasised the value of the shared language and understanding that was perceived to result from training multiple workforces. If, however, the aim is more about improving practice and engagement with vulnerable young people, then it may be more effective to focus on those workforces where the greatest change is sought.

Consideration should also be given to support functions as well as frontline practitioners. For example, administrative staff may need to be aware of the impact of trauma in order to avoid triggers and re-traumatisation as these act as barriers to accessing support and services.

Involving stakeholders from the sector(s) you intend to train in the co-design process should also ensure the training is more bespoke and help to identify specific examples of how the knowledge gained during training can support changes in practice.

Location-specific considerations

Carefully consider any barriers or restrictions to delivering training in particular settings. This might include:

the need for clearance or DBS checks of trainers or external practitioners when working with police or in certain settings (schools, custody suites, prisons etc.)

being clear on the information and time required to secure these when designing, commissioning or creating your delivery plan, communicate this to delivery partners and consider optimism bias in your planning

considering the mitigations to a delay in delivery if personnel are not able to secure clearances in time or are unable to complete all the delivery, for example if you need to replace key personnel part-way through delivery

some sectors/locations having particular restrictions that need to be taken into account when planning training or other forms of support. This could include shift patterns, remote workers, very limited organisational capacity or specific days/times allocated for training (for example training in schools or with teachers is often confirmed early in the year for the whole school year as there are very limited days and times available)

Having a thorough co-design process which includes representatives from the sectors and professions you intend to train, or including their representation in any programme governance structures should enable you to spot these kinds of issues in advance and mitigate them as part of your programme commissioning process or programme design.

Train the trainer

Train the trainer (TtT) can be an effective way to quickly scale the delivery and impact of a training programme. However, it comes with significant risks you should consider before deciding on this as a delivery model. In some organisations there are also existing training teams who may be able to adapt to deliver your TI programme, however this approach is also subject to similar risks as set out below:

See the qualifications, skills and experience section above: Are you sure the trained trainers will have the appropriate mix/levels of these to deliver the quality you require? How will you maintain those criteria over the longer-term?

Do the trained trainers have the skills to appropriately respond to instances of triggering or re-traumatisation within the training? Do they have sufficient knowledge of appropriate support available in such instances?

Monitoring & Evaluation: How will you measure the quality, effectiveness and impact of the training to end beneficiaries? How will you capture any learning and recommendations to continue to iterate/improve the design and delivery. Also see Evaluation section below.

If you need to make changes to the content or way the training is delivered in the future how will you cascade this and ensure consistency of message, content and delivery?

Have you considered the risks if the training is delivered poorly, or participants receive incorrect or outdated information?

Virtual or in-person training?

VRUs have used varying approaches to training delivery. Whether delivered virtually or in- person, both approaches can be effective and you should weigh the pro's and con's of each format before deciding which model suits you best. You may also opt for a hybrid model, for example a basic training delivered virtually and some in-person trainings for different groups/sectors, for example for managers/senior leaders or as part of an advanced or supplementary training offer. We are not currently aware of any evidence that suggests either format is more or less effective than the other.

Considerations for virtual training:

The main disadvantage to virtual training is that there is often a considerable drop- out rate (especially if free). You may need to put additional effort into communications, ask people to re-confirm their place and commitment to attend or think of incentives such as informing people's employers if they do not attend.

Think carefully about the optimum group size in a virtual environment that will still ensure people are comfortable enough to ask questions and participate.

Think about how you can build trust in a virtual environment to make people comfortable discussing sensitive topics - see Managing trauma in training below.

Consider ways you can keep the training engaging and interactive. How will you cater to different learning styles in the virtual environment?

If you are using virtual workshops or group discussions think about how you will capture the outputs of these and/or support participants in the group sessions.

Let participants know whether you will send out slides and any resources referred to in the training.

Considerations for in-person training:

This may mean you reach fewer people and incur additional costs (for example venue, travel, food and drink). However, there may be significant upsides in terms of building relationships and trust with and between attendees, particularly if the training is across multiple teams and services.

There may be opportunities where partners are able to provide a venue for free or reduced costs, however you should ensure that the venue is appropriate to deliver this kind of training in and accessible for participants.

Consider if you hold all your training in the same venue, could this exclude or dissuade some of your intended participants from attending?

Think about including some time for participants to get to know each other and explore connections between their work and how you can apply this to implementing TIP at a systems level.

Managing trauma in training

A key assumption of TIP is that trauma is widespread and more prevalent than people might initially realise. You should therefore assume that participants in your training will come with their own traumatic experiences, and that this might also act as a barrier to engaging with the training itself. You should have a plan as to how to manage this in the training environment and communicate clearly with participants before, during and potentially after the course to ensure you are delivering in a trauma-informed way.

Ensure your trainers/delivery personnel are sufficiently qualified and experienced to support people or sensitively address concerns if they are raised by participants. See Qualifications, skills and experience above.

Pre-screening - If it's appropriate you might ask people to flag prior to the training if they think they might find it challenging for any reason. You don't necessarily need to know the specific reasons, but it could help trainers identify if they might need to check-in with them at any point during the training.

Tips for self-regulating during training - You might wish to cover at the start some practical tips and exercises people can do during the training or breaks if they feel the need to ground themselves. This can be as simple as a breathing exercise, taking a short walk or pressing their thumb and fingers together repeatedly.

Be flexible and allow time for breaks - If you feel a topic has been particularly challenging, you should be prepared to adapt your training schedule to give participants time and space to regulate.

While you might wish to encourage people to keep their cameras on in a virtual environment, you should give them space to turn them off, or permission to leave the room at any point if they need.

Give appropriate warning if you are going to use examples or case studies which reference a particular traumatic event or subject.

Ensure you are able to sign-post people to further support if they need it, this might include knowing the welfare offer, policies or appropriate personnel for the organisations who are receiving the training.

The trainers may also wish to offer support post-session if someone requires it, though they should be clear about their boundaries and the level of assistance they can offer.

Case study: West Midlands - Implementing TIP in custody settings

In Autumn 2021, Barnardo's staff began the implementation of a trauma awareness programme with West Midlands Police custody staff, commissioned by the West Midlands Violence Reduction Partnership. The programme was delivered in learn, implement and review phases.

The learn phase consisted of focus groups with custody staff; shift observations; interviews with custody focussed researchers and academics; interviews with young people who had experience of custody; and walkthroughs of the physical environment of custody blocks. The team then co-designed training inputs with serving and former custody staff.

The implementation phase involved training, physical changes and embedding learning. This consisted of:

co-delivering half day trauma awareness training to all custody staff with a former custody officer (Inspector)

the creation of a trauma aware champions group amongst custody staff, and an online resource bank for all staff to access and for trauma aware champions to continue to update and promote the use of

Barnardo's staff supporting West Midlands Police's efforts to better co-ordinate interventions for young people based in custody run by public and third sector organisations

alterations to the physical environment and processes of custody including memory aids to be located at booking in desks with key themes from the training, calming murals painted in cells of the young persons' wing, easy read rights and entitlements booklets, improved food options and reading materials and the installation of clocks in the light recess to help self-regulation and reduce anxiety

the use of distraction packs for young people and 'tough-book' tablets with teachable-moment-linked educational content

the use of emotional safety plan worksheets

The programme evaluation concluded that training led to an "immediate impact on knowledge of trauma-informed practices", and qualitative measures "suggest that the TI training programme has a positive influence on police practice and that further efforts to provide TI training to police officers and senior management should be considered."

The evaluation particularly praised the champions group as helping to embed learning from training over the longer term, indicating the need for more time to be granted for trauma awareness programmes to be implemented. Dip samples from West Midlands Police indicated that the use of distraction packs helped to calm young people in custody preventing self-harm and confrontation towards staff. The evaluation also found that whilst initially sceptical, many staff had embraced the changes once it became clear that trauma aware approaches were of benefit to staff as well as young people in custody.

Trauma-informed practice as part of systems leadership

TIP can enable VRUs to sustainably enhance their systems leadership and embed multi- agency working. TI training (as part of a comprehensive TI strategy) can influence specific changes in practice, both of which can be embedded in wider systems of support. These can enhance the provision of evidence-based interventions, for instance by improving the quality and suitability of referrals. This might be achieved through creating communities of practice, or standardising practice and procedures (so similar tools, referral pathways, data and language are used to enhance outcomes and avoid the potential for re-traumatisation through engaging with multiple services/systems). This approach is illustrated in the Lancashire and West Yorkshire case studies below.

This approach to multi-agency working and systems leadership was identified by independent evaluators as a core strength and example of good practice for VRUs' delivery in 2022. Evaluators found that the training and support provided by VRUs supported implementing changes to partners' longer-term strategies and policies:

"Elements noted as sustainable included trauma-informed training provided to professionals, and supporting changes to partners' longer-term strategies and policies. An example of the latter included the VRU supporting education partners to update local schools' exclusions policies for students found in possession of a knife."

When thinking about implementing TIP across systems, a few key elements to consider include:

identifying champions within organisations, potentially at different levels or across different teams to continue to advocate for the approach and reinforce practice beyond training. Additional training for champions may be necessary, but could be more sustainable than delivering top-up or refresher training to all staff

developing a network within and between organisations (could be linked to champions) to take forward additional work, develop recommendations, propose changes to policy and practice as well as continue to develop knowledge and cascade it internally and externally

creating a bank or library of resources practitioners can continue to access and where new resources can be stored, updated and easily accessed

ensuring there are good, clear and accessible referral routes to available evidence- based support and trauma-specific (for example therapeutic) interventions

paying due consideration to the language and vocabulary used in services design and delivery, policies and practice

building in mechanisms for co-design with those with lived experience across different services/sectors and who have different experience of trauma and vulnerabilities (both practitioners and beneficiaries)

ensuring there are specific roles and structures such as delivery boards, senior responsible owners and named leads who are connected across the system. They may have specific programmes of work to progress implementing TIP both in their own sector and through collaboration with each other

Case study: West Yorkshire - Multi-agency partnership working

NHS West Yorkshire Integrated Care Board (WYICB) / West Yorkshire Health & Care Partnership (WYH&CP) and West Yorkshire Violence Reduction Unit (WYVRU) share a common commitment with all partners across the system to prevent harm and improve the wellbeing of our population. A key strength of the partnership is the convening of different sectors and organisations that wouldn't traditionally work together to share and build on the wealth of expertise and knowledge that exists across our system. By developing a strong foundation for the partnership, building relationships, and working together as a team, further opportunities and collaborations have become available that might not otherwise have been within reach, including the West Yorkshire Adversity, Trauma and Resilience (ATR) Programme.

The Vision: 'Work together with people with lived experience and colleagues across all sectors and organisations to ensure West Yorkshire is a trauma-informed and responsive system by 2030'.

The West Yorkshire Adversity, Trauma and Resilience (ATR) Programme

The West Yorkshire ATR Programme was established in June 2020 during a significant time of adversity. Our ethos was then, and continues to be, about connections.

Connecting organisations, communities, and individuals to understand adversity, trauma, and the impact across the life course to both physical and mental health, to understand our services better, prevent re-traumatisation and offer better care for all that is equitable and accessible.

The approach is for all organisations, sectors, and system leaders to work together as trauma and adversity cannot be prevented and responded to by one sector. The programme is co-produced by over 500 professionals and people across West Yorkshire and all 5 places, with each place leading on their local ATR programmes and delivery.

The West Yorkshire ATR provides support across the system to improve health and wellbeing outcomes for the population and workforce through the following ambitions:

Prevent adversity and trauma across the life course.

Prevent and intervene early to reduce adversity and trauma as a result of poverty and inequalities.

Respond to trauma and adversity that already exists, mitigating harm where possible.

Facilitate an integrated trauma-informed and responsive system that enables all children and young people, including those with complex needs to thrive.

Build and strengthen resilience assets and protective factors for individuals and communities.

Reduce risks and improve outcomes for those who experience adversity and trauma.

Ensure CYP can develop meaningful relationships with experienced professionals, who will be champions on their behalf, placing them at the centre of care, coordinating services around the child & family.

Provide senior clinical leadership across the system, strategic oversight, embedded reflective practice, specialist input and psychosocial interventions.

Ensure an understanding of adversity and traumatic events and the impact they have on an individual, their life chances and opportunities.

Develop our response to adversity, trauma, and complex needs in this window of opportunity to build back better and fairer and minimise harm caused by COVID -19 and associated measures.

Examples from West Yorkshire of how this change is being implemented include (but are not limited to):

Ensuring coproduction with those who live and or work in West Yorkshire through the development of a Community Action Collective - the West Yorkshire trauma-informed coproduction guidance.

Supporting and developing trauma-informed services and support for adults facing multiple disadvantage in HMP Leeds and with West Yorkshire Police.

Service improvement and development supporting trauma-informed organisations.

Building on existing resources and capability to enhance trauma-informed practice across the system including the Launch of the West Yorkshire Adversity, Trauma and Resilience Fellowship.

Commissioning insight reports, including: Adversity Trauma and Resilience in West Yorkshire - a review of life-course evidence, approaches (2021), and Trauma-informed education settings insight guidance (2022).

Generating intelligence, insight, and evidence. As a system we have commissioned a number of insight reports, including: Adversity Trauma and Resilience in West Yorkshire - a review of life-course evidence, approaches (2021), and Trauma-informed education settings insight guidance (2022).

Commission and development of Adversity Trauma and Resilience Navigators in A&E: Calderdale and Huddersfield Foundation Trust

Increasing capacity, capability, and knowledge sharing through annual ATR Knowledge Exchanges and the development of the West Yorkshire Adversity Trauma and Resilience Academy online hub.

Delivery of trauma-informed training to thousands of multi-agency professionals: Police response teams, School's officers, all Housing Providers, Primary Care, A&E, Local Authority Prevent, Prison officers, Acute Trusts, Cancer Alliance and Local Maternity and Neonatal System staff.

Case study: Lancashire - A trauma-informed approach to data sharing

The Family Hubs Information Sharing Service (FHISS) is Lancashire's solution to the large amount of information and data being captured and held on children, young people, and families, being largely shared manually across services. This solution is based on learning and best practice from areas such as Thames Valley, Bristol, and Liverpool, with the aim of creating a 'golden record' (single source of data truth) to ensure trauma-informed approaches are at the forefront of practice and response.

Lancashire has recognised issues and challenges with the current processes that impact directly on communities, such as practitioners spending excessive time inputting and processing information and therefore having less time to focus on delivering quality outcomes for families; delays in information sharing due to differing and incompatible systems; families having to constantly re-tell their stories to practitioners in different services; limited capability and resource within services meaning delays and inaccuracies in information sharing; and ultimately, there being no holistic view being formed of the needs of a family, the services they are receiving and which practitioners they are working with and therefore as a result, a lack of system join-up and partnership working.

By recognising this need for a trauma-informed response to data sharing, Lancashire are working across partners, services and organisations, such as Local Authority, NHS, Police, Public Health, and Schools, to create this solution which will allow data to be securely shared in a standardised, and automated way with appropriate services and practitioners. This will minimise the excessive time spent on data processing, therefore ensuring practitioners can provide the right service, at the right time to communities. Additionally, this solution has obtained leadership buy-in and funding from both the police and the Integrated Care Board (ICB) to create a 'tunnel' like process which will automate the relevant data from these organisations into the FHISS, creating a holistic view of Lancashire communities. This process is intended to be embedded over the next several years as part of delivering the partnership vision that children, young people and families are safe, healthy and achieve their full potential.

Theory of change and evaluation

Theory of change and TIP outcomes

When developing your Theory of Change (ToC), you might wish to consider a range of outcomes across different groups or sectors (for instance for end beneficiaries, professionals/practitioners and for organisations, services and systems). There may also be sector specific outcomes, for example educational attendance or attainment depending on the sector or setting you are implementing your project in (not covered here).

You should make use of the best available evidence to support your choice of approach, the activities that will deliver it and the outputs and outcomes you expect to achieve. Where you identify gaps in evidence or it is weakest, this can be used to generate your evaluation questions and help prioritise which activities/outcomes you might focus on evaluating.

In addition, it can also be helpful to identify the barriers, enablers and assumptions that sit behind your ToC. By bringing stakeholders together to identify these you are most likely to develop a comprehensive picture, mitigate potential risks and issues and generate buy-in for implementation.

You should consider whether the outcomes you identify are likely to come in the short, medium or long-term as this will help you prioritise and evaluate your programme. For the purposes of evaluation, we recommend focussing on the short- and medium-term outcomes you expect to achieve unless you are involved in a long-term impact evaluation. Even if you are looking at evaluating short- and medium- term outcomes, it may still be beneficial to measure these over a longer time-frame (for example 1-2 years). For instance, you may wish to measure whether improvements in practitioners' knowledge and confidence are sustained.

You should also ensure that your project activities are clearly related to the outcomes you expect to achieve and be clear about how those activities will lead to those outcomes, for example how the knowledge you expect practitioners to acquire through training might lead to identifiable or specific changes in practice, and then how these in turn will lead to the changes you hope to make for your end beneficiaries.

An example of how to articulate these connections could be:

increased knowledge leads practitioners to challenge their assumptions and increase their confidence and communication skills in using trauma-informed language and tools in their practice;

this enables practitioners to spot trauma-induced behavioural responses and react in a trauma-informed manner;

this change to ways of working is supported by organisational changes to policies and procedures which help to embed and reinforce practitioners' new knowledge, ensuring it becomes standardised in practice;

this allows practitioners to build stronger relationships with beneficiaries, enables them to ask the right questions and make better assessments in their decision- making;

decisions should therefore be better suited to beneficiaries' needs, leading to an increase in accessing the right services at the right time.

Table 2 below gives several examples of the outcomes that VRUs have aimed to achieve through their TIP programmes, which we have organised into suggested short- medium- and long-term (not comprehensive or definitive). However, there are currently varying levels of evidence to support these outcomes and some are more complex than others (see Limitations of TIP section above). The outcomes the EIF viewed as being most plausible, based on the existing evidence base include: increasing knowledge and understanding of trauma, shifting perceptions, and contributing to changing practice and making improvements to multi agency working (when other TIP components are implemented alongside TI training).

Table 2: Examples of TIP Outcomes

Practitioners

Short-term

Increased practitioner knowledge of ACEs, trauma and its causes, trauma-informed practice, and use of this knowledge in professional practice

Confidence in applying knowledge of trauma

Medium-term

Improved staff recognition and response to trauma

Reduction in vicarious trauma

Improved wellbeing and resilience

Long-term

Improved staff retention

Reduced burn-out

Organisations / Systems

Short-term

Improvements or changes to frontline practice, policies or processes

Improved structures of support for staff well-being

Medium-term

Better multi-agency collaboration, for example multi-agency case formulation / intervention planning

Improved referrals between partners

Changes in systems, for example better data and information sharing processes between agencies

Reduced violence in specific settings

Improved organisational recognition and response to trauma

Long-term

Common TI policies and strategies across agencies

Consistency in use of TI language across services

End Beneficiaries

Short-term

Improved relationships with staff and trust

Improved access to and engagement with support services and specialist therapeutic services

Medium-term

Improved emotional regulation and trauma response

Improved wellbeing

Reduced behavioural difficulties

Reduction in re-traumatisation

Long-term

Improved sector-specific outcomes, for example educational attainment or reduced offending, leading to improved life chances

Evaluation

The evidence-base for TIP is still emerging and VRUs and partners can play an important role in helping to develop it further by generating appropriate high-quality evaluation of their TIP programmes. However, as TIP is often implemented at the level of practitioners, organisations and systems, evaluating its impact is extremely complex.

It is important to remember that system-level outcomes are influenced by a range of factors at a local level (including the quality of support services for beneficiaries and systems that support staff wellbeing). This makes measuring the specific contribution of training / TIP challenging. One option could be to take a place-based approach and look at the contribution of the training and practice within a wider set of activities at a local level, though it may be hard to robustly evidence its specific impact.

There is currently no one set tool for evaluating the impact of TIP. However, the attitudes relating to trauma-informed care (ARTIC) scale has been used by several VRUs to evaluate staff outcomes in relation to training, as well as in the youth justice sector and is a validated scale. The ARTIC tool is a licensed product that is not free to use.

Beyond outcomes for practitioners, VRUs should consider how they might also measure outcomes for end beneficiaries and including these where possible in the evaluation design, while being realistic about what is feasible within time and cost constraints.

Considerations for evaluation:

Build evaluation in from the start of programmes if possible. This gives evaluations the best chance of getting the necessary data, including baseline comparison data, and finding ways to integrate data collection into routine work. It will also help evaluators understand the journey of staff and systems and more easily identify changes and impact of TIP on the systems and practices it is integrated into.

Recognise that TIP has a long outcomes chain because it is usually working at practitioner/organisational level and changes to knowledge/practice take time to affect relationships and then more time to result in better outcomes for beneficiaries. Think carefully about the intensity and duration of the intervention, link it your ToC, and consider the timescale an evaluation has to collect data and what outcomes and data are feasible. It may only be possible to measure your short- or medium-term outcomes, though you may be able to measure these over a longer time frame (for example 1-2 years) to see if improvements or changes are sustained.

You may also need to prioritise which outcomes you are looking to evaluate due to cost constraints. If your evaluation budget is limited it is better to focus on a few key outcomes in-depth and get good data and evidence than to try and include more outcomes by using less robust methods.

Outcomes should be measured at least six months after training has been completed to assess if any knowledge has been retained and led to changes in behaviours. Ideally there should be multiple post-test points to see if knowledge and practice have been retained and maintained over time.

Having matched comparison groups: A matched comparison group allows you to compare the change and difference in knowledge and practice between workforces who have received the TIP intervention and those that haven't, to better understand the impact of training or practice outcomes. This is a robust way to evidence impact, but can be complex to implement in practice and needs to be built into the design before the programme starts.

Using qualitative methods (for example, focus groups, interviews, case studies): The use of qualitative methods can aid in providing a more in-depth understanding of how and why interventions might impact staff, systems and beneficiaries and who might benefit most from these interventions. You might want to include training providers, senior managers, practitioners and end beneficiaries (if appropriate).

Feedback surveys: Can be a useful format alongside pre- and post-course surveys to examine the engagement and interest in training content from attendees as well as exploring knowledge attainment or how they will implement what they have learned in practice.

Observations: Observations can help delivery providers to understand and monitor a process as it occurs, helping to gain insight into practitioners' engagement, interactions and behaviours. Observations are also a great way to quality assure your programme and ensure consistency as well as understand any changes or adaptations needed for specific audiences.

Comparability: Where VRUs are able to align their approaches to evaluation, for example by using the same tools to measure impact (particularly validated surveys), they should do so. This would greatly increase the ability to compare different approaches and understand the impact of differences in design and delivery of TIP.

Resources and further information

Guidance and research

ACE Hub Wales, Trauma-Informed Wales (traumaframeworkcymru.com)

ACE Hub Wales, 2022, 'Trauma-informed': Identifying Key Language and Terminology through a Review of the Literature

Department for Levelling Up, Housing and Communities (DLUHC), 2023, Trauma Informed Approaches to Supporting People Experiencing Multiple Disadvantage

Early Intervention Foundation (EIF), 2019, 10 Steps for Evaluation Success

Early Intervention Foundation (EIF), 2020, Adverse childhood experiences: What we know, what we don't know, and what should happen next

Early Intervention Foundation (EIF), 2022, Trauma-informed care: Understanding the use of trauma-informed approaches within children's social care

Early Intervention Foundation (EIF), 2022, Understanding the potential of trauma-informed training in violence reduction units

Emerald Insight: Trauma-Informed mental healthcare in the UK; what is it and how can we further it's development

HM Inspectorate of Probation, Adversity and Trauma

L.Hilder, H.Strang, S.Kumar, 2021, Adverse Childhood Experiences (ACE) Among Prolific Young Robbery Offenders in London: Targeting Treatment for Desistance?

Office of Health Improvement and Disparities (OHID), 2022, Working definition of trauma- informed practice for the health and care sector

P.Gray, H.Smithson, D.Jump, 2021, Serious Youth Violence And Its Relationship With Adverse Childhood Experiences

Research in Practice, Tackling Childhood Exploitation Practice Principles: Tackling Childhood Exploitation Practice Principles: Recognise and respond to trauma Scottish Government, 2021, Trauma-informed practice: toolkit

Substance Abuse and Mental Health Services Administration (SAMHSA), 2014, SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach

Trauma-Informed Lancashire: Resources Traumatic Stress Institute: The ARTIC Scale UK Trauma Council: Resources and Research

West Yorkshire Health and Care Partnership: Adversity, Trauma and Resilience Knowledge Exchange event resources

Youth Endowment Fund Toolkit: Trauma-Informed Training and Service Re-Design

Projects and Evaluations

Anna Freud Centre, 2022, Independent Evaluation of the Framework for Integrated Care (SECURE STAIRS)

Bangor University, 2021, Adverse childhood experience (ACE) and trauma-informed approaches in youth justice services in Wales (2021): An evaluation of the implementation of the enhanced case management (ECM) project

Home Office, 2023, Violence reduction units, year ending March 2022 evaluation report Liverpool John Moores University, 2023, Merseyside Police Trauma-Informed Training: Impacts on Trauma-Informed Knowledge and Attitudes

Opinion Research Services, 2023, Enhanced Case Management Evaluation, South West England (2023): Phase one report

Public Health Wales, 2019, The Prisoner ACE Survey (Wales): Understanding the prevalence of adverse childhood experiences (ACEs) in a male offender population in Wales Public Health Wales, 2017, An evaluation of the ACE Informed Approach to Policing Vulnerability Training (AIAPVT) pilot

Youth Endowment Fund (YEF), Co-Funded TI Grant Round, Trauma-informed practice and preventing young people from becoming involved in violence - Youth Endowment Fund

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Trauma informed practice: learning from experience (accessible)

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This document aims to share practice among violence reduction units (VRUs) and with sector partners for implementing programmes to develop and embed trauma-informed practice (TIP). There are 20 violence reduction units across England and Wales funded to bring together local partners to tackle the drivers of serious violence in their area.

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Online video-based training with a PDF guidebook. Bronze level is currently open, there will also be a Silver and Gold level. More information here: Trauma-Informed Practice training – Thrive LDN

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E-learning with 4 parts

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About the Trauma-Informed Care programme

Recognising that NHS and social care staff are routinely exposed to trauma at work and experience moral injury, NHSE has worked in collaboration to design bespoke 'trauma-informed care training', ensuring these workforces become truly trauma- informed. Whilst we acknowledge that embedding trauma-informed care requires a systematic, multifaceted approach, the aim of this trauma-informed training is to support the learner in deepening their understanding on the importance of becoming more trauma sensitive in the way care is delivered, both as an individual and within a team or service.

The learning journey will be an ongoing and adaptive process which fosters a trauma-sensitive culture throughout all health and social care settings. The endpoint will be all staff understanding the impact of actual, potential and vicarious trauma on the lives of those who access services, and those who work within them, in order to reduce the potential for trauma to cause lasting harm and instead promoting post traumatic growth.

An introduction to trauma-informed care

The following animation gives you an introduction to trauma-informed care and the 5 sessions of the programme.

Primary and secondary audiences

Health and social care staff

How to access

To access this elfh programme, you will require a Learning Hub account. If you do not have one, then you can register by selecting the Register button below. Note that if you hold a full elfh account, you can sign into the Learning Hub using your existing login credentials.
Register
To view the Trauma-Informed Care programme, select the View button below. If you already have a Learning Hub account, you will also be able to login and access the resources within the programme .
View
NHS healthcare staff in England - ESR

The Trauma-Informed Care programme is also available to NHS healthcare staff via the Electronic Staff Record (ESR). Accessing this e-learning via ESR means that your completions will transfer with you throughout your NHS career.
Further details are available here.

Not an NHS organisation?

If you are not an NHS health or care organisation and therefore do not qualify for free access to the Learning Hub, you may be able to access the service if you have an existing OpenAthens account. Please go to Learning Hub and sign in with your existing credentials.

If you do not have an existing OpenAthens account, please contact elfh directly to check whether you may be eligible for access.

Registering large numbers of users

If you are a HR, IT or Practice Manager and would like to register and enrol large numbers of staff within your organisation for access onto the Trauma-Informed Care programme, please contact elfh directly.

Organisations wishing to use their own LMS

For HR departments wanting to know more about gaining access to courses using an existing Learning Management System please contact elfh directly to express interest.

More information

Please select the following link for more information on how to use the Learning Hub

elfh is a NHS England programme in partnership with the NHS and professional bodies

© elearning for healthcare 2023

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Trauma-Informed Care - elearning for healthcare

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A suite of sessions promoting trauma-sensitive practice in health and social care

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​

The London ACEs Hub (LAH) is a network of survivor activists and multidisciplinary professionals committed to spreading the fundamental lessons of Adverse Childhood Experiences (ACEs) research and practice in Greater London, on individual and collective levels.

​

The LAH is an independent and voluntary network. We are nonpartisan and do not speak for a particular organisation.

We welcome the opportunity to work with everyone who supports making London an ACE-aware metropolis.

​

Build awareness and transform London.

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​ The London ACEs Hub (LAH) is a network of survivor activists and multidisciplinary professionals committed to spreading the fundamental lessons of Adverse Childhood Experiences (ACEs) research and practice in Greater London, on individual and collective levels. ​ The LAH is an independent and voluntary network.

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Outcomes Framework for LGBTQ+ people's health and wellbeing

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Outcomes Framework for LGBTQ+ people's health and wellbeing

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LGBT Public Health Outcomes Framework Companion Doc.pdf (london.gov.uk)

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NICE Guidelines for mental wellbeing at work (2022)

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NICE Guidelines for mental wellbeing at work (2022)

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https://www.nice.org.uk/guidance/ng212

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Overview | Mental wellbeing at work | Guidance | NICE

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This guideline covers how to create the right conditions for mental wellbeing at work. It aims to promote a supportive and inclusive work environment, including training and support for managers and helping people who have or are at risk of poor mental health

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Video about trauma-informed approaches in Tower Hamlets

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Video about trauma-informed approaches in Tower Hamlets

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https://www.youtube.com/watch?v=avPSdzjRmIo

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How can Tower Hamlets become a better place for people who have experienced trauma?

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Five to Thrive Webinar and Online Interactive Course

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Five to Thrive Webinar and Online Interactive Course

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For people working with young children, babies or parents
Webinar link: https://connected.kca.training/register.cfm?form=FTTTH-2022
Online interactive course link: https://connected.kca.training/register.cfm?form=FTTIntVid2022

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Adverse Childhood Experiences (ACEs) Special Interest Group - ACAMH

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Contents

1. The wider maltreatment context around ACEs
'Ten Adverse Childhood Experiences - 'The 'Classic ACEs Profile'
3. Current definition of ACEs
4. The cycle of ACEs

1. Measuring ACEs
2. The pathways to adult mental and physical ill-health
3. The prevalence of ACEs
4. Intervention to modify and prevent the impact of ACEs

1. Toxic Stress and Trauma-Informed Care
2. ACEs Trauma-informed practice
3. The effects of reducing ACEs - Health Equity
4. A systematic review of trials to improve child outcomes associated with ACEs
5. Parallel developments: The Framework for the Assessment of Children in Need and their Families (2000)
6. The Hope for Children and Families Modular Programme

1. A Pair of ACEs
2. Relationship between ACEs and deprivation
3. The Covid-19 pandemic as an Adverse Experience
4.The impact of climate change on mental health and emotional well-being
5. Exposure to harmful influences online
6. The Hope for Children and Families Modular Programme

1. Direct research with children and young people
2. Forty forms of Adverse Experiences
3. A National Traumatic Stress Survey
4. The harmful effects of ACEs associated with children and young people in conflict with the law
5. Suicidal ideation and adversity
6. Traumatic experiences of foster care and children and young people
7. The impact of neglect
8. Spanking and adult mental health impairment: The case for the designation of spanking as an Adverse Childhood Experience

1. Lifespan outcomes of Adverse Childhood Experiences and costs to the community
2. Outcomes associated with ACEs
3. Costs associated with ACEs
4. Factors which protect against the impact of ACEs
5. Strengths and limitations of the ACEs score
6. The ACEs score does not predict poor health outcomes at the individual level
7. Research on risk calculators to identify which children exposed to ACEs will develop poor health outcomes
8. Adverse Childhood Experiences are associated with neurobiological and inflammatory responses

1. The wider maltreatment context around ACEs
Maltreatment has been increasingly recognised over past decades including the emergence of different types of child abuse.

A recent review outlines the historical, social and research contexts in which ACEs emerged from the extensive maltreatment literature. The current political and financial implications for practice and research are discussed (Vizard, Gray & Bentovim, 2021, p.1, p.9)

Definition of ACEs in Felitti et al. 's 1998 study

Vincent Felliti and his colleagues at the Kaiser Permanente Organisation (1998) defined Adverse Childhood Experiences as follows:
2. 'Ten Adverse Childhood Experiences - 'The 'Classic ACEs Profile'

1. Physical neglect: failure to supervise or provide for the child

2. Emotional neglect: caregiver unable to express affection or love for the child due to personal problems

3. Physical abuse: severe assault or physical abuse such as shaking or hitting

4. Sexual abuse: child experienced sexual abuse or forced sex

5. Emotional abuse: caregiver engaged in psychological aggression towards the child such as threatening

6. Caregiver treated violently: domestic violence of an adult in the home including slapping hitting or kicking

7. Caregiver substance-abuse: active alcohol and drug abuse by a caregiver

8. Caregiver mental illness: serious mental illness or elevated mental health symptoms

9. Caregiver divorce/family separation: child's parent(s) deceased, separated or divorced or child was abandoned or placed in out of home care

10. Caregiver incarceration: caregiver spent time in prison or is currently in jail or detention centre

What was unique in Fellitti et al. 's approach was that they established an "ACE score" by summing the number of ACEs reported by more than 17000 adults in the USA. The study showed that the higher the ACE score, the stronger the association was with poor subsequent health as adults, and the greater their risks of health-harming behaviours heart disease, cancer, stroke, type 2 diabetes, chronic bronchitis, fractures, hepatitis and poor self-rated health.

3. Current definition of ACEs
ACEs are defined as experiences which require significant adaptation by the developing child in terms of psychological, social and neurodevelopmental systems, and which are outside of the normal expected environment (adapted from (McLaughlin, 2016). ACEs may include other adversities not included in Felitti et al.'s 1998 study, such as bullying victimisation, parental death, and community violence.

4. The cycle of ACEs

Shanta Dube recently described the cycle of ACEs (Dube 2020):

Childhood adversity - abuse, neglect, and stressors in the home

Adolescent outcomes - associated with substance use, suicidality, mental health, early pregnancy, substance misuse, and sexually harmful behaviour and exploitation

Adult outcomes, associated with chronic diseases, substance use, obesity, STD/HIV risk, sexual risk behaviour, mental health, suicidality, emotional dysregulation

Impact on Parenting - The cycle is completed through the association with harmful parenting which completes the cycle.

References
Dube S (2020). Twenty years and counting - the past, present and future of ACEs Research, in G. Asmundsen and T Afifie (eds). Adverse Childhood experiences. Academic Press.

Felitti V.J. Anda R.J et al (1998). Child Abuse and Household dysfunction and adverse health impact ACE. Am J Preventitive Med, 14: 245-258.

McLaughlin K et al (2016). Maltreatment Exposure, and the long shadow of adverse childhood experiences. Psychological Science Agenda.

Vizard, E., Gray, J., & Bentovim, A. (2021). The impact of child maltreatment on the mental and physical health of child victims: A review of the evidence. BJPsych Advances, 1-11. doi:10.1192/bja.2021.10.
Back to Contents

What we don't know about ACEs
1. Measuring ACEs
As we have commented, the introduction of Adverse Childhood Experiences as a risk matrix has resulted in significant developments. The relationship has been demonstrated as robust, there are concerns that high levels of adversity associated with neurobiological traumatic responses may result in a harmful outcome. There is a growing awareness of the relationships, advocacy of regular screening in adult and young people, the introduction of Trauma-Informed approaches.

However there has been a growing awareness of limitations of the ACEs score, and the need to be aware of a wide range of adverse influences in the community, associated with health inequity, deprivation, racism, and disadvantage. There are concerns that the ACEs score has been ascertained retrospectively in many studies, and that the items of the ACEs score are not equal in relevance. A high ACEs score is associated with harmful outcomes on a population level, but is not associated with outcomes for the individual. The 'Classical Ten' ACEs has been extended to 'Forty Aces' when ACEs in children are studied directly.

Current evaluation of the uses of ACEs scores to measure adversity as an indicator has indicated that there is limited support for universal screening or routine enquiry utilising the ACEs score in childhood or adults. There is a need to define effective measures of adversity to predict future harm. There is growing research on the network of risk, resilience and vulnerability factors which need to be considered, when there are concerns about children and young people referred across services for children and young people.

We need to develop reliable ways of predicting health outcomes for the individual, a variety of approaches have been researched - using single forms of adversity, groupings by theoretical constructs, e.g. DMAP - threat or deprivation, or combinations of ACEs through Latent Class Analyses. Extending and operationalising the Assessment Framework developed for welfare contexts, across services may be a further approach to consider. We have described the potential value of a risk calculator approach as an alternative to the ACEs score.
2. The pathways to adult mental and physical ill-health
In the review of research on cases in the last 20 years we have noted that there has been a shift in emphasis from the original research of Felliti and colleagues (1998) which explored the association between childhood adversity and adult physical and mental health, Direct research on childhood and young people and the social context, together with longitudinal research has significantly enlarged our understanding of possible pathways from adversity to adult morbidity and mortality. Adversity and risk has to be balanced with resilience and vulnerability factors, from the individual, parenting, the family and community. This makes for a more nuanced understanding of potential pathways and associations with psychopathology and health. However, what remains unanswered is an understanding of the processes which drive the transformation.

A number of theories have been advanced including neurobiological responses to adversity. Traumatic responses have been researched including 'Latent Vulnerabilities', 'Chronic Inflammatory Responses and 'Allostatic 'Wear and Tear'. Longitudinal Research shows promise in differentiating a variety of adversities, and outcomes - psychological, behavioural and neurobiologically. Further research is essential to find more effective ways of intervening to prevent ill health in identified vulnerable individuals.
3. The prevalence of ACEs
Another important area where we need to develop knowledge is to understand the prevalence of ACEs in the community. There is an extensive literature on the prevalence of the core forms of maltreatment, physical, sexual and emotional abuse and exposure to violence (Radford et al., 2011) and the overlap through the research on polyvictimisation (Finkelhor 2007). With the addition of a wide range of household dysfunctions such as parental mental health, substance abuse, separation, loss, divorces and community violence associated with different forms of adverse experiences, there is a a significant challenge to assess the prevalence of ACEs.

The work of the UC Health Equity Group has illustrated the relationship between deprivation and higher levels of ACEs providing a model for future research. The introduction of extensive screening tools based on epidemiological research by Turner and Finkelhor which includes a wide range of Adverse Experiences may assist researchers to determine the prevalence of Childhood Adverse Experiences in the community as part of a more extensive evaluation of children and young people's development,
4. Intervention to modify and prevent the impact of ACEs
The challenge to effectively intervene to prevent the harmful impact of ACES when identified in childhood, and young people to prevent the associated morbidity, mortality and ill-health in adult life is considerable. The introduction of Trauma-informed approaches has the potential to transform the views and responses of the workforce in relation to the needs and responses of children and young people referred to mental health, safeguarding, offending and care services, and children and young people looked after or living in contexts of significant stress of adversity. It also has the potential to transform adult services to be aware of the adversities children and young people experience when parents have a variety of mental health difficulties, to be aware of the association between exposure to multiple adversity, and subsequent health.

However, the evidence for the effectiveness of these approaches, both short term and longer-term reduction of harmful psychological and physical health is limited, and at an early stage. Research on specific interventions for ACEs is limited to children under six years of age. Implementing the recommendation that there should be a focus on identifying and intervening with maltreatment in childhood is also challenging.

There is extensive research on intervening with single forms of maltreatment. However, there is limited research on overlapping multiple maltreatment. Trauma - Focused CBT being the one intervention which is associated with more favourable outcomes, and parenting interventions are effective.

Intervening with the many areas of potential adversity parental mental health, substance misuse violence in the home and the community is far more challenging and requires collaborative services. There is a need for further primary, as well as secondary and tertiary prevention activities, including strengthening communities and families, building resilience and support to provide trauma- informed services. (Gentry and Paterson, 2021)

A modular approach which provides a library of interventions derived from common treatment elements, can be integrated to meet complex needs children, parents, and families when significant adversities are identified. The approach works well in practice. Although it includes an effective model of intervention for mental health concerns of children and young people, further research is required to evaluate the effectiveness to reduce longer term morbidity and mortality.

Van IJzendoorn and colleagues (2020) conducted an umbrella synthesis of meta-analyses on child maltreatment antecedents and interventions. They concluded that there was now good evidence to identify parental risk factors for maltreatment. These risk factors include parents who have themselves been victims of child maltreatment, been subjected to interpersonal violence, had negative personality attributes associated with mental health disorders, and have limited social and material resources.

However, they noted there was a "'power failure' of interventions to prevent or decrease child abuse and neglect in the next generation, with the effect sizes for intervention being substantially smaller than the effect sizes for most of the antecedents of child maltreatment" (Van IJzendoorn et al., 2020, p. 283). They further commented,

" The scarcity of evidence-based means to break the circle of maltreatment is deplorable. Child maltreatment is a widespread global phenomenon affecting the lives of millions of children all over the world, which is a betrayal of the United Nations Convention on the Rights of the Child (United Nations, 1989)" (p. 284).

References
Finkelhor, D., Omrod, R. K., & Turner, H. A. (2007). Poly-victimisation: A neglected component in child victimization. Child Abuse and Neglect, 31, 7-26.

Radford, L., Corral, S., Bradley, C., et al. (2011). Child abuse and neglect in the UK Today. London: NSPCC. https://learning.nspcc.org.uk/media/1042/child-abuse-neglect-uk-today-research-report.pdf

Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., Coughlan, B., & Reijman, S. (2020). Differential susceptibility perspective on risk and resilience. Journal of Child Psychology and Psychiatry, 61(3), 272-290.

Adverse Childhood Experiences, Adverse Community Environments, climate change, the pandemic, the internet and refugee asylum seekers
1. A Pair of ACEs
One of the results of the introduction of ACEs was the observation that a common factor in the direct effects of adversity on children and young people was exposure to trauma and associated traumatic responses. 'Toxic Stress' was the term applied to exposure to prolonged stressful experiences. The neurobiological impact of traumatic and stressful events has been described as resulting in a " cascade of toxic stressful, inflammatory and hormonal responses with marked effects on brain morphology, function and network architecture" (Teicher, Samson, Anderson, & Ohashi, 2016, p. 254).

Complex adversity leads to clusters of symptoms and multiple different types of disorders rather than specific disorders - 'trauma-related psychopathology' (Lewis et al., 2019). A spectrum of overlapping internalizing and externalizing disorders results, as noted in the research of Meehan and colleagues. The specific response depends on their interaction with other risk and protective factors (McCrory, Gerin, & Viding, 2017), and the more extensive the adversity, the number of victimisations experiences the greater the severity of psychiatric symptoms (Cecil, Viding, Fearon, Glaser, & McCrory, 2017)

As a result many services have adopted a 'Trauma Informed Focus.' Pachter and colleagues (2017) described the development of a ' Community-Wide Initiative to Address Childhood Adversity and Toxic Stress: A Case Study of The Philadelphia ACE Task Force".

Gentry and Paterson (2021, p. 2) define Trauma Informed approaches:

Trauma informed: 'A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures and practices, and seeks to actively resist re-traumatization'.

Rebeca Lacey and Helen Minnis in their 20 year review of ACEs noted,

A dverse Childhood Experience scores have been instrumental in stimulating innovations in practice. ACEs awareness promotion - data from population studies has increased public awareness, Trauma-Informed Training of front-line staff helps staff understand 'what has happened' and consequences, with a resulting compassionate workforce, early intervention, integrated and collaborative services.

The illustration below gives an idea of the elements of an ACEs hub.

The structure and function of an ACEs hub
2. Relationship between ACEs and deprivation
Based on the evidence of potential harmful impact of ACEs, Hughes et al (2017) argue that ACE informed practice can (should) be developed across multiple settings:

including schools,

criminal justice agencies,

social care assessments of children and their families

when children are showing evidence of being subject to maltreatment, with associated parental mental health, substance abuse, or conflict.

Routine enquiry and service development

A programme of routine enquiry concerning the presence of ACEs has been advocated (REAch) and initiated to enable identification of need and early intervention or access to services. Routine enquiry of children and young people has been established in the State of California, and will provide important information about the approach and its value in reducing health concerns on a population level.

However, in a review of the value of routine enquiry from the Early Intervention Foundation, Asmussen and McBride (2021) conclude,

'In our view all ACE universal screening activities should be stopped until robust testing and validation takes place. Additionally, practitioners should recognise that it is unlikely that ACE scores will ever represent an appropriate way of measuring individual risk or making treatment decisions. This means that ACE scores should never be used as a basis for treatment referral and, given the emerging evidence showing that many vulnerable individuals are less likely to answer ACE questionnaires truthfully, probably should not be used to initiate conversations with children and adults about difficult childhood histories'

Community Responses - Trauma-Informed Care

Services have come together to develop a community response. Integrated ACEs hubs have been developed in Scotland and Wales, and across a number of states in the US. Authorities across the UK are considering the need to develop a Trauma-informed Approach to planning and delivering services to children, young people and their families. These include children who are abused and neglected, sexually exploited, refugees, looked after, and those who have offended. In these contexts ACEs scores would need to be contextualised through information on a wide range of risk, resilience and vulnerability factors to make a holistic assessment.

Bendall and colleagues (2021) have conducted a systematic review and synthesis of trauma-informed care within outpatient and counselling health settings for young people. They found there was good evidence for the implementation of the approach, and improvement in trauma-informed knowledge, practice and collaboration but limited evidence of outcomes.

Research on the value of Trauma-informed Care

Asmussen and McBride (2021, p. 16) state that

'While the principles underpinning trauma-informed care may be beneficial for improving practice, we are concerned that most trauma-informed activities have yet to be robustly evaluated'
'Although Trauma focused practice is being widely adopted and advocated there is a need for further research to determine the effectiveness of the approach....and that government should fund a series of national evaluations aimed at investigating the benefits of trauma-informed care training for the frontline practitioners who are receiving it, including social workers, teachers, health visitors and the police'.

The evolution of trauma-informed care will require

a clear consensus on the deﬁnition, principles, and components of trauma-informed care to create a uniform set of practice guidelines.

instrumentation to measure its effectiveness and assess organizations to capture their degree of trauma-informed care and its link to client-level indices of well-being.

methodologically rigorous studies to build the evidence base of trauma-informed care as a framework and complement to trauma-speciﬁc services; and,

public and private support, at the federal, state and local levels, to fund research and implementation.

3. The Covid-19 pandemic as an Adverse Experience
The Health Inequity group based on the incidence studies of Bellis et al. (2014) have asserted that reducing ACEs would have a significant impact on harmful responses associated with ACEs - reducing early sex, unintended pregnancy, smoking, binge drinking, cannabis use, heroin crack use, violence victimisation, and perpetration, incarceration and poor diet. They advocate the importance of reducing the impact of social inequity as a pathway to improve the health of children young people and adults.

A public health approach to reducing ACEs is advocated as a key approach to reducing the impact of ACEs. Gentry and Paterson's review (2021, p. 3) concluded that

Policy approaches to reducing child poverty/inequality have potential to reduce ACEs. Prospective cohort and cross-sectional studies suggested family, institutional and community support were associated with fewer adverse outcomes. Peer-led home visiting programmes using volunteer or paraprofessional home visitors from the local community could support parenting and attendance at healthcare appointments compared with standard community maternal-child care (Walsh et al., 2020).

Asmussen and McBride (2021, p. 19) in their Delphic survey of professionals reported a consensus that

The UK government should adopt a public health approach which explicitly aims to prevent child maltreatment from conception to age 18.

'Specifically targeting child maltreatment may be a particularly effective way of improving the lives of vulnerable children, including those who have experienced multiple ACEs .

Evidence-based parenting support should be made available at the universal, targeted and individual level as a first step in a population-wide strategy for preventing and reducing ACEs. a sustainable whole- system strategy needs to be developed in every community to prevent and reduce ACEs at the population level.

We have noted the alliance to stop the corporal punishment of children and young people. There is an extensive literature on prevention of sexual abuse and violence through school's programmes, and there is evidence that a 'blended' prevention approach through introducing Triple P Parenting at a primary level through public education - video - and secondary and tertiary levels through more direct work, reducing the incidence of abuse and neglect (Prinz 2009).

4.The impact of climate change on mental health and emotional well-being
Whilst there is an extensive literature associated with modifying the impact of abuse and neglect e.g. Macdonald et al. (2016) described 162 studies and 66 controlled trials.

Marie-Mitchell and Kostolansky (2019) were able to identify 20 Randomised Control Trials which focused on ACEs. The studies all focused on children under five years of age.

The commonest ACE was parental mental health; there were fewer parent alcohol, substance abuse or domestic violence associated ACEs studied

Multicomponent medium- to high-intensity interventions that utilized professional home visitors to provide parenting education or mental health counselling demonstrated the largest effects. There was evidence of reduction of the impact of ACEs and improved parent-child relationships.

However, there was no research which included children older than 6 years of age, or on improving child outcomes for other ACEs

We have emphasised the importance of researching the effectiveness of the Trauma -Informed model of Intervention.

5. Exposure to harmful influences online
The Framework for the Assessment of Children in Need and their Families (the 'Assessment Framework') (Department of Health et al., 2000) was introduced as part of the process of enlarging the field of vision of professionals concerned with children in need of services, as well as in need of protection. This eco-systemic framework provides a conceptual map to help professionals consider the child's functioning and needs, the capacity of parents to provide for those needs, the way their needs were being met (or not) and the role of family and environmental factors on the child or the parenting capacity of their caregivers. The approach was intended to extend professional practice from a narrow focus on 'risk assessment' and protection to a broader holistic consideration of the child and their family and the context in which they lived, to raise the standard of professional understanding of needs and to focus interventions more effectively. The approach is a parallel to the development of the concept of Adverse Childhood experiences which includes forms of maltreatment and the family context.

The Assessment Framework is underpinned by a series of principles that emphasise the centrality of the child, that an understanding of child development is critical to working with children and their families, the importance collaboration with children and their families, placing an emphasis on identifying strengths as well as difficulties and the influence of environmental factors on parent's capacities to respond to their child's needs.

A series of tools and approaches were identified and developed to support the implementation of the Assessment Framework for use by a range of practitioners from different professional and voluntary backgrounds and with differing levels of experience and expertise.

Identification of abuse and neglect, assessment, and analysis

The assessment tools included the Family Pack of Questionnaires and Scales (Cox and Bentovim, 2001) which included tools to gather information about emotional and behavioural difficulties in both children and adults, parenting problems, recent life events, mental health difficulties, alcohol problems, and the quality of family life; the HOME Inventory UK Approach (Cox et al., 2008; Cox and Walker, 2002) which was originally developed as a research tool in the USA (Caldwell and Bradley, 2001) and assesses the quality of parenting and the home environment provided for a child using a semi-structured interview schedule; and the Family Assessment (Bentovim and Bingley Miller, 2002; 2012) which enables practitioners to assess family functioning and family relationships, including parenting, and the impact of family history.

The Safeguarding Children Assessment and Analysis Framework (SAAF) (Bentovim et al., 2009; Pizzey et al., 2016) was developed to assist practitioners make an analysis of the information gathered using the assessment tools. The SAAF makes a systemic analysis of the strengths (protective and resilience factors) and difficulties (risk and harm factors) identified from the assessment, provides a prediction of the likely outlook for the child if nothing changes, assesses the prospects for successful intervention and provides the evidence for the plan of intervention. The Safeguarding Children Assessment and Analysis Framework assessed in a RCT by Macdonald et al. (2017).

An intervention approach, the Hope for Children and Families Modular Approach (Bentovim et al., 2021; Bentovim and Gray (eds)., 2016; 2017; 2018) was designed to meet complex needs associated with child abuse and neglect, and is relevant to intervention to prevent the associated harm of ACEs.

The assessment framework domains and dimensions

The definition of Child in Need is set out in Section 17 of the Children Act 1989 and was operationalised in the Assessment Framework. The elements Felliti et al. (1998) introduced can be mapped on to the dimensions of the Assessment Framework, including parental mental health, parenting capacities, and an extensive description of strengths and difficulties across the framework - a potential approach to make a holistic assessment when there are concerns about children and young people presenting across services.
6. The Hope for Children and Families Modular Programme
The limitations of current intervention approaches to modify the harmful impact of ACE (Bentovim et al., 2021)

Despite the availability of a wide range of effective evidence-based interventions to prevent the harmful effects of adversity, there is limited and patchy use of these interventions to address the needs of individuals who have experienced extensive exposure to ACEs with the complex mental health impacts, and the cumulative harmful impact on the developing child's mental health and wellbeing.

The NICE guidance (2017) on intervention invites practitioners and commissioners to consider utilising about 15 evidence-based manualised approaches for specific forms of child maltreatment from different theoretical approaches (psycho-dynamic, systemic, and cognitive-behavioural). These are to be delivered in the home or office, for a range of parenting relationships (birth, foster or adoption) and developmental stages of children. The importance of being trained in the relevant approaches is stressed.

These approaches include:

Enhanced Triple P programme, UK Department of Health's Healthy child programme and Parents under Pressure for early help contexts

Attachment-based interventions, e.g. Attachment and Biobehavioural Catch-Up, and child-parent psychotherapy for physical or emotional abuse or neglect of children under 5

SafeCare and parent-child interaction therapy for physical or emotional abuse or neglect for children up to the age of 12

Multi-systemic therapy for child and abuse (MST-CAN) for adolescents aged 10 to 17

Trauma-focused cognitive behavioural therapy, individual psychoanalytic therapy, group psychotherapeutic and psychoeducational sessions for sexual abuse where there is evidence of anxiety, sexualised behaviour or PTSD symptoms.

In general, these are well evidenced approaches, which will be helpful to services for children aged 0-5 years, looked after children and sexually abused children and adolescents, and specialist services. It is recognised that the most effective interventions working with maltreated children draw on differing theoretical models and concepts. However, in practice, implementation of such a complex set of evidence-based approaches presents a considerable challenge to planners and commissioners of services because both practitioners and their managers need training and supervision in the different approaches mentioned above and elsewhere.

Macdonald et al. (2016) comment that Trauma-Focused Cognitive Behavior Therapy is the most effective for post-traumatic stress disorder, complex trauma, and associated emotional problems. However, "most children experience more than one form of maltreatment, and there is growing recognition of the need to better take into account children's profiles of maltreatment in order to improve policy and practice" (p. 38). The complexity of an individual's responses to multiple ACEs, therefore, demands a therapeutic approach that can encompass an infinite range of responses.

How a modular intervention approach may help

Modular approaches were developed to meet the treatment needs of children and young people with a range of overlapping mental health problems (e.g., Chorpita, Daleiden, & Weisz, 2005). The approach capitalized on the knowledge embedded in evidence-based treatments for mental health (e.g., Chorpita & Daleiden, 2009). A structured methodology was developed to map, identify and categorise the common treatment features from 615 treatments in 322 randomized trials. It was possible to distill out the specific practice components of each type of treatment i.e. practice elements from different manuals.

The Modular Approach for Children with Anxiety, Depression, Trauma and Conduct problems (MATCH-ADTC: Chorpita & Weisz, 2009) is a multi-disorder intervention system that incorporates treatment procedures (elements) and treatment logic (coordination) based on four successful evidence-based CBT interventions for childhood anxiety, depression, trauma (TF-CBT), and conduct problems, with modifications allowing the system to operate as a single protocol. The approach was more effective in improvements in a wide range of mental health problems, than using the component manuals.

The Hope for Children and Families Intervention Resources

Building on the MATCH-ADTC in collaboration with Chorpita and colleagues, common treatment elements were distilled from across the field of interventions for individual forms of child maltreatment, Twenty-two RCTs were identified for the treatment of different forms of maltreatment (Bentovim & Elliott, 2014). The forty-seven common practice elements that emerged were categorized as focusing on work with children, young people, parents/caregivers and the family as a whole, and were added to the MATCH-ADTC to create a library of modules which can be integrated into a management plan, establishing collaborative goals, with children and families, and can be adapted for use across services.

Elements targeting the antecedents of adverse childhood experience include psychoeducation for parents; exploration of the impact and origins of abuse and exposure to violence; addressing parental mental health difficulties; and learning positive parenting skills.

The elements targeting work with children and young people include psychoeducation on the impact of their maltreatment; managing and exposing traumatic thoughts and feelings; relaxation; problem-solving; relationship building; and, social skills talent/skill building. Modules are gathered into a set of guides organised around the Assessment Framework Triangle.
Guides
Each of the guides is described below.

Engagement and Goal Setting

The ' Engagement and goal setting guide' (Bentovim et al., 2017) helps practitioners promote a sense of hopefulness, orientates the practitioner and family to the profile of Adverse Childhood Experiences, family strengths and difficulties, and establishes shared goals, and the measures by which outcomes will be monitored.

Targeting the parental antecedents of maltreatment and ACEs

Four intervention guides cover different areas of parenting: 'Promoting positive parenting' (Roberts, 2016), ' Promoting children and young people's health, development and wellbeing' (Bentovim, 2017a); ' Promoting attachment, attuned responsiveness and positive emotional relationships' (Gates & Peters, 2017); and, ' Modifying abusive and neglectful parenting' (Bentovim, 2017b). The guides' modules provide an understanding of the historical and familial stresses associated with ACEs -abusive and neglectful parenting; the impact of abuse and neglect on children's health and development; interrupting and modifying abusive and neglectful processes, modifying negative perceptions of children, and improving the standard of care. They can be adapted for use with foster, adoptive, and residential caregivers.

Working with families

The ' Working with Families' intervention guide (Jolliffe, 2016) supports practitioners in their work with families as a group, and in various combinations. This skill helps them to facilitate parent-child communication, and interrupt and find alternatives to conflict within the family, and between the parents and community.

Direct work with children and young people

Two intervention guides consider working with children and young people: ' Addressing emotional and traumatic responses' (Weeramanthri, 2016); and, 'Addressing disruptive behaviour' (Eldridge, 2017). These are core guides for working with children and young people who have been subject to ACEs. These modules help practitioners work with parents and caregivers to develop children and young people's generic skills to manage their emotions, be safe and develop problem solving abilities. Once basic coping skills have been mastered there are modules for addressing specific anxiety, mood, traumatic responses and disruptive behaviour.

Working with child sexual abuse

The ' Working with child sexual abuse' guide (Eldridge, 2016) considers working with children and young people who have been abused sexually, their parents/caregivers, and with those who are responsible for or who display harmful sexual behaviour. It is essential that practitioners develop skills to support children and young people who have been exposed to sexual abuse and demonstrate sexually harmful behaviour, often in association with other forms of maltreatment and adversity, and to support their parents.
Effectiveness of the HfCF
The piloting and subsequent implementation of the program have demonstrated that the HfCF Intervention guides for practitioners could provide effective resources for use within different types of children's services provision (e.g., social care/child protection, health, education, and youth justice services), and at all stages of the therapeutic process. They proved helpful for a range of services - intervening early and targeting vulnerable families, to responding to identified maltreatment, and working with children placed in foster care, residential or adoptive placements.

The HfCF resources could provide the tools to deliver effective Trauma-Informed Practice, to address the impact on children's health and behavior of multiple ACEs across different agencies in the community. Modular approaches have proven effective in RCTs for children and young people with overlapping mental health disorders and have proven valuable to practitioners. However, the effectiveness of the HfCF has not yet been tested for polyvictimization and multiple ACEs through a RCT.
Relevance to Child and Adolescent Mental Health
It is estimated that over 40% of Children's and Adolescents' mental health problems are associated with adversity, demonstrated strikingly during the pandemic as a source of significant adversity. Research to prevent harmful impacts is a key challenge for our field.
References
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Back to Contents
Adverse Childhood Experiences, Adverse Community Environments, climate change, the pandemic, the internet and refugee asylum seekers
1. A Pair of ACEs

Ellis and Dietz in 2017 introduced a framework to address ACEs by describing ACEs in the context of Adverse Community Environments, a model which can be extended to include the impact of climate change and the Pandemic as potentially adverse experiences.

The tree describes the 10 Classic ACEs described by Fellitti et al., and the soil which 'nurtures' adversity includes Poverty, Discrimination, Community Disruption, Lack of opportunity, mobility and Social Capital, Poor Housing Quality, and Affordability, and Violence in the community.

This approach to putting in context represents more recent research on ACEs - direct research on children and young people, and research on the social context.

2. Relationship between ACEs and deprivation
Michael Marmot's UC Health Team (Allen and Donkin, 2015) noted in an extensive review of the prevalence of ACEs across communities, that those communities with the highest index of deprivation also had the highest incidence of individual ACEs. Parental separation was experienced by the highest number of respondents, followed by verbal abuse, mental illness, physical abuse and domestic violence.

It is striking to note the role of environment stress reinforcing parenting and family stress. The Health Equity group advocates a model to understand the responses associated with high levels of adversity in childhood which includes the social context as stressors - poverty, social isolation, and protection policies, parenting and family factors, and social determinants - education and income.

The Health Equity Group has advocated the need for community intervention to 'Build back Better' in the face of the impact of deprivation in communities, a recommendation reinforced with the evidence of higher rates of Covid infections in deprived communities, associated with higher levels of adversity.
3. The Covid-19 pandemic as an Adverse Experience
There has been universal concern about the pandemic as an Adverse Experience which has affected whole populations. Adverse factors associated with harmful health outcomes, have also been noted by the Health Equity Group to be associated with worse outcomes of Covid infections.

There have been enormous economic and social shifts. Families have been living in virtual confinement coupled with massive economic disarray. There has been an increase in Domestic Violence and Substance Misuse. These are ideal conditions for a rise in children ' s experience of abuse and neglect, with the reduction of contacts with those in the outside world who would see and identify harmful incidents.

A recent study (NHS Digital, 2020) of the mental health of children and young people In July 2020 during the COVID-19 pandemic concluded:

One in six (16.0%) children aged 5 to 16 years were identified as having a probable mental disorder, increasing from one in nine (10.8%) in 2017. The increase was evident in both boys and girls.

Ford and colleagues (2021) noted there was a higher rate of admissions of younger children to hospital with self-harming behaviour

There was a striking increase in eating disorders

There was an increased rate of such responses when parents have mental health problems, family functioning difficulties and financial hardships

There was also an increase when children have ASD or ADHD which acted as a vulnerability factor.

The impact of the Pandemic as a universal Significant Adverse Experience depends on a number of associated factors -for example when there are other risk factors - e.g. associated with deprivation, and limited resoience factors.

4. The impact of climate change on mental health and emotional well-being
With increasing concern about Climate Changes as a significant Environmental Adversity Lawrence et al. (2021) from the Institute of global health innovation - Grantham Institute have described the environmental adversity as climate changes manifested as - Heat and droughts, wildfires, smoke, storms and flooding, rising sea levels, associated with negative mental health and emotional wellbeing of people around the world. This is manifested as:

Increased suicides; severe distress following extreme weather events; provision of care disrupted

Distress among young people and 'eco-anxiety'

The exacerbation of social inequalities, associated costs are often unaccounted for, underestimated, and hidden!!

5. Exposure to harmful influences online
Vizard et al. (2021) noted learning online and developing a wide range of IT skills is now the norm for many children in Western society. There are potential substantial benefits for all children and particularly those with special needs. Acquiring online skills, including competence at certain video games, may have offline social and educational benefits. These new skills could directly enhance the physical, emotional and social development of children with special needs in particular. Young people have embraced the internet and social media which has a powerful impact sometimes organising on their lives, self-images, entertaining, gaming, connecting and learning. Important issues such as the identification of young people's gender as male or female can be debated.

However, the online world is not always a positive and safe environment for children, since potential predators are also online, seeking access to victims of all ages, there are risks of children being groomed for abuse, e.g. images of the sexual abuse of children, the entrapment of children to circulate images, falsification of identities as a way of meeting and exploiting children sexually. There is potential for children and young people to abuse other children and young people, cyber-bullying, attacking, and excluding which can trigger and maintain traumatic responses, associated with self-harm and suicidal responses (Vizard et al. 2021).

Children from all backgrounds can view harmful or outright abusive material online via live streaming sites. Parents in 'safe' families may be unaware of the nature of the material being viewed by their children. Exposing children and young people to sexually explicit material may be part of a 'grooming' process of the victim leading to direct sexual abuse (NSPCC, 2020).

Unsupervised access to violent and sexualised video games online may 'desensitise' a child or young person to the images and behaviour within the game. They may become increasingly determined to play the game up to certain 'levels', the repetition of which can lead to a form of addiction.

There is also a potential for the internet to act as force to promote health and wellbeing. Sites which focus on anorexic and self-harm can give adolescents and young people information which reinforces harmful behaviour, self-harming tendencies, such sites can also be helpful, provide informal support, and deliver on -line therapeutic interventions. The issue of safety of the internet, helping children, young people and parents understand the harmful and risks associated, and manage their children and young people's internet use are constant themes.
6. ACEs in child refugee and asylum-seeking populations
(Ward et al., Public Health Wales, 2020)

The University team in Bangor have gathered the evidence together to demonstrate the significant level of ACEs in child refugees and asylum-seeking populations. In addition to ACEs within the home or family, are added the set of ACEs pre-migration - destruction, deprivation, witnessing and experiencing violence, during the migration journey, and post-migration. This is an example of taking a highly stressful context for children and young people, understanding the adversities children and young people might experience, to assist practitioners helping children and young people process those experiences and develop resilience and coping.

Von Werthern and colleagues (2019) have noted in the case of unaccompanied refugee minors, it is clear that a young person on the move from one hostile country to another over months or years cannot develop a secure sense of self-identity without a stable home background, a peer group to relate to and a sense of roots and belonging. At the very least this is a serious neglect of the young person's emotional and social development.
Conclusion
This brief review of the contextual factors which are associated with significant adversity in children and young people's lives associated with harmful health and development has significantly enlarged our understanding of ACEs as a concept. There are significant challenges to mitigate harmful effects on children and young people's associated with deprivation, community violence, climate change, ,the refugee and asylum seeking, and the internet!!
References
Afifi T et al (2017). Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience. Child Abuse & Neglect, 71: 24-31.

Allen M and Donkin A (2015). The impact of adverse experiences in the home on the health of children and young people, and inequalities in prevalence and effects. Institute of health Equity, UCL.

Ellis, W.R., & Deitz, W.H. (2017). A new framework for Addressing Adverse Childhood and Community Experience: The building Community Resilience Model. Academic Pediatrics, 17(7S), S86-S93.

Ford T et al (2021). Recent studies of health disorders in children and young people during the pandemic. BMJ 372: n614.

Lawrence E et al (2021). The impact of climate change on mental health and emotional well-being, implications for policy and practice. Institute of global health innovation - Grantham Institute.

NHS Digital (2021). Mental health of Children and Young People in England

NSPCC (2020). Protecting children from online abuse (last updated 23 Dec 2020). NSPCC Learning.

Wood S, Ford K, Hardcastle K, Hopkins J, Hughes K and Bellis M (2020) ACEs in child refugee and asylum-seeking populations. Public Health Wales.

Vizard, E., Gray, J., & Bentovim, A. (2021). The impact of child maltreatment on the mental and physical health of child victims: A review of the evidence. BJPsych Advances, 1-11. doi:10.1192/bja.2021.10

von Werthern M, Grigorakis G, Vizard E (2019) The mental health and wellbeing of unaccompanied refugee minors (URMs). Child Abuse and Neglect, 98: 104-46.
Back to Contents
Studying ACEs in Childhood Directly; Increased numbers of Adverse Childhood Experiences, offending behaviour, suicidal ideation and children in foster care

1. Direct research with children and young people
Finkelhoret al. (2012) pointed out that much of the original research focused on retrospective information and was limited to the Classic Ten Adverse Experiences. Predictors missing from the ACE study model were peer rejection, exposure to violence outside the family, low socio- economic status, and poor academic performance. Using an adapted form of their Juvenile Victimisation Questionnaire, Finkelhor et al. added to the original ACEs form.
2. Forty forms of Adverse Experiences
Subsequently Heather Turner working with David Finkelhor ( International Journal of Child Abuse and Neglect, 2020), described 40 forms of Adverse Experiences which better predicted traumatic responses in childhood. These ACEs were derived from their epidemiological research on adversities experienced during childhood. They also developed screening questionnaires for use with parents for younger children, and questionnaires for use directly with young people.

The forty Adverse Childhood Experiences (ACEs), were assessed under 11 different conceptual domains, to predict trauma in childhood:

Family instability - e.g., divorce homelessness

Family disorder - e.g., mental health, drug, alcohol

Interpersonal loss - e.g., death, illness, suicide

Natural disaster - e.g., fire, flood, pandemics

Economic stress - e.g., job loss, welfare

Child-maltreatment - e.g., physical, sexual abuse

Exposure to community violence

Threatened serious assault, racial, homophobia,

Physical assault

Sexual victimisation - e.g., direct or on-line

Peer bullying - e.g., cyber-bullying.

A different set of 15 items was associated with trauma symptoms for younger (2−9 year-old) compared to older (10−17 year-old) youth.

Physical and emotional abuse proved important for both age groups.

However, family-related factors were associated with trauma symptoms in younger children, while community and peer violence exposures were more relevant for older children.
3. A National Traumatic Stress Survey
Dierkhising et al. (2019) carried out an analysis of a longitudinal study of health outcomes associated with multiple adversity. They concluded:

Exposure to multiple adversity from early childhood to middle childhood, and adolescence represents cumulative trauma exposure which is associated with higher scores - Internalizing, Externalizing, and PTSD symptoms

Early childhood adversity is associated with both internalizing and externalizing problems

Recent adversity in adolescence, is associated with internalizing problems -anxiety and depression in adolescence, and is also associated with self- harming behaviour.

This research has added to the findings of the association between adversity and mental health responses, noting the differential associations between early and later adversities.
4. The harmful effects of ACEs associated with children and young people in conflict with the law
The studies reviewed above have indicated that Externalising Disruptive behaviours are a characteristic response associated with cumulative adversities, and large-scale studies of young people who have been referred for offending behaviour has confirmed the association with ACEs.

There is a higher prevalence rate of adversity and trauma compared to population studies (Baglivio and Epps et al., 2014; Dierkhising et al., 2013). The figure shows that juvenile offenders are more likely to have associations with four or more ACEs than the study population. These responses may be associated with intellectual disabilities, emotion dysregulation and out-of- control behaviours, antisocial behaviour which is associated with involvement in the criminal justice system (Vizard, 2013; Walsh 2018, p. 18). Vizard also draws attention to the cycle of traumatic effects of a young person's own sexual or violent behaviour on themselves, on their child victims and on assessing and treating professionals.

Other findings include.

Multiple forms of trauma are more likely

Higher ACEs also associated with higher likely of re-offending.

There are also protective factors operating which mitigate against the association.

The Cambridge longitudinal study (Craiga et al., 2017) noted young people who had been subject to multiple ACEs were less likely to offend if they also had high school attainment, low daring, low hyperactivity, low impulsivity low neuroticism, low dishonesty, and low troublesomeness

Those individuals who have a Life-course-persistent antisocial trajectory experienced extensive adversity associated with brain cortex differences.

5. Suicidal ideation and adversity
Some of the most concerning situations are young people who self- harm, or display suicidal preoccupations, and suicide attempts. Longitudinal research with young people has explored the association between adversities and subsequent self-harming behaviour.

The Longscan study (Thompson et al., 2012) notes that cumulative lifetime adversities are associated with teen suicidal ideation. Life-time adversities include maltreatment, emotional and sexual abuse, witnessing violence, parental mental health, and residential instability, separations.

Aged 16 each additional ACE led to 11% was associated with likelihood to report self-harm.

Recent high adolescent adversity -maltreatment and high peer stress, face to face and cyber-bullying, was also associated with suicidal ideation, poor health, somatic complaints, and any health problem (Carbone et al., 2021).

High ACEs - generally were associated with lower educational attainments, depression, smoking drug use and obesity.

Girls were significantly more likely to report suicidal ideation than were

The Avon Longitudinal Study of Parents and Children has been studied to establish predictors of future suicidal and self-harm (Mars et al., 2019) Among participants with suicidal thoughts, they found that the

' strongest predictors of transition to attempts, - non-suicidal self-harm, cannabis use, other illicit drug use, exposure to self-harm, and higher levels of the personality type intellect/openness. Among participants with non-suicidal self-harm at baseline, the strongest predictors were cannabis use, other illicit drug use, sleep problems, and lower levels of the personality type extraversion'.

These findings indicate the importance of using longitudinal, prospective studies to establish further understanding between adversity and specific outcomes.
6. Traumatic experiences of foster care and children and young people
Research by Lehman et al., (2020) focused on significant adversities reported by children and young people in foster care in Norway. This is an example of research on a specific population of children and young people in alternative care and examines the association between the complex trauma. Many of these young people were exposed to Post- Traumatic Stress Disorders and Attachment Disorders.

Traumatic experiences

Traumatic events

Involved in a serious accident - 13%

Experienced terror or war 1%

Injury, sickness, sudden death of loved ones 54%

Experienced bullying or threats 24%

Abduction, kidnapping 6%

Hit, kicked, pulled, injured, threatened outside family 25%

Witnessed others outside family being kicked, pulled, injured, ridiculing, attacking each other 36%

Confusion or helplessness 27%

Any Abuse 36%

Witnessing parents or other grown-ups being injured or threatened 16%

Kicked, injured, threatened by a parent 18%

Being sworn at, offended, and ridiculed 24%

Any Neglect 36%

Cared for a parent 15%

Felt unloved, not taken care of, not enough to eat, wearing dirty clothes, caring for siblings 23%

Any Sexual Abuse 24%

Sexual abuse pictures taken 6%

Touching, force to touch 13%

Attempted intercourse 6%

Half of the 302 Norwegian children and young people showed symptoms of PTSD, and a significant proportion demonstrated

reactive attachment disorders B Type - Low social responsiveness/ emotional dysregulation - significant association

DSED - Disinhibited social engagement disorder - significant association

It was noted there was a similarity in these response to Complex PTSD which is characterised by 'Disturbances in Self-Organization' (DSO), dysregulated affects, a negative self-concept, and disturbed relationships. This research extends the growing number of direct research studies exploring potential pathways from adversity to significant psychopathology.
7. The impact of neglect
A core dimension of ACEs is neglectful care associated with many forms of adversity. When combined with there is a significant cumulative impact. The impact of neglect and emotional maltreatment on the developing child is less recognised than the impact of other types of abuse (Brassard, 2020), despite neglect being the most 'challenging and prevalent' form of abuse (Hibbard, 2020).

A recent review of systems to protect children from severe disadvantage (Walsh, 2018, p. 20) found childhood abuse, neglect and other ACEs to have been associated with subsequent psychosocial disorders. These include behavioural problems, attention-deficit hyperactivity disorder diagnosis in middle childhood, bipolar disorder, childhood autobiographical memory disturbance, chronic mental health problems, eating disorders, personality disorders, post-traumatic stress disorder, psychosis, self-harm, suicide attempts and uncontrollable anger.

Associated with neglect is the impact of institutionalisation, and the risk of extreme neglectful care. Although Rutter's longitudinal review of the 'spectacular progress' demonstrated by Romanian orphans adopted in the UK, van IJzendoorn et al. (2020) in their review of the findings associated with institutionalisation associated with severe neglect showed,

Attachment difficulties: in the sample of 471 children in 11 studies, a significantly lower proportion of securely attached children (24%) was found in the institution-based children compared with the normative proportion (62%); in addition, there was a much higher rate (57%) of the two most dysregulated types of attachment (insecure-disorganised and unclassifiable) compared with the normative proportion (15%);

Delayed physical growth, brain development, cognitive development and attention: within the institutionalised group of children at least 80% were below the mean for the comparisons;

A dose-response association: larger developmental delays and atypical development were predicted by longer stays in the institution.

8. Spanking and adult mental health impairment: The case for the designation of spanking as an Adverse Childhood Experience
Research on the impact of spanking as a form of discipline has included recommendations of classifying spanking as a significant ACE. This is one element in a world-wide movement to get societies and governments to put a stop to corporal violence and chastisement as a form of disciplining children and to encourage 'Positive parenting' techniques.

Afifi et al. (2017) in a review of the literature on the associated harmful impact of spanking concluded

is defined as "the use of physical force with the intention of causing a child to experience pain, but not injury, to correct or control behaviour" but there is no evidence io its effectiveness!!

There are similar responses associated with spanking as those associated with physical and emotional abuse

Longitudinal studies indicate Spanking is associated with increased odds of suicide attempts, heavy drinking use of street drug

Spanking in childhood is associated with authoritarianism in adulthood, support for punitive public policies

The specific focus on one form of ACE, and a movement to prevent it represents an example of primary prevention of ACEs.
Conclusion
This brief review of the association between ACEs and a variety of situations in children and young people's lives demonstrates how extensive is their potential influence. It underlines the importance of developing approaches to assessment which builds on the extended range of ACEs described by Finkelhor and colleagues, and also begins to take account of the range of protective influences which mitigate against their associated impact, and to introduce preventative and targeted approaches to mitigate their impact when identified.
References
Afifi T et al (2017) Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience. Child Abuse & Neglect, 71 (2017)

Baglivio MT, Epps N et al (2014). The Prevalence of Adverse Childhood Experiences (ACE) in the Lives of Juvenile Offenders. Journal of Juvenile Justice, 3(2): 1-23.

Brassard MR, Hart SN, Glaser D, et al (2020) Psychological maltreatment: an international challenge to children's safety and well being. Child Abuse & Neglect, 110(Pt 1): 104611.

Carbone IT et al (2021). Childhood adversity, Suicidality and Non-Suicidal Self-Injury among children and adolescents admitted to emergency departments. Ann Epidemiol: 33932570

Craiga J.M., Piquerob A.R, Farrington, D.P. Ttofic M.M., (20170 Adverse childhood experiences and life-course offending in the Cambridge study. Journal of Criminal Justice 2017 53 34 -45

Dierkhising CB et al (2013). Trauma histories among justice involved youth. European Journal of Psychotraumatology, 4: 20274

Dierkhising CB et al (2019). Developmental timing of polyvictimisation. Continuity, change and association with adverse outcomes in adolescence. Child Abuse and Neglect, 87: 40 -50

Finkelhor D, Shattuck A (2012). Improving the adverse childhood experiences study scale. American Journal of Preventative Medicine, 167, 70-75.

Flaherty, E.G., Thompson, R., Dubowitz, H., Harvey, E.M., English, D.J., Everson, M., Proctor, L.J., & Runyan, D.K. (2013) Adverse childhood experiences and child health in early adolescence. JAMA Pediatrics, 167(7), 622-629

Ford T et al (2021). Recent studies of health disorders in children and young people during the pandemic. BMJ, 372: n614.

Hibbard R, Barlow J, McMillan H, et al (2020) Clinical report: psycho- logical maltreatment. Pediatrics, 130: 372-8.

Lehman S, Breivik K et al (2020). Potentially traumatic events in foster youth, and association with DSM-5 trauma and stressor related symptoms. Child Abuse and Neglect 101: 104374.

Mars B et al (2019) Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: a population-based birth cohort study Lancet Psychiatry 6 327 - 339

Thompson, R., Litrownik, A.J., Isbell, P., Everson, M.D., English, D.J., Dubowitz, H., Proctor, L.J., & Flaherty, E.G. (2012). Adverse experiences and suicidal ideation in adolescence: Exploring the link using the LONGSCAN samples. Psychology of Violence, 2(2), 211-225. doi: 10.1037/a0027107.

Turner H, Finkelhor D (2020). Strengthening the predictive power of screening for adverse childhood experiences (ACEs) in younger and older children. Child Abuse and Neglect 107: 104522/

Wood S, Ford K et al (2020). ACEs in child refugee and asylum -seeking populations 2020. Public Health Wales.

van Ijzendoorn MH, Bakermans-Kraneburg MJ, Duschinsky R, et al (2020b) Institutionalisation and deinstitutionalization of children 1: a systematic and integrative review of evidence regarding effects on development. Lancet Psychiatry, 7: 703-20.

Vizard E (2013) Practitioner Review: the victims and juvenile perpetrators of child sexual abuse - assessment and intervention. Journal of Child Psychology and Psychiatry, 54: 503-15.
Back to Contents
Twenty years of ACEs research - what have we learned?
1. Lifespan outcomes of Adverse Childhood Experiences and costs to the community
Recent papers in the January 2021 edition of the International Journal of Child Abuse and Neglect (CAN) underline the exponential growth in research in the field of ACEs in the last 20 years.

What is unique about the last 20 years research on ACEs, and how does it differentiate from the general field of child maltreatment and child protection, and what is its relevance to child and adolescent mental health?
2. Outcomes associated with ACEs
ACEs are associated with a range of poor health outcomes. For example, a meta-analysis of studies by Karen Hughes and colleagues in the Lancet Public Health (2017) of 253,719 individuals found that those individuals who had experienced at least 4 recorded ACEs reported an increased risk of poor health outcomes:

modest - physical inactivity, overweight, obese, diabetes

moderate - smoking, heavy alcohol use, cancer, heart disease, and respiratory disease

strong for sexual risk taking, mental ill health, and problematic alcohol use

strongest for problematic drug use and interpersonal and self-directed violence

strong for sexual risk-taking, problematic alcohol use, strongest for problematic drug use, interpersonal and self -directed violence.

The associations between ACEs and mental health outcomes have been observed for ACEs examined both prospectively and retrospectively in a study at University College (Gondek, Patalay and Lacey, 2021), This was based on the Longitudinal 1958 National Child Development Study (NCDS).

Mental health-related outcomes were assessed spanning age 16-55 years. Utilisation of mental health services, taking psychotropic medications, psychological distress, life satisfaction, quality of life, and self-reported general health were measured.

There was a robust dose-response association prospectively and retrospectively between reported ACEs and all mental health-related outcomes, regardless of whether ACEs were reported prospectively or retrospectively.
3. Costs associated with ACEs
A preliminary study of the economic costs of child maltreatment in the UK estimated that the discounted lifetime costs of non-fatal maltreatment were £89,390 per victim. Lifetime costs per death from child maltreatment were over 10 times higher, at £940,758. Bellis and colleagues (Lancet Public Health, 2019) estimated that the annual health costs associated with ACEs were US$581 billion in Europe (equivalent to 2·67% of gross domestic product) and $748 billion in north America (equivalent to 3·55% of gross domestic product).

A later study published in Lancet Public Health (Hughes et al., 2021) estimated the annual health costs linked to ACEs in 28 European countries, and found that the total ACE-attributable costs exceeded 1% of national gross domestic product (GDP) in all countries, ranging from 1·1% (Sweden and Turkey) to 6·0% (Ukraine).

These estimates were based on the associations between ACEs and health outcomes and therefore may not reflect direct costs caused by ACEs, which are nonetheless likely to be high. This research is allied to the direct costs associated with child maltreatment in the US, e.g. Fang (2012). The costs were attributed to the failures of education, mental and physical health, aggression, crime and violence associated with being subject to abuse and neglect - core adversities of childhood. The estimate was $200,000 for each maltreated individual.
4. Factors which protect against the impact of ACEs
Researchers have identified protective factors which could mitigate against poor health outcomes associated with high levels of ACEs. The Bellis Team (Bellis, 2018) described the protective value of community assets included - networking opportunities and settings to build friendships; being treated fairly; having supportive childhood friends, being given opportunities to use abilities; having a trusted adult, having someone to look up to.

Fritz and colleagues (2018) conducted a systematic review of resilience factors which moderated or mediated the relationship between childhood adversity and mental health in young people. They identified studies on individuals, the family context, and the community. Individual level protective factors which fostered resilience included mental flexibility as opposed to rigidity, a capacity to tolerate stress, high self-esteem, a secure attachment, and not ruminating on stressful events. Family factors included living in a family with a high level of togetherness, and parents who were involved with their children, and living in communities where a high level of social support was available.

Multiple resilience factors supported the development of resilience more effectively than single factors. It was concluded that resilience factors should not be studied in isolation. Interrelations between resilience factors needed to be taken into account when predicting psychopathology after childhood adversity. Resilience factors function as a 'complex interrelated system'.

Some individuals may be genetically more or less vulnerable to stressful environmental influence and show resilience in the face of highly stressful events. This research has prompted considerable interest in 'Protective Experiences' (PACES) as a parallel to Adverse Experiences.
5. Strengths and limitations of the ACEs score
An ACEs profile is a cumulative risk score - reflecting challenges across multiple domains (Dube, 2021), for example, in the cycle of ACEs influencing adult mental health and functioning, influencing parenting capacities, and on the development of children and young people.

The ACEs score as a cumulative risk index has been used extensively in research studies. Lacey and Minnis (2019) in their review of 20 years research pointed out the strengths of ACEs score. It was simple to understand and carry out, and more likely to find strong, statistically significant associations with outcome, and acknowledges that adversities tend to co-occur. This observation also applies to child maltreatment research, where it has been established that forms of maltreatment co-occur, and are cumulatively associated with mental health problems (Cecil et al., 2017).

However, a limitation of the ACE score is that it assumes that each adversity has the same association with outcomes of interest - which may not be the case (e.g., sexual abuse may affect children differently to parental separation). The score in the original research was reliant on retrospective reports likely to be biased or unreliable, and many studies focus on adult outcomes rather than child outcomes. The associations between ACEs and subsequent health were correlational. Direct research is now being carried out on the adversity children experience and has begun to explore whether these associations were causal, and the pathways to poor health outcomes through prospective, longitudinal research.

Lacey and Minnis (2019) stated:

" The challenge now is to find more nuanced ways of measuring and conceptualising ACEs that are still easily usable so that detailed models of development can better inform practice and policy."
"There is a need to carry out methodologically rigorous studies to build the evidence base of trauma-informed care as a framework and complement to trauma-specific services (p. 28)."

They advocated a variety of different approaches, e.g. studies of specific adversities - physical abuse, neglect, or sexual abuse to elucidate the mechanisms, and compare different adversities. Other approaches e.g. research on theoretically driven themes, threat, or deprivation, or person centred, latent class analysis.

A longitudinal study from University College (Bevilacqua et al., 2021) 'explored the association between different ways of operationalising ACEs and later trajectories of internalizing, externalizing, and prosocial behavior from age 3-14'.

Three approaches to operationalising ACEs were used - ACE scores, individual ACEs, and ACEs clustering using latent class analysis. It was established in line with the general finding that a higher number of ACEs predicted worse mental health and prosocial outcomes in childhood and adolescence. In most cases these differences were evident by age 3 and persisted through to adolescence.

Exploring the impact of individual ACEs physical punishment and harsh parenting was more strongly related to externalizing behaviours, as noted in other research; parental discord and parental depression was more related to internalizing problems. In this study clustering of ACEs did not predict outcomes.

Henry et al., (2021) compared different approaches to understanding the way ACEs influence development. This included a study of Independent Risks, e.g. particular forms of adversity, the Dimensional Model of Adversity and Psychopathology (DMAP) which gathers adversities as forms of Threat and Deprivation, and the Cumulative Risk Approach.

The study demonstrated the way different models helped to understand the association of ACEs with internalising and externalising symptoms in children and young people - an important finding for the Child Mental Health field.
6. The ACEs score does not predict poor health outcomes at the individual level
An important issue is to determine whether the ACEs score being utilised in some services, and as a screening tool, can predict poor health outcomes at the individual level.

Baldwin and colleagues (2021) studied 2 birth cohorts: the Environmental Risk (E-Risk) Longitudinal Twin Study, including 2232 participants studied to aged 18 years, and the Dunedin Multidisciplinary Health and Development Study, including 1037 participants studied to age 45 years. ACEs were measured through repeated interviews and observations. ACEs were also measured retrospectively in the Dunedin study at 38 years. They reported that in line with other studies, ACE scores forecast mean group differences in health but showed poor accuracy in predicting an individual's risk of later health problems.

They concluded:

"Targeting interventions based on ACE screening is likely to be ineffective in preventing poor health outcomes". (E6)

Another study led by Meehan (2021) used data from the seminal ACE study (first used by Felitti et al., 1998) and found that in this ACE scores did not accurately identify individuals at high risk of health problems.

This research confirms the harmful association of ACEs with health outcomes, but demonstrates that the ACEs score does not accurately predict such outcomes at the individual level.

There is a tension between the recommendation to ascertain an ACEs score as part of an assessment of a child or young person referred to a service as a result of concerns - e.g. mental health, safeguarding, or offending services, and as a routine procedure in community services.

Gentry and Paterson (2021) carried out a rapid evidence summary of whether screening or routine enquiry for adverse childhood experiences (ACEs) meet the criteria for a screening programme.

' Routine enquiry': is defined where professionals 'proactively and sensitively enquire about past childhood experiences with all service users and tailor support accordingly'

'Screening: 'the process of identifying healthy people who may have an increased chance of a disease or condition. The screening provider then offers information, further tests and treatment. This is to reduce associated problems or complications.'

They matched the value of ACEs screening against established criteria for screening approaches:

The importance of the health problem being screened for - good evidence ACEs and health outcomes

Whether cost effective primary prevention had been implemented - available but not implemented

Whether there is a safe, precise, validated, acceptable screening test available - no consensus, suitable tool, setting, timing or frequency

Whether there is an agreed pathway for further investigation - safeguarding for children, limited evidence for adults

An effective intervention if given early - some evidence e.g. safeguarding, trauma-informed care

RCT evidence for the screening programme reducing morbidity and mortality - none identified

Whether the programme is acceptable - generally acceptable.

They concluded.

' Routine enquiry among adults (REACH) was assessed as feasible and acceptable to service users and professionals and resulted in the delivery of potentially effective interventions...... but there was doubt whether screening or routine enquiry could improve morbidity, mortality, health and well-being (p. 7).'

7. Research on risk calculators to identify which children exposed to ACEs will develop poor health outcomes
Research which has been conducted balancing risk and protective factors to develop a risk calculator which identify which children exposed to ACEs will develop poor health outcomes. This was studied in a series of papers based on the longitudinal study of Twins in the Environmental Risk (E) study. Participants were 2232 twin children born in England and Wales in 1994-1995. Lewis et al. (2019) explored the epidemiology of trauma and post-traumatic stress. Meehan et al. (2020) studied a sub-set exposed to any type of victimisation, and Lewis et al. (2021) the impact of complex trauma.

In the subset of the E-Risk Study sample exposed to any type of victimization during childhood was studied. Victimisation included the following:

Exposure to victimization was assessed at 5, 7, 10, and 12 years of age

Cumulative information was gathered about exposure to domestic violence; frequent bullying by peers; physical abuse sexual abuse; emotional abuse and neglect; and physical neglect - all significant forms of adversity

Non-complex traumas were defined as a one-off assault, an accident and learning about the sudden death of a parent.

Multivariate Risk/Resilience Predictors were established gathered from recorded experiences during the child or young person's regular reviews:

Individual characteristics: Sex, intelligence, personality factors, openness, conscientiousness, extraversion, agreeableness neuroticism

Mental health was recorded during development: ADHD symptoms, conduct disorder, anxiety, depression, self-harm, psychotic symptoms

Family and Community Factors - maternal warmth, sibling warmth, family psychopathology, socio-economic circumstances, community crime, victimisation, social cohesion, status among peers.

A psychiatric assessment was conducted when the young people were aged 18, providing detailed understanding about the associations of the associations of risk and resilience factors and mental health in early adult life, with implications for the longer term.

Psychiatric Assessment aged 18

The figure demonstrates that exposure to any trauma during childhood results in a spectrum of mental health responses measured at aged 18: Post-traumatic responses, through Depression, Anxiety, Conduct disorder, Alcohol and Cannabis dependence, Psychotic symptoms, Self-harm and Suicide attempts.

Complex trauma exposure included multiple events, interpersonal assaults or threats in childhood or adolescence, repeated child abuse, severe bullying, witnessing neighbourhood violence resulted in more extensive mental health responses.

The studies demonstrated that when the risk and resilience factors are taken into account the more risk factors and the less resilience factors the more likely the association with any Psychiatric Disorder, Internalising or Externalising disorders.

There was a risk of later complex trauma and more severe psychopathology, and cognitive deficits, when there was evidence of significant early vulnerabilities internalising and externalising symptoms at age 5 years, and family members with a history of mental illness.

A further analysis of the study (Lathem et al., 2019) demonstrated that a different set of factors were associated with risk for psychosocial disadvantage or economic disadvantage. Psychosocial disadvantage was associated with individual, family and community factors, economic disadvantage with individual and family factors. The value of being able to predict which child or young person is at risk of disadvantage is an important step to prevention. The risk calculator that was developed could be used as a reliable screening tool, with an individualised score which guides intervention.

Conclusions

This work represents an important development in the field because it demonstrates and confirms the complexity of mental health responses to exposure to trauma associated with multiple adversities. The research also established how few of the young people in the study had received treatment for traumatic responses. Considering a range of individual, family and community risk, vulnerability and resilience predictive analytic factors could better predict mental health outcomes for the individual, and guide intervention. Balancing risk factors represented in the ACEs score with resilience factors could guide the practitioner's assessment and intervention.
8. Adverse Childhood Experiences are associated with neurobiological and inflammatory responses
The traumatic impact of various forms of maltreatment and neurobiological functioning - particularly those involving threat - physical abuse, emotional abuse and sexual abuse has been well established (Teicher et al., 2016). The association between Childhood Adversity and Abuse on later health has evoked considerable research.

A review summarising the impact of early adversity on children's development noted that chronic stress can be toxic to the child's development and significant early adversity can lead to lifelong problems (National Scientific Council on the Developing Child, 2008/2012). For example, when maltreatment-induced chronic elevation of cortisol occurs in the context of 'toxic stress', damaging effects in the brain can include deficits in memory formation and recall and impaired cognitive control over thought, emotion and behaviours, resulting in poorer later performance in school, the workplace and relationships (Vizard et al.. 2021, p. 5).

McCrory and Viding (2017) observe that neuro-biological and neuro-cognitive systems adapt to early abusive and neglectful experiences. The classical post-traumatic responses of heightened response to threat, avoidance and turning away from relationships, restricted memories provide short-term functional advantages to atypical environments, but compromise the capacity of the individual to negotiate more normative contexts or adapt to future stressor events. Latent vulnerabilities predict future psychiatric risk, before disorders emerge. Brain differences are markers of latent vulnerability at the neural level and impacts on establishing relationships in the family, school and community.

The Dunedin Multi-Disciplinary Health and Development study (Danese, 2007) investigated significant biomarkers of inflammation in adulthood, investigating links with later Inflammatory Disease. They found a significant association between childhood maltreatment in the first decade of life and elevated adult inflammatory markers such as C-Reactive Protein (CRP). It was already known that adult health outcomes linked to these inflammatory biomarkers included cardiovascular disease, diabetes and chronic lung disease. The association between childhood adversity and inflammation has since been reported in meta-analytic research (Baumeister et al., 2015) although stronger associations are found for inflammation in adulthood relative to childhood (Kuhlman et al., 2020).

Cumulative exposure to adversity may be associated with ' allostatic overload', beyond the usual bodily 'wear and tear', and may cause the normal neurobiological responses to become pathological rather than protective, and to attack the child's body with raised inflammatory markers. (Danese and McEwan, 2012). A link is examined between stress, cardiac responses, inflammatory responses, accelerated aging of chromosomes - telomere length and psychopathology. A variety of early adverse events - divorce, separation, physical abuse, and multiple adversity - were associated with later inflammatory responses (Nelson et al., 2021).

Lacey and colleagues (2020) based on the Longitudinal 1958 British birth cohort were able to use a variety of different models to explore the association of Adverse Childhood Experiences reported prospectively and retrospectively with inflammatory processes. Single adversities, cumulative risk and Latent Class Approaches were studied for possible associations with chronic inflammatory processes. The authors concluded that looking at combinations of ACEs could be a helpful alternative way of operationalizing ACEs.

Current research on ACEs is beginning to move from the original focus on the association with harmful outcomes with a cumulative impact of ACEs to a more nuanced understanding of the processes which underpin the longer-term impact of adversity in childhood.

Longitudinal studies looking at the later adverse impact of ACEs on children's mental health and brain functioning suggest that early damage to a child's developing brain is not necessarily irreversible. The brain retains plasticity throughout the lifetime and if the child has acquired sufficient life-course resilience from a relationship with an 'always available adult', recovery from early ACEs may be possible, at least in part (Bellis, 2017).
References
Baldwin J et al (2020). Population vs Individual prediction of poor health from results of Adverse Childhood Screening. JAMA Paediatrics, 10.1001/5602.

Baumeister, D., Akhtar, R., Pariante C.M., Mondelli, V. (2016) Childhood trauma and adulthood inflammation: a meta-analysis of peripheral C-reactive protein, interleukin-6 and tumour necrosis factor-α. Mol Psychiatry, 21, 642 - 649

Bellis MA, Hardcastle K, Ford K, et al (2017) Does continuous trusted adult support in childhood impart life-course resilience against adverse child- hood experiences - a retrospective study on adult health-harming behaviours and mental well-being. BMC Psychiatry, 17, 1, 110.

Bellis, M. A., Hughes, K., Ford, K., Rodriguez, G. M., Sethi, D., & Passmore, J. (2019). Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America; a systematic review and meta-analysis. The Lancet Public Health, 4(10), e517-528. https://doi.org/ 10.1016/S2468-2667(19)30145-8.

Bellis, M. A., Hughes, K., Ford, K., Hardcastle, K. A., Sharp, C. A., Wood, S., ... Davies, A. (2018). Adverse childhood experiences and sources of childhood resilience: A retrospective study of their combined relationships with child health and educational attendance. BMC Public Health, 18, 792

Bevilaqua, L., Kelly ,Y. Heilman, A., Priest, N. Lacey, R. (2021) Adverse childhood experiences and trajectories of internalising and externalising, and prosocial behaviours from childhood to adolescence Child Abuse and Neglect 112. 104890

Cecil, C.A.M., Viding, E., Fearon, P., Glaser, D., & McCrory, E.J. (2017). Disentangling the mental health of childhood abuse and neglect. Child Abuse and Neglect, 63, 106-119.

Conti G, Morris S, Melnychuk M, et al (2017) The Economic Costs of Child Maltreatment in the UK: A Preliminary Study. NSPCC.

Danese A, Pariante CM, Caspi A, et al (2007) Childhood maltreatment predicts adult inflammation in a life-course study. Proceedings of the National Academy of Sciences of the United States of America, 104 (4): 1319-24.

Danese A, McEwan BS (2012) Adverse Childhood Experiences, allostasis, allostatic load, and age-related disease. Physiology and Behavior, 106 (1): 29-39.

Fang X, Brown D.S., Florence C.S. and Mercy ,J.A. (2012) The economic burden of child-maltreatment in the United States and implications for prevention Child Abuse and Neglect 36, 156 - 165

Fritz J., de Graaff A.M. Caisley ,H. van Harmelen, A .Wilkinson P.Q. (2018) A Systematic Review of Amenable Resilience Factors That Moderate and/or Mediate the Relationship Between Childhood Adversity and Mental Health in Young People ³.frontiersin.org/articles/10.3389/fpsyt.2018.00230/full?report=reader

Gondek, D., Patalay P, Lacey R.E (2021) Adverse childhood experiences and multiple mental health outcomes through adult a prospective birth cohort study J. Public Health , https://doi.org/10.1093/pubmed/fdy0992018

Gentry, S.V. Paterson, B.A., (202), Does screening or routine enquiry for adverse childhood experiences (ACEs) meet criteria for a screening programme? A rapid evidence summary, Journal of Public Health, fdab238, https://doi.org/10.1093/pubmed/fdab238

Henry L.M., Gracey K., Shaffer A. et al (2021) Comparison of Three Models of Adverse Childhood Experiences: Associations With Child and Adolescent Internalizing and Externalizing Symptoms Journal of Abnormal Psychology 130 , 9 -2

Hughes K, Bellis MA et al (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. The Lancet Public Health 2: 356-366.

Hughes, K., Ford, K., Bellis, M.A., Glendinning, F., Harrison, E., Passmore, J. (2021) Health and financial costs of adverse childhood experiences in 28 European countries: a systematic review and meta-analysis The Lancet - Public health, 6 e848- e857

Kuhlman, K. R., Horn, S. R., Chiang, J. J., & Bower, J. E. (2020). Early life adversity exposure and circulating markers of inflammation in children and adolescents: A systematic review and meta-analysis. Brain, Behavior, and Immunity, 86, 30-42

Lacey R & Minnis H (2019). Practitioner Review: Twenty years of research with adverse childhood experience scores - Advantages, disadvantages and applications to practice. Journal of Child Psychology and Psychiatry, 61(2), 116-130.

Lacey R. Pinto Pereira S.M, Danese A., (2020) Adverse childhood experiences and adult inflammation: -Single adversity, cumulative risk and latent class approaches. Brain, Behavior, and Immunity 87 820-830

Latham R.M., Meehan A.J., 2019 Arseneault, L, Danese A., Fisher, H.L (2019 ) Development of an individualised risk calculator for poor functioning in young people victimised in childhood: a longitudinal cohort study Child Abuse and Neglect 98 104188

Lewis, S.J., Arseneault, L, Caspi, A., Fisher, H.L., Mathews, T., Moffitt, T., & Danese, A. (2019). The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. Lancet Psychiatry, 6, 247 - 256.

Lewis S. et al (2021) Unravelling the contribution of complex trauma to psychopathology and cognitive deficits: a cohort study. BJPsych 2021 419-455

McCrory, E., Gerin, M. I., & Viding, E. (2017). Child maltreatment. Latent vulnerability, and the shift to preventative psychiatry - The contribution of functional brain imaging. Journal of Child Psychology and Psychiatry, 58, 338-357.

Meehan AJ et al (2020). Developing an individualised risk calculator for psychopathology among young people victimised during childhood: a population- representative cohort study, J Affective Disorders 262 90 -98.

Meehan A.J. , Baldwin ,J. Lewis, S.L. Macleod J.G., Danese A. (2021) Poor Individual Risk Classification from Adverse Childhood Experiences Screening Am J. Prev. Med. Doi:10.1016?jamepre.2021.08.008

National Scientific Council on the Developing Child (2008/2012) Establishing a Level Foundation for Life: Mental Health Begins in Early Childhood (Working Paper No. 6) (Updated Edition). Center on the Developing Child, Harvard University.

Nelson B.W, Sheeber L., Pfeifer J. Allen N.B 2021 psychobiological markers of allostatic load in depressed and non-depressed mothers and their adolescent offspring Journal Child Psychology & Psychiatry 62, 199 -211

Struck S, Syewart-Tufesco A et al (2021). Adverse childhood experiences (ACEs) research: A bibliometric analysis of publication trends over the first 20 years. CAN 112: 104895

Teicher, M. H., Samson, J. A., Anderson, C. M., & Ohashi, K. (2016). The effects of childhood maltreatment on brain structure, function and connectivity. Nature Reviews Neuroscience, 17, 652-666. https://doi.org/10.1038/nrn.2016.111.

Thompson, R., Litrownik, A.J., Isbell, P., Everson, M.D., English, D.J., Dubowitz, H., Proctor, L.J., & Flaherty, E.G. (2012). Adverse experiences and suicidal ideation in adolescence: Exploring the link using the LONGSCAN samples Psychology of Violence, 2(2), 211-225. doi: 10.1037/a0027107.

Vizard, E., Gray, J., & Bentovim, A. (2021). The impact of child maltreatment on the mental and physical health of child victims: A review of the evidence. BJPsych Advances, 1-11. doi:10.1192/bja.2021.10

Available from: https://www.cambridge.org/core/journals/bjpsych-advances/article/impact-of-child-maltreatment-on-the-mental-and-physical-health-of-child-victims-a-review-of-the-evidence/D5A662192092FADD5E9F594B65C083FA/share/bf4f35a8cd7c6f7fbd92ed4bf8c44e8c13b88247
Back to Contents

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Adverse Childhood Experiences (ACEs) Special Interest Group - ACAMH

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1. The wider maltreatment context around ACEs 'Ten Adverse Childhood Experiences - 'The 'Classic ACEs Profile' 3. Current definition of ACEs 4. The cycle of ACEs 1. Measuring ACEs 2. The pathways to adult mental and physical ill-health 3. The prevalence of ACEs 4. Intervention to modify and prevent the impact of ACEs 1.

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Webinar from Violence and Mental Health Network

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Webinar from Violence and Mental Health Network

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Exploring Trauma and Mental Health - VAMHN

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On 22nd July 2020 we hosted a webinar in collaboration with the Trauma Informed Community of Action (TICA) on Exploring Trauma and Mental Health hosted by VAMHN member Dr Jill Domoney (King's College London). We were delighted to welcome our incredible speakers; Sally Amor (NHS Highland), Andrea Danese (King's College London), Dr John Read (University of East London), Dr Vishal Bhavsar (King's College London) and Dr Khadj Rouf (Northamptonshire Healthcare Trust). You can watch the recording of the full webinar below.

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On 22nd July 2020 we hosted a webinar in collaboration with the Trauma Informed Community of Action (TICA) on Exploring Trauma and Mental Health hosted by VAMHN member Dr Jill Domoney (King's College London).

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DHSC Office of Health Improvement and Disparities: Working definition of trauma-informed practice - GOV.UK (www.gov.uk)

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This folder includes resources from the training about how to be a Trauma-Informed Champion delivered by WAVE Trust in Tower Hamlets

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WAVE Trust Trauma Champions resource pack

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Practical guide for implementing a trauma-informed approach (2023)

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Practical guide for implementing a trauma-informed approach (2023)

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https://store.samhsa.gov/sites/default/files/pep23-06-05-005.pdf

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Trauma-Informed Care: Revolution or Rhetoric? 19 April 2022 on Vimeo

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Trauma-Informed Care: Revolution or Rhetoric? 19 April 2022

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This webinar, presented by the Digital Academy, originally took place live on 19 April 2022. 

The term ‘trauma-informed care‘ has recently become a buzzword and is now finding its way into the mainstream menu of must-have training across the public sector. But ‘trauma’, in itself, is nothing new. This begs the question – aren’t we already informed enough about trauma?

This free webinar, presented by Dr Sheena Webb, explored some of the meaning and myths around what it means to be trauma-informed and considered the value, challenges and potential pitfalls of trying to adopt a trauma-informed approach within the public sector.

After watching this webinar, you will have gained:
- A deeper knowledge of what trauma-informed care is and the range of ways it may be applied
- A critical understanding of some of the myths and misconceptions surrounding trauma-informed approaches
- An appreciation of the potential benefits of trauma-awareness across a range of settings as well as the consequences of not being trauma-informed.

This is a free webinar for frontline practitioners working with vulnerable adults, including those involved in clinical work, support work or key-working within settings such as health, social care, housing, forensic, domestic abuse services or other public, or voluntary support services. However, anyone with an interest in the subject is welcome to watch the recording.

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This folder includes resources from the training about trauma and trauma-informed approaches delivered by WAVE Trust in Tower Hamlets

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Concept of Trauma and Guidance for Trauma-Informed Approaches

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Concept of Trauma and Guidance for Trauma-Informed Approaches

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https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf

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Mindful Emotion Coaching (recording) - ACAMH

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Support for mental health at work | Able Futures Mental Health Support Service (able-futures.co.uk)

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Support for mental health at work | Able Futures Mental Health Support Service

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https://www.researchgate.net/publication/326996820_A_paradigm_shift_Relationships_in_trauma-informed_mental_health_services

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Culturally appropriate communication toolkit (Tower Hamlets)

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Culturally appropriate communication toolkit (Tower Hamlets)

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Culturally Appropriate Health Communication and Engagement Toolkit

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https://www.adph.org.uk/wp-content/uploads/2021/12/ACES-Guidance-for-the-health-Sector.pdf

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Learn how to give practical and emotional support to individuals using PFA

Psychological First Aid (PFA) is the globally recommended training for supporting people during emergencies and offers guidance on delivering psychosocial care in the immediate aftermath of the emergency event.

On this 3-week course, you'll explore the psychological impact of the COVID-19 pandemic and what you can do to help people cope.

This course has been produced by Public Health England and is based on international guidance from the World Health Organisation, United Nations and partners.

Learn everything about Psychological First Aid

We'll start off by discussing how emergencies impact mental health, and other ways people respond to emergencies like the COVID-19 pandemic.

There are many common responses to the pandemic, and you'll be taught how to distinguish between signs of distress and signs of mental health conditions.

Preparing for mental health training

Preparation is key, and this will be your focus in week 2. You'll learn about the role, discover the services and support you can offer, and gain an understanding about how to respect a patient's dignity and rights alongside their culture and religion.

In the next stage, you'll learn how to identify those most in need of PFA, assess support needs and look out for high-risk groups.

Offering emotional support and coping strategies

In the final week, you'll learn about effective listening practices such as establishing communication and the do's and don't of providing emotional support.

Learn how to promote wellbeing, offer bereavement support, tackle practical problems and decide whether someone needs mental or physical support.

Finally, you'll discover the best ways to support yourself and your colleagues while delivering PFA to others. We'll teach you how to manage stress and explain the best places to get help.

What topics will you cover?

What is psychological first aid?

How do emergencies impact mental health?

The psychological first aid stages: Prepare, Look, Listen, Link

Supporting yourself and your colleagues

Example scenarios

Anyone can use this approach. The following is what you will need to use PFA:

Be a good listener. An important part of PFA is identifying what help and support each person requires.

Be well informed about the COVID-19 pandemic, so you can give people accurate information. It is important that people can trust you.

Have the ability to encourage active coping by, for instance, helping people make decisions about the next steps they will take.

Encourage and help people to connect with their loved ones, or community and spiritual supports. Be aware of people's cultural preferences and needs, and adopt a non-judgemental approach.

Know how to look after their own wellbeing and access support through friends, family, supervision or managers.

Learning on this course

On every step of the course you can meet other learners, share your ideas and join in with active discussions in the comments.

What will you achieve?

Demonstrate an understanding of what Psychological First Aid is

Identify for whom it is suited and how to help them

Identify how to better support yourself and peers in such crises

Engage with further reading into psychosocial support during emergencies.

By the end of the course, you'll be able to...

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COVID-19: Psychological First Aid Training Course - FutureLearn

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Psychological First Aid (PFA) is the globally recommended training for supporting people during emergencies and offers guidance on delivering psychosocial care in the immediate aftermath of the emergency event. On this 3-week course, you'll explore the psychological impact of the COVID-19 pandemic and what you can do to help people cope.

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How mental health problems develop | UK Trauma Council

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https://knowhow.ncvo.org.uk/organisation/collaboration/coproduction-and-service-user-involvement

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https://www.mind.org.uk/information-support/tips-for-everyday-living/racism-and-mental-health/

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https://www.adph.org.uk/wp-content/uploads/2021/12/ACES-Guidance-for-the-education-Sector.pdf

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https://developingchild.harvard.edu/science/key-concepts/

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Psychological First Aid - Children and Young People

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Psychological First Aid - Children and Young People

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https://www.futurelearn.com/courses/psychological-first-aid-for-children-and-young-people

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https://www.adph.org.uk/wp-content/uploads/2021/12/ACES-Guidance-for-the-housing-Sector.pdf

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https://www.adph.org.uk/wp-content/uploads/2021/12/ACES-Guidance-for-the-policing-Sector.pdf

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https://actearly.org.uk/wp-content/uploads/2022/03/Co-production-Strategy-May-2022-V3.pdf

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49d9d6_5cc6585ff27a4753ac527db34fb31182.pdf (traumascapes.org)

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peer-support-toolkit-final.pdf (mind.org.uk)

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NHS England » Supported self-management: peer support guide

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Peer support is a supported self-management intervention. It happens when people with similar long-term conditions, or health experiences, come together to support each other – either on a one-to-one or group basis. It is enabled through relationships that build mutual acceptance and understanding.

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Guidance document from West Yorkshire Health and Care Partnership

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Webinar | Trauma Informed Approaches to working with Children and Young People (2021)

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Webinar | Trauma Informed Approaches to working with Children and Young People (2021)

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https://www.youtube.com/watch?v=9IiCfvE63dw

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Clinical Services Audit.pdf (candi.nhs.uk)

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Challenging behaviour and restrictive interventions in schools

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Challenging behaviour and restrictive interventions in schools

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https://www.centreformentalhealth.org.uk/publications/trauma-challenging-behaviour-and-restrictive-interventions-schools

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Briefing 54

9 January 2020

How do restrictive interventions in schools affect young people's mental health?

Our 54th briefing focuses on restrictive interventions in schools (such as seclusion, restraint and exclusion), highlighting the way they can exacerbate distress and behavioural problems among children who have experienced trauma.

Trauma, challenging behaviour and restrictive interventions in schools is a review of recent literature on the subject, and examines the links between trauma and challenging behaviour. The review highlights the way restrictive interventions can create a vicious circle of trauma, challenging behaviour, restriction and psychological harm.

There are, however, a number of alternative approaches to challenging behaviour in schools, which are less likely to exacerbate trauma. These include positive behavioural support and creating trauma-informed schools. We're calling on the Government to take a trauma-informed approach to schools and managing behaviour, to ensure all children feel valued and understood.

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Trauma, challenging behaviour and restrictive interventions in schools

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Briefing 54 9 January 2020 How do restrictive interventions in schools affect young people's mental health? Our 54th briefing focuses on restrictive interventions in schools (such as seclusion, restraint and exclusion), highlighting the way they can exacerbate distress and behavioural problems among children who have experienced trauma.

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Presentation from Fulfilling Lives in Lambeth Southwark and Lewisham 

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Presentation from Fulfilling Lives in Lambeth Southwark and Lewisham 

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https://www.youtube.com/watch?v=jYJl01Z420k

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0:00 / 17:56•Watch full video

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Fulfilling Lives Lambeth, Southwark and Lewisham

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Co-production: Forget about the word and focus on the principles

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Psychologically-informed environments and working with people who are at risk of homelessness

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Psychologically-informed environments and working with people who are at risk of homelessness

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https://homeless.org.uk/knowledge-hub/trauma-informed-care-and-psychologically-informed-environments/

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Practical information about trauma and psychologically informed approaches.

Trauma Informed Practice and Psychologically Informed Environments (PIE) are related and complementary approaches to service delivery for people with complex needs. Both aim to improve the psychological and emotional well-being of people accessing, or working in, services.

Use these resources as a starting point to understand why, and plan how, to become trauma or psychologically informed.

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Practical information about trauma and psychologically informed approaches. Trauma Informed Practice and Psychologically Informed Environments (PIE) are related and complementary approaches to service delivery for people with complex needs. Both aim to improve the psychological and emotional well-being of people accessing, or working in, services.

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https://www.cqc.org.uk/guidance-providers/adult-social-care/culturally-appropriate-care

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Cultural Competence – elearning for healthcare (e-lfh.org.uk)

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If trauma can be passed down through generations, so can joy

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If trauma can be passed down through generations, so can joy

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https://www.rethink.org/news-and-stories/blogs/2021/10/if-trauma-can-be-passed-down-through-generations-so-can-joy/

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If trauma can be passed down through generations, so can joy

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Psychotherapist and author Lola Jaye explains that although the issue of racism is more embedded in society’s consciousness, the effects of historical and systemic racism are still having far-reaching effects on the mental health of Black people.

My role as a psychotherapist and historical fiction author means I get to write about racism in a historical context, whilst seeing first-hand how it can affect us in the present day.

The last 18 months may have shone a global spotlight on the COVID-19 pandemic, but the ‘topic’ of racism wasn’t far behind. Whether it be the Black Lives Matter protests, tearing down statues of slave traders, or the vicious racial abuse of three footballers who missed penalties during the Euros, the issue of racism has more recently become embedded in the nation’s consciousness.

Yet, before this worldwide acceptance, there’d always been a problem.  Black people were used to enduring a silent pain in order to simply ‘live’ - whether this meant having to endure ‘well meaning’ racist jokes, microaggressions or being denied opportunities based on the colour of their skin.  And now with it suddenly thrust into the public sphere, with hours of debate and online discussions, this public acceptance of their reality, simply allowed feelings to re-surface; such as powerlessness, anxiety, anger and intense bouts of exhaustion. Black people were tired. They’d had to live with racial inequalities and injustices every day of their life, regardless of whether racism had made the news that week or not.

Racism

Internalised racism lies within individuals and private beliefs and biases, including: prejudice towards others of a different race; and internalised privilege - beliefs about superiority or entitlement. Individual racism is insidious, unconsciously shaping belief systems, attitudes and ultimately decisions. For a complete understanding of racism, we also need to look at the term ‘systemic racism’, developed by Joe Feagin. Systemic racism affirms that ‘racism is embedded in all social institutions, structures, and social relations.  It is composed of co-dependent racist institutions, policies, practices, ideas, and behaviours that give an unjust resources, rights, and power to white people’ – at the same time denying them to Black people.

Microaggressions can also be very damaging both in the outside world and inside the therapist’s consulting room.  Described as; ‘A statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalised group such as a racial or ethnic minority.’  For example, to be constantly told ‘you have good English’ when England is your place of birth, to being followed around a shop on the assumption of being a criminal (this has happened to me on numerous occasions).  ‘Microaggressions are a clinically relevant factor in understanding mental health problems.’ It has also been described as ‘the new face of racism’. (Sue, et al, 2007).

With psychotherapeutic interventions, research shows that a Black client’s lived experience regarding racism and the trauma associated with it – racial trauma - can be misinterpreted by a therapist and can lead to dangerous misdiagnoses. If we look at the independent review of the UK’s Mental Health Act in 2018, “profound inequalities” were found to exist. This highlighted that Black British people were four times more likely to be sectioned than white people and just as alarmingly, more likely to be administered a psychoactive medication instead of a talking therapy.

Medication may treat symptoms associated with mental illness but the absence of a talking therapy leaves underlying issues unaddressed.

The Theory of Generational Trauma

Psychotherapists generally acknowledge that a client may have a reaction to recent events which have roots in the past. When it comes to racism, whether it be systemic, individual or internalised, it can influence psychological and social trauma passed down from previous generations. My own parents arrived in the UK during the ‘60s to “No Blacks, No dogs, No Irish” signs, and there are many more stories, members from that generation and before, can recite. But, listening to these traumatic stories of survival can condition a Black person from an early age to believe their own immediate world is a threatening one – something that is then reinforced by their own interactions with society, whether this be linked to racism or microaggressions.

If trauma is described as an experience that happens in a person's life resulting in serious physical, mental, or emotional harm and causing them to feel out of control of the situation, then racial trauma should also be viewed in a similar way.

This means at the very least acknowledging the psychological effects of racial trauma being transferred from one generation to another.  This can be allowed to continue due to unawareness of the impact, but also through the stigma related to accessing help with mental health - something which has also been passed down due to the horrific treatment of Black people by the medical community in the past. Such mistrust may also need to be acknowledged between therapist and client.

PTSS / PTSD

Author and researcher Joy DeGruy used the term Post Traumatic Slave Syndrome (PTSS) to describe the enduring effects Black people are experiencing. While PTSD (Post Traumatic Stress Disorder) results from a single direct or indirect trauma, PTSS asserts that Black people globally have suffered collective grief and trauma over the years and subsequent generations.

This explains “the consequences of multigenerational oppression from centuries of chattel slavery and institutionalised racism, and identifies the resulting adaptive survival behaviours.”

Continual global news coverage in the summer of 2020, constantly showing the murder of a Black person felt brutalising and reinforced embedded belief systems, that Black people are ‘less than.’ It is both distressing and dehumanising, and when the person looks like you, there are added implications for mental health.

This re-experiencing of racial trauma can lead to depression, hyper-vigilance, chronic stress and fatigue, bodily inflammation and symptoms similar to post-traumatic stress disorder. It is unsurprising that during the summer of 2020 some Black therapists saw an increase in enquiries.

So what can Black people do to limit the effects of racial trauma?

Acknowledge it

Being open to the possibility that generational trauma is real and can exist is a good starting point for both therapist and client.

Be open

Whether you are still attempting to uncover more and more about how the past is affecting your future, it’s possible to do the work now, by being mindful of what’s possibly being created and perpetuated. Start with your family members, tribes, circle (whatever that looks like). Then it can become possible to address what’s been handed down, before deciding what’s worth keeping and what to release.

Limit social media

This may seem obvious, but the addictive nature of swiping online may be an avenue to absorb what’s ‘good’ out there, but also what is both negative and toxic. It is important to be mindful of what we allow into our ‘selves’ and space and maintain a healthy balance, especially when there's already a pot of emotions regarding past and current experiences.

Rest

Give yourself permission to do nothing.  For example, as a Black woman, it’s easy to fall into the popular ‘superwoman’ narrative and take on a deluge of anti-racism work, whilst taking care of families, work etc. However, for the sake of managing your mental health, it’s important to do so in a way that doesn’t seek to constantly re-traumatise and subsequently cause that exhaustion related to racial trauma. Whatever is decided as a means of action or protest - whether this be marching or funding a charitable organisation – mental wellbeing must be paramount.

Be your own supporter/cheerleader

This can be done daily by developing a strong sense of ethnic identity; educating yourself on a history that does not solely rest on the negative, but also embraces the positive aspects of who you are. Allow yourself to embrace YOU, including the rich and varied history, languages, food, traditions and customs which come with being a Black person. Be kind to yourself!

Carve out a safe space

A place you are allowed to switch off and not have to be anything to anyone. What and where this is, will differ from person to person and can range from reading for an hour a day, gardening, running, to calling a friend - anything that gives you pleasure, whilst transporting you away from the inevitable realities of a world in which there is limited control.

Therapy

If it’s affordable, long term psychotherapy and counselling is a great way to unpack racial and generational trauma. If you prefer a therapist with the same cultural and ethnic background to yourself, but have difficulty finding one, this isn’t the end of the story. Just as there’s a belief that a ‘good’ therapist should have been or is in therapy, it’s fair to believe that one who has learnt and studied the impact of systemic racism on their clients, can work very well.

Lastly….

It’s important not to place everyone in a single ‘BAME’ box. The lived experience of say, an Asian therapist will be different to that of a Black client. Experiences of people of colour do vary and should be respected.

It’s fair to assume that if trauma can be passed down through generations, so can joy.

Seek to develop a strong sense of ethnic identity that can involve educating yourself on the history of your culture not based solely on negatives, but which also celebrates the positive.  African history did not begin with slavery, it was interrupted by it.

Resources:

Rethink Mental Illness – Black, Asian and Minority Ethnic (BAME) mental health

The Black, African and Asian Therapy Network (BAATN)

Therapy for Black Girls

Mind’s Young Black Men Programme

British Asian Trust

100 Black Men of London

NHS Every Mind Matters

Lola Jaye is an author, registered psychotherapist and speaker who has penned six novels and a self-help book. She was born and raised in London, England and has lived in Nigeria and the United States. She has written for CNN, HuffPost and the BBC and is currently writing her new novel The Attic Child (Pan Macmillan) to be released in 2022.

lolajaye.com
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If trauma can be passed down through generations, so can joy

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Psychotherapist and author Lola Jaye explains the effects of historical and systemic racism on the mental health of Black people.

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Impact of Trauma - Online Microcredential - FutureLearn

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Trauma is a global phenomenon that can affect anyone at any time. It's a person's response to extreme stress which overwhelms their capacity to cope, and it can stem from life-threatening events such as injury, natural disasters, war, accidents and terrorist attacks, or, from life-changing medical diagnoses, sexual assault and rape, or domestic violence. Unresolved traumatic experiences can have long-lasting damaging effects on physical and mental well-being. Trauma has consistently been shown as one of the strongest predictors of developing a mental disorder and coping responses such as substance use and social isolation can increase the risk of poor overall well-being.

Understanding trauma is vital for promoting recovery and resilience in individuals and communities, which is why the University of Glasgow has created this online course. Our short program explores the links between trauma and psychological well-being to enhance your understanding of distress reactions following a traumatic event. The course has been put together by a diverse team of academics and psychiatrists from one of the prestigious Russell group of leading UK research universities, with expertise in global mental health, resilience, attachment, recovery, stigma, domestic violence and HIV. They'll help you understand the spectrum of distress, from transient feelings of vulnerability, fear and sadness, to more disabling psychological conditions that need specialist interventions. You'll also learn about evidence-based prevention and treatment options for managing psychological distress.

So if you want to get an insight into common psychiatric disorders and expand your knowledge of trauma and psychological well-being this course is the perfect introduction.

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Impact of Trauma - Online Microcredential - FutureLearn

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Trauma is a global phenomenon that can affect anyone at any time. It's a person's response to extreme stress which overwhelms their capacity to cope, and it can stem from life-threatening events such as injury, natural disasters, war, accidents and terrorist attacks, or, from life-changing medical diagnoses, sexual assault and rape, or domestic violence.

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https://www.youtube.com/watch?v=BJfmfkDQb14

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What is trauma? The author of “The Body Keeps the Score” explains | Bessel van der Kolk | Big Think

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This short video introduces key concepts, and insights into how to start the journey of becoming an informed service. As discussed in the event, the video highlights the Informed Approach Champions project, initiated by FLLSL, which supports individuals to become role models and help embed a culture of change within their own teams and organisations.

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You searched for informed approach | Fulfilling Lives

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This short video introduces key concepts, and insights into how to start the journey of becoming an informed service. As discussed in the event, the video highlights the Informed Approach Champions project, initiated by FLLSL, which supports individuals to become role models and help embed a culture of change within their own teams and organisations.

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Five ways to good mental wellbeing | Good Thinking (good-thinking.uk)

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Feeling anxious or stressed? Experiencing low mood or depression? Having trouble sleeping? There's a lot going on in the world at the moment that could be affecting your mental health.

The five steps below were developed by the New Economics Foundation more than a decade ago and are recommended by the NHS, Mind and other mental health organisations as a way to start feeling more positive and boosting your wellbeing. It only takes a few minutes to read through them and think about how you could incorporate these simple actions in your daily life.

If you live in London and need support for your wellbeing, Good Thinking provides a range of free apps, 'how to' guides and other online tools. We've included links to some of our resources at the end of this article, including 'Five ways to good mental wellbeing' advice for young people and for Londoners of different faiths.

1. Connect with other people

Having good relationships with your family, friends and colleagues is important as it can:

Improve your feelings of belonging and self-worth

Give you the chance to share positive activities and experiences

Provide emotional support for you and allow you to support others

There are lots of things you can do to stay connected and build stronger relationships (either in person or remotely), such as:

Spend time together as a family every day (e.g. over dinner)

Go for lunch with a friend

Call someone to find out how they are or send them a text message

Travel home from work with a colleague

Make the most of video chat apps like FaceTime and WhatsApp

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2. Be physically active

Being active and exercising regularly is important for your physical health but it can also improve your mental health by:

Boosting your self-esteem

Reducing depression, anxiety and stress

Lowering your risk of long-term health conditions, such as heart disease, Type 2 diabetes and some cancers

Helping you to set goals for yourself and achieve them

Causing chemical changes in your brain that can have a positive impact on your mood

It is recommended that adults should try to be active every day and do at least 150 minutes of physical activity over a week. This might include:

Slower-paced activities, such as walking around your home or garden

10-minute workouts on the NHS website

A walk, bike ride or outdoor game with your kids

Using YouTube or a fitness app to exercise at home

Easy, low-impact exercise whenever you can (e.g. stretches while the kettle boils)

Getting off the bus or tube one stop early and walking to work

Use the tomo app (free for Good Thinking users) to build positive habits

3. Learn new skills

Learning something new can be good for your mental wellbeing as it:

Raises your self-esteem and self-confidence

Helps you to gain a sense of purpose

Connects you with other people

Reduces low mood and depression

There are lots of ways to bring learning into your life. For example, you could:

Sign up for an online course (e.g. at your local college or through FutureLearn)

Read some books (and perhaps set up a book club with your friends)

Rediscover an old hobby or try a new one

Cook or bake something you've not made before

Work on a DIY project (there are lots of free video tutorials online)

Visit YouTube or Instagram to learn a dance routine or some art and craft techniques

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4. Give to others

Acts of giving and kindness are known to help improve mental wellbeing by:

Creating positive feelings

Providing a sense of reward

Giving you a feeling of purpose and self-worth

Helping you to meet other people

Those who have a greater interest in helping others are more likely to consider themselves happy. You could try:

Saying thank you to someone for something they have done for you

Doing some shopping for an elderly neighbour

Asking people how they are and really listening to their answer

Spending time with friends or relatives who need support or company

Listening to our podcast about making positive changes where you live

Volunteering in your local community (e.g. for a charity)

5. Pay attention to the present moment

Being in the moment and being aware of your thoughts, your feelings, your body and the world around you can improve your mental health. Often called 'mindfulness', this can help you to understand yourself better, change the way you approach challenges and enjoy life more.

To get you started, you could:

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Good Thinking resources

Useful websites

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Feeling anxious or stressed? Experiencing low mood or depression? Having trouble sleeping? There's a lot going on in the world at the moment that could be affecting your mental health. The five steps below were developed by the New Economics Foundation more than a decade ago and are recommended by the NHS, Mind and other mental health organisations as a way to start feeling more positive and boosting your wellbeing.

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Rapid review of effectiveness of trauma-informed approaches

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Rapid review of effectiveness of trauma-informed approaches

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RR Trauma informed approaches in non-healthcare settings 2021

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https://mentalhellth.xyz/p/going-beyond-diagnosis-in-east-london

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How bureaucratic health services are slowly adapting to a more trauma-focused future

This is a guest post by Mina Hadi. Mina is a journalist and poet. A fierce advocate for mental health and human rights, she is an intersectional feminist and proud Muslim. She's written before for Amaliah Magazine and Lacuna Magazine.

For the past eight years, I’ve accessed various mental health services, from cognitive behavioral therapy to talking ther…

This post is for paid subscribers

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How bureaucratic health services are slowly adapting to a more trauma-focused future

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I have Borderline Personality Disorder - it shouldn't be used against Amber Heard

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I have Borderline Personality Disorder - it shouldn't be used against Amber Heard

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https://www.independent.co.uk/life-style/health-and-families/amber-heard-borderline-personality-disorder-b2068992.html
By Mina Hadi

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I was diagnosed with borderline personality disorder (BPD) around three years ago. I'd had a particularly uncharacteristic outburst at a family member and finally decided to go to my GP, who referred me to a psychiatrist. He saw me for just two sessions before he diagnosed me.

As many BPD sufferers feel when they first receive a diagnosis, there's a sense of relief because there's a name for how you're feeling, a concrete term that you can point to. But once my emotions had settled, I felt differently. I was hesitant to mention my diagnosis to my family or employer because - let's face it - the phrase "emotionally unstable" does not inspire confidence. The description of me as borderline paints a specific, misleading picture of me being inherently dangerous - but the air needs clearing on the reality of BPD for many people.

This week Amber Heard received a diagnosis of BPD along with histrionic personality disorder by psychologist Dr Shannon Curry, who was hired by Johnny Depp's legal team. The diagnosis is part of the ongoing defamation trial between Depp and Heard which began on 11 April. Depp is arguing that Heard defamed him when she wrote an op-ed published in The Washington Post in 2018 titled "I spoke up against sexual violence - and faced our culture's wrath. That has to change". Depp was not mentioned by name in the article.

BPD is the most commonly recognised personality disorder. There are nine symptoms in all, and five need to be met in order to have a BPD diagnosis - among them are impulsive behaviours (like substance overuse), self-harm, chronic emotional hollowness, intense fears of abandonment and unstable relationships. Around 75 per cent of people with BPD make at least one suicide attempt in their lifetime, with up to 10 per cent of people with BPD dying by suicide.

Dr Curry considers Heard to be "self-righteous", "judgemental" and angry, describing the actor as flitting between "princess and victim". I'm not a psychologist, but I do use my lived experience to deliver training to plenty of mental health professionals. By Dr Curry's own admission, her observations "aren't fact". Rather, "[Heard's] scores were consistent with other people who had obtained these scores [...] [with] these specific traits".

Recommended

I am not the first to dispute the terminology of personality disorders, potential biases in diagnosis and how it doesn't take social context into account enough. So when Dr Curry put forward this diagnosis as part of the case being built in the libel trial against Heard, and which appeared to attribute Heard's alleged antagonism to her BPD, the grounds for doing so are shaky at best, particularly as BPD is so often misdiagnosed.

These labels are being placed on an alleged domestic abuse survivor in an attempt to discredit her claims. The US trial follows a similar libel case brought by Depp in the UK against The Sun newspaper in 2020. In November of that year, a judge found the newspaper's description of Depp as a "wife-beater" to be "substantially true".

Research has also shown a strong correlation between trauma and BPD. So you'd think this, and the sensitive nature of the case, would prompt a more compassionate discussion of the diagnosis.

These labels are being placed on an alleged domestic abuse survivor in an attempt to discredit her claims

Perhaps it's the language used which should be reconsidered. Many mental health interventions now use an alternative term, Complex Emotional Needs, which doesn't imply, as "personality disorder" does, that there is something inherently wrong with someone. With BPD, this negativity is even more intensely felt when considering its other term: emotionally unstable personality disorder.

Dr Curry spoke to the court in her testimony about the use of scales in diagnosis and she described mental health issues as generally having genetic, neurological and environmental components. So how far along on the scale were Heard's alleged outbursts? To me, these aren't characteristics of a specific personality disorder but rather the fallibility and flaws of human behaviour. Her alleged actions should be adjudicated as such, and not conflated with a diagnosis to be weaponised.

Recommended

When these conversations about complex psychological issues are brought into the public eye, they're oversimplified and risk tarring so many others with the same brush. Not to mention placing blame on someone who, in this case, has claimed to be the victim of abuse. It sets a precedent for future cases involving people with BPD, whose diagnoses can be used against them in a court of law.

So rather than pathologise the alleged actions of a single individual and throw everyone with BPD under the bus in the process, I suggest normalising these conversations - in the public eye, in workplaces and at home. Irrespective of the outcome of this trial, we need to listen to people who have BPD. It's not easy to live with, but it's also not what defines me or others with the diagnosis - and it certainly shouldn't be a defence in a domestic abuse trial.

I have BPD - it shouldn't be used against Amber Heard

Michael Reynolds/Pool Photo via AP

I have BPD - it shouldn't be used against Amber Heard

Actor Amber Heard listens in the courtroom at the Fairfax County Circuit Court in Fairfax, Va., Wednesday, April 27, 2022

AP

I have BPD - it shouldn't be used against Amber Heard

Actor Johnny Depp stands in the courtroom during a recess amid the Depp v Heard defamation trial at the Fairfax County Circuit Courthouse in Fairfax, Virginia, USA, 27 April 2022

EPA

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Why it's wrong to use BPD against Amber Heard

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I was diagnosed with borderline personality disorder (BPD) around three years ago. I'd had a particularly uncharacteristic outburst at a family member and finally decided to go to my GP, who referred me to a psychiatrist. He saw me for just two sessions before he diagnosed me.

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Here's how trauma can be political for minorities

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Here's how trauma can be political for minorities

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https://www.inspirethemind.org/blog/heres-how-trauma-can-be-political-for-minorities

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Here’s how trauma can be political for minorities

Trauma comes in many forms. Some are less understood than others, sometimes even by clinical professionals. Using my lived experience, I deliver trauma-informed care training to clinicians and third sector workers. My blog is about the definition of trauma. I advocate for its expansion to reflect its insidious nature for minorities.

Early on in my career, pre-pandemic, I was sexually harassed at work. I was never touched, but my male colleague spoke to me in increasingly sexual terms in a way that scared me. I felt constantly on edge, with a sinking feeling in my stomach every time I was alone in a room with him thereafter. Every interaction I’ve had with men I’ve worked alongside since then has been marred by this. It’s like my body was on autopilot: my heartbeat would skyrocket, I would feel nausea, dizziness, and I couldn’t think. It felt like my brain was threatening to shut down.

Years later, I now recognise these reactions as trauma responses, a way for me to survive when facing a threat. Innate in us as humans is an evolutionary mechanism, commonly known as ‘fight or flight’.

There are actually five of them in total, which is part of the training I help deliver. It’s helpful to think of this through animal behaviours as well as human. Imagine being in the woods and coming face-to-face with a bear. Survival instincts kick in, and these manifest as the 5 Fs:

1. Fight (the primal instinct to attack and fight off the danger, and to aid this, one’s heart rate and breathing speeds up, so more oxygen and blood circulates around the body)

2. Flight (as the body prepares to run away from the threat, adrenaline is released, energising us enough to escape from danger)

3. Freeze (think of a rabbit or deer caught in headlights, staying still and silent until the danger passes)

4. Flop (like a mouse playing dead, the body’s muscles can literally flop and shut down, as if preparing to die)

5. Friend (manifesting in two forms, this can mean a call to bystanders to help, but it can also mean “befriending” the threat as a survival instinct)

Our brains perceive threats of any kind in similar visceral ways. That is why our primal ancestors may have had an adrenaline rush, heart pumping, to help them flee from a wild predatory bear. Likewise, my pulse would race in panic every time I felt someone getting uncomfortably close to me at work.

Sexual harassment is commonplace (with four in five women having experienced it). So, really, it was no wonder that it felt traumatic over time, particularly if it happened repeatedly — and even if in my case, no physical harm was ever done.

My experience was one form of trauma, but it can be felt in many different circumstances.

Microaggressions and trauma

I’m also a visibly Muslim woman of colour. I can’t remember a time when racism wasn’t prevalent in Britain, but in recent years the evidence of institutional racism has been overwhelming. This is in spite of efforts to downplay the effects of racism, such as the government’s racism report in 2021. It was condemned by a UN-backed human rights expert for attempting to “normalize white supremacy”.

Since I was a child, I have faced microaggressions — a more subtle, covert form of racism that people are reluctant to name as such. For example, at the age of five, the area I grew up in had very few people who looked like me. At the time, the predominantly white children in my class would mock me for not having a “normal” name. They would purposely mangle it to make fun of me. My name was mispronounced, misspelled and butchered so often as a student that I ended up shortening my name to avoid this.

Of the dozens of times this happened, I can’t say with certainty if it was intentional or malicious. But students and teachers deliberately or repeatedly doing so, especially after being corrected, was a microaggression that many people of colour face. Instilled in me was a deep feeling of alienation as a child, as well as anxiety over something so central to my identity.

When 9/11 happened, I was only six years old, and I can’t remember very much from it at all. But I will never forget the number of times in the following years that people would ask me things like “Isn’t your religion a terrorist one?” In Sweden on a school trip, I was approached by several Swedish students who remarked on my perfect English. They failed to see how that could be a backhanded compliment, coupled with the presumption that wearing hijab and having brown skin meant the automatic assumption that I couldn’t speak English. I didn’t want to start an argument, but it reminded me of all the times I would tell people I’m from East London and they would ask, “No, where are you really from?”

One study shows that “constantly being on edge because your environment is hostile can often leave people feeling invisible, silenced, angry, and resentful”. Speaking from experience, I can attest to this. Being vigilant and on the lookout for these comments made me feel like I didn’t deserve to belong. Even when my neighbourhood diversified growing up, I still felt like the odd one out because that was my normal.

Worsening the effect of these microaggressions and the resultant hypervigilant mindset for Muslims like myself is structural Islamophobia and racial bias. An example of this is Prevent, one of four parts of the government’s counter-terrorism programme, CONTEST. Its purpose is to “prevent people from being drawn into terrorism”. That this is a well-intentioned purpose should go without saying, but even the BBC has labelled it “difficult”.

Human rights charity Liberty has criticised it for its disproportionate impact on Muslims. “[Prevent] defines extremism […] so wide[ly] that thousands of people are being swept up by it — including children engaging in innocuous conduct, people protesting climate change, and a nurse who began wearing a hijab.”

In light of multiple news reports that have shown it alienates and wrongly targets Muslims, Prevent is due for a second review, after the first government-backed review. Even a Home Affairs Committee in the House of Commons branded the strategy as “toxic”. Not only does this create an environment that is hostile to Muslims, it also reinforces existing misconceptions about Muslims.

Fostering a hostile environment for minorities isn’t limited to racism, sexism and Islamophobia, either. For trans and gender non-conforming people, being misgendered — to use the wrong pronouns or other gender-specific words when referring to or speaking to someone — can be incredibly disrespectful. This can have a negative impact on trans people’s mental health, as can deadnaming (when somebody refers to a trans person using the name they had before they transitioned).

As a cis woman, I don’t assume to speak for the trans community. However, being around more trans and nonbinary people has made me more cognisant of why these things matter. Where deadnaming or misgendering happens repeatedly, it erodes any sense of safety that a trans person might have had in a specific space, particularly young trans people at school. In turn, by default, this could activate their fight-or-flight response.

Being “othered” (made to feel like you’re less than or different) can also elicit a trauma response. That’s because, in evolutionary terms, social exclusion (or ostracism) was directly linked to an animal’s safety. Being excluded from a group or punished within one was literally a matter of survival, so it’s no surprise that our bodies continue to perceive it as such.

Defining trauma

When I ask clinicians to define trauma, their first answer usually isn’t sexual harassment, deadnaming, or racial microaggressions. It’s not the most obvious answer, because no physical harm is usually done.

Instead, the answers I get usually fit the bill for trauma in its strictly clinical definition. Typically, this means situations where someone fears for their life or their physical safety. A physical assault will leave bruises, broken bones, or scars. A sexual assault, unlike sexual harassment, is physically invasive and thus considered traumatic. Similarly, someone living in a war-torn region has an ongoing, imminent threat to their physical safety. That makes the origin of the trauma easier to pinpoint.

Clinically speaking, they’re correct — but subjectively so. Trauma definitions vary depending on where and when you look. The DSM-5 definition excludes psycho-social stressors like divorce or medical problems like cancer. These were factors included in the previous DSM-4 definition. The SAMHSA definition is much broader and acknowledges the cultural and social context of what trauma means.

Now, it’s easy for healthcare professionals to get bogged down in the language of acronyms. They work in systems that rely on arbitrary criteria. But being clinically specific ignores the prevalence of trauma in people’s lives, especially in how trauma relates to mental health difficulties.

When someone asks me if I’m traumatised, there’s no doubt I would reply “yes”. But I don’t know if I could point to a specific event in my life to prove that. Ironically, emotional and psychological safety almost takes a backseat in conversations surrounding trauma. And when it comes to minorities and marginalised groups — that carries its own traumatic weight.

Informing mental health care

For people working in mental health, it’s so important to be aware of how trauma manifests in different people. Trauma can be collective, in that it’s felt by a group of people, like the mass effect of the Covid pandemic on the world.

Meanwhile, vicarious trauma is when someone witnesses the trauma of another. An example is healthcare workers watching patients die of Covid. Another is police brutality, which traumatises Black people, directly and vicariously (when watching the footage of the killing of George Floyd). In this way, trauma can be intergenerational as well.

When entire generations or groups of people become conditioned to being treated as inferior, it can create a legacy of trauma. This is felt in systems long after the trauma occurs, as in the enslavement of Black people. Research further shows intergenerational trauma applies to the offspring of Holocaust survivors, especially Jewish and Roma populations.

As someone who is an ethnic and religious minority, I understand the level of systemic racism, misogyny and Islamophobia because I have experienced it. These struggles are not commonly understood by clinical professionals who may not have that lived experience, especially given the lack of BAME psychologists and psychiatrists in the UK. And the figures speak for themselves: in the year to March 2020, Black people were found to be four times as likely as white people to be detained under the Mental Health Act. Over 100 psychiatrists in the UK wrote an open letter to The Royal College of Psychiatrists, challenging the status quo of “institutional racism and colonial mentality”. This was in 2020. More recently, the NHS’s first Black psychiatrist, Dr. Aggrey Burke, spoke about being othered and “unfairly treated” as a result of challenging the institutional racism in psychiatry.

The racism endemic in psychiatry is further evident around the world. The American Psychiatric Association issued an apology last year to Black, Indigenous and People of Colour, in acknowledgement of the discipline’s structural racism. In fact, the so-called “father” of American psychiatry, Dr. Benjamin Rush, was said to have clear and unequivocal racist views.

When mental health care is so often whitewashed in the UK, I firmly believe that it takes lived experience as someone of a marginalised identity to truly understand the traumas faced by minority groups.

That’s why coproduction is crucial — where people with lived experience of accessing mental health services are part of shaping mental health care. Peer support workers’ mental health challenges are seen as an asset, rather than a liability. Part of the reason why trauma is so subjective in its definition is because it depends on the person’s demographic.

Treating mental health issues requires a substantive understanding of the populations being served. That means understanding the barriers they face, including their traumas. It’s vital to recognise that what is traumatic for one person isn’t for another. Just by nature, trauma is subtle and insidious, so it may not be obvious.

Ultimately, I advocate for a more progressive approach to mental health care. Instead of shying away from issues that are often labelled as political in nature, we need to recognise that politics and trauma are both rooted in power imbalances. Nothing clinical ever exists in a vacuum, and to understand one is to understand the other.

And the first step towards a better system for minority groups is to listen when we speak out. It means giving marginalised populations — often mislabelled as “hard to reach” — a voice, empowering us to come forward and share our experiences, without undermining them. Clinical professionals need to recognise that those experiences can be traumatic in nature, even if they don’t fit a strict definition, and the only way to do this is to be actively, unabashedly antiracist and inclusive, across systems and practices.

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Depression, Science, Research

Luca Sforzini

February 15, 2022

Depression, Depression treatment, Luca Sforzini, Science, Research

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Diversity, Feminism, Gender equality, Science, Society, Womens Rights

Amina Begum

February 11, 2022

Amina Begum, Women in STEM, womens rights, Education

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Here's how trauma can be political for minorities - Inspire the Mind

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Trauma comes in many forms. Some are less understood than others, sometimes even by clinical professionals. Using my lived experience, I deliver trauma-informed care training to clinicians and third sector workers. My blog is about the definition of trauma. I advocate for its expansion to refl

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City Hackney Childhood Adversity Trauma Resilience Program

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Insight report on Trauma Informed Education across West Yorkshire
Trauma Informed Education Settings Insight West Yorkshire - Guidance
Cherry, L. & Froustis, E, (2022) Trauma Informed Education Settings In West Yorkshire. West Yorkshire Health and Care Partnership and Violence Reduction Unit. West Yorkshire: England.

This report provide insight and recommendations for trauma informed schools and educational institutions across West Yorkshire that have committed to strengthening educational outcomes for vulnerable young people through attachment and trauma-informed methods. The report includes, review of the evidence base, evaluation of a pilot programme in a West Yorkshire school, Case studies of good practice and examines the barriers and opportunities for trauma informed schools and education. The report concluded with key findings, areas for consideration and recommendations to be taken forward across West Yorkshire with the help of the West Yorkshire Adversity Trauma and Resilience Education workstream.

Co-production guidance
West Yorkshire Trauma Informed Co-Production Guidance - April 2022
At our Adversity, Trauma and Resilience Knowledge Exchange 2022 we launched new guidance for trauma co-production. The guidance, authored by Lisa Cherry, Schools, Services and Systems Change Consultant, sets out an understanding of how to engage in co-production using a trauma informed lens. The guidance has some great tips offering things to consider, reflect on and questions to ask rather than instruction.

Adversity, Trauma and Resilience Knowledge Exchange 2022 presentations and links

In this section you can find the presentations used during the three-day Adversity, Trauma and Resilience Knowledge Exchange which took place from Tuesday 26 to Thursday 28 April 2022. Please also see the photo projects and audio resources links. If the presentations are not accessible to meet your needs please let us know by emailing caroline.andrews16@nhs.net and we will contact the relevant presenter for a more accessible format.

Co-production guidance
West Yorkshire Trauma Informed Co-Production Guidance - April 2022
At our Adversity, Trauma and Resilience Knowledge Exchange we launched new guidance for trauma co-production. The guidance, authored by Lisa Cherry, Schools, Services and Systems Change Consultant, sets out an understanding of how to engage in co-production using a trauma informed lens. The guidance has some great tips offering things to consider, reflect on and questions to ask rather than instruction.

Films used at the Adversity, Trauma and Resilience Knowledge Exchange 2022

In this section you can find links to some of the films used during the Adversity, Trauma and Resilience Knowledge Exchange 2022. We encourage you to use the films for your own individual purposes. If you want to use these films for training or public showings, please check with the originator as you may need a license.

Verd de gris arts - leaving service (commissioned by West Yorkshire Health and Care Partenrship)
MindMate - being Black and me

Cambridge Documentary Films, Inc. Strong at the broken places - turning trauma into recovery

Additional resources used at the Adversity, Trauma and Resilinece Knowledge Exchange 2022

Brightsparks - Poster Presentation

(Leeds Trinity University)

Community Interest Company - trauma informed and trauma sensitive - learning and development opportunities

Dawn Bland - lived experience

Poetry created by Dawn about her experiences of trauma and adversity
Trauma triggers Survivors reach out Online bullying

Denise Wheatman, Wakefield Council

Artwork created by young people
CCE Project 'not around here'
Children from Upton Primary school used art as a vehicle to talk about and share their experiences of what they had seen or heard, their thoughts and worries. The children explored strategies and protective factors to help improve their resilience. The project helped raise awareness of the adversity and family situations some of the children were living within. Funded by the Violence Reduction Unit and facilitated by Young Lives Consortium, Ryhill and Havercroft Leisure and Wakefield Public Health, the script was written by John Godber and young people were involved in the language used and final edit. The art work has been created in metal and displayed around the school and area.
Wrenthorpe Pru 'loving myself'
Young people who struggle to attend mainstream school due to a variety of reasons. The focus of the creative sessions was around the resilience framework section 'loving myself - self awareness' and provided an opportunity to develop a positive sense of self, self-esteem and self-confidence.

Denise Wheatman, Wakefield Council

STAR assessment conversation tool

The conversation tool was created in 2021 with STAR bereavement based on the 'Milestones of Healing' a process they currently use as part of their assessment. The conversation tool provides tips around creating a trauma responsive environment and amplifies the voice of the child. It provides a series of questions based on evidence based competences within the resilience framework to identify what protective factors, strategies and resilience the child or young person has around managing difficult situations and changes in their life.

Marcia Hylton - Author

Marcia has written an eight-week course around recovery and resilience after emotional abuse in intimate toxic relationships
Life inspired wellness Five-step process for healing trauma

New online training - understanding refugee and asylum seeker mental health and wellbeing and providing effective therapeutic support for asylum seekers
Solace elearning elearning flyer course 1 elearning flyer course 2

The Wakefield Resilience Framework

Adversity, Trauma and Resilience Knowledge Exchange 2021 documents and links

Adversity, Trauma and Resilience in West Yorkshire

A review of life-course evidence, approaches and provision to support the transformation to a trauma informed health and care system by 2030.

Violence aginst women and girls

To provide an insight into the causes and impacts of Violence Against Women and Girls as understood in current literature and service provision.

To identify the needs of women and girls in West Yorkshire to support the development and introduction of intelligence led, evidence based sustainable intervention and provision.

To provide an overview of current knowledge whilst identifying knowledge gaps in knowledge and recommendations to prompt engagement and localised research.

'Ready to Relate' cards for professionals

Parent interview themes - an intervention using Ready to Relate parent-infant relationship resource cards with parents, produced by Bradford District Care Trust
Ready to Relate poster

One Adoption West Yorkshire

Working to support you and your family One Adoption West Yorkshire multi-discliplinary team

Young People attending Child Bereavement UK group in Leeds share their experiences and advice

It's particularly relevant in the case of traumatic bereavements such as suicide or violent death, but also if there are additional vulnerabilities in the family and/or if they are not supported well after the death.

Asking patients about ACEs ... because waiting to be told doesn't work

To contribute to the current evidence base on ACE enquiry and further develop an understanding of how enquiry can support patients' health and wellbeing within primary care in Scotland. A mixed-method evaluation scheduled for 2020 aimed to understand what difference enquiry can make to patients, staff and the healthcare system within deep-end practices.

Evaluation of a system wide approach to implementing Routine Enquiry about Adversity in Childhood (REACh™) across Nottinghamshire

In 2019, the Public Health Institute, Liverpool John Moores University was commissioned to carry out a two-year evaluation of a system wide approach to implementing Routine Enquiry about Adversity in Childhood (REACh™) across Nottinghamshire. This report provides interim findings from the evaluation, covering April 2019 to February 2020

Addressing adverse childhood experiences: implications for professional practice

Warren Larkin, Consultant Clinical Psychologist, Visiting Professor, University of Sunderland

Peter Cairns, GP, Wester Hailes Medical Practice, Edinburgh

Childhood adversity and trauma: experiences of professionals trained to routinely enquire about childhood adversity

Josie Pearce and Craig Murray, Lancaster University

Warren Larkin, Consultant Clinical Psychologist, Visiting Professor, University of Sunderland

The aim of this study was to construct an understanding of the experiences of these practitioners. Seven interviews were conducted, and the data was analysed using thematic analysis.

LEAPlets - A School Readiness Programme based on the BUSS model. A development between the Therapeutic Social Work Team, Leeds Virtual School and Leeds Gymnastics Club

MNingful Life

A Training Activity for Understanding Multiple Needs

MNingful Life has been co-designed and co-produced to provide opportunities for learners to explore the issues and barriers faced by people experiencing multiple needs. It was originally developed for our Peer Mentor training programme, MNingful Life has been created to suit all learning styles.

Racism: Some Indisputable Truths
Becoming anti racist (infographic)

Racism exists

Racism is not biological

Racism is a system of power

Racism is a social construct

Racism is a public health issue

We can act to dismantle racism

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Adversity and Trauma resources :: West Yorkshire Health & Care Partnership

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Trauma Informed Education Settings Insight West Yorkshire - Guidance Cherry, L. & Froustis, E, (2022) Trauma Informed Education Settings In West Yorkshire. West Yorkshire Health and Care Partnership and Violence Reduction Unit. West Yorkshire: England.

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Manchester - ACE and Trauma Informed City

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https://www.hse.gov.uk/stress/standards/downloads.htm

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There are a number of tools associated with the Management Standards process provided across this website which are free for you to use or share with your colleagues. There are also a number of templates for you to use as a starting point. Below is a quick access list of those tools:

Why should you do something?

The case for action

Securing management commitment - details the legal requirements for taking action

What should you be doing? The Management Standards

Survey and analysis tools:

Developing a Stress policy:

Developing an action plan:

Action plan and Worked Example

Running focus groups:

Management competencies:

Return to work after absence:

Return to work discussion question template

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There are a number of tools associated with the Management Standards process provided across this website which are free for you to use or share with your colleagues. There are also a number of templates for you to use as a starting point.

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https://www.wypartnership.co.uk/application/files/2416/5158/7832/Emily_Griffiths_Trauma_Informed_Leeds.pdf

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National trauma-informed training programme https://www.nes.scot.nhs.uk/our-work/trauma-national-trauma-training-programme/

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In 2016 NHS Education for Scotland was asked by the Scottish Government to develop a set of resources to promote and implement trauma informed practice within Scotland. This was due to the growing recognition of the impact of traumatic experiences on people.

Vision

Our overarching vision is to develop a trauma informed and responsive nation and workforce, that:

is informed by people with lived experience

recognises the importance of wellbeing in the workforce

recognises where people are affected by trauma and adversity

responds in ways that prevent further harm

supports recovery

and can address inequalities and improve life chances

What do we mean by trauma informed practice?

Being 'Trauma Informed' means being able to recognise when someone may be affected by trauma, collaboratively adjusting how we work to take this into account and responding in a way that supports recovery, does no harm and recognises and supports people's resilience.

Being 'Trauma Informed' is underpinned by the 5 R's:

Realising how common the experience of trauma and adversity is

Recognising the different ways that trauma can affect people

Responding by taking account of the ways that people can be affected by trauma to support recovery

Opportunities to Resist re-traumatisation and offer a greater sense of choice and control, empowerment, collaboration and safety with everyone that you have contact with

Recognising the central importance of Relationships

In the 'Learning resources' section below you will find a link to a range of eModules, key documents and other training materials that will help to operationalise the above.

Learning resources

Please view a summary of all of our current trauma training resources.

The knowledge and skills framework

This interactive document details the different knowledge and skills needed by workers to respond to those affected by trauma at different stages in their recovery:

The training plan

This practical guidance tool is designed to be used in conjunction with the Knowledge Skills and Framework to support all organisations in Scotland to develop their workers to understand the impact of trauma on people's lives and be trauma-responsive.

For more information, go to our website.

Contact us
psychology@nes.scot.nhs.uk

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trauma – national trauma training programme

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Trauma – national trauma training programme | NHS Education

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The Trauma – national trauma training programme page of the NHS Education for Scotland website.

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Somerset - emotional wellbeing response after flooding

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Somerset - emotional wellbeing response after flooding

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Addressing emotional wellbeing as part of the public health response to flood recovery in Somerset - YouTube

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Addressing emotional wellbeing as part of the public health response to flood recovery in Somerset

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Exploration of the concepts of 'flourishing' versus 'resilience' from a health care perspective

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5 point model of flourishing created by Louise Younie
Ecological
Our inner life has seasons, is affected by the soil we grow on, the weather that is coming our way
Interconnected
Wellbeing of 'what is' rather than do better (run, eat, sleep)... This is when we build trust and can share challenges e.g. our sense of uncertainty or imposter syndrome...we haven't changed the external situation but we are re-humanised through sharing and realising we are not alone.
Shared meaning making
Drawing on Aristotle's eudaimonia, (purpose, growth, meaning), creating rich meaning making spaces whether in the learning space (student-doctor, or student-patient) or the clinical space (doctor-patient).
Compassion
Compassion for the other and self-compassion are necessarily linked. Kindness is needed for our own humanity and inevitable flaws as well as those of others.
Shadow work
Drawing on Jungian thinking, Shadow work is choosing to engage with and be present to ourselves and our situations that may be uncomfortable or difficult.

Acrostic poems on resilience and flourishing

Creative arts medical students SSC 2023

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Ecological Our inner life has seasons, is affected by the soil we grow on, the weather that is coming our way Interconnected Wellbeing of 'what is' rather than do better (run, eat, sleep)... This is when we build trust and can share challenges e.g.

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Quality Indicators Framework for Trauma-informed Services, Systems and Workforces Proposal and Development Plan: Stakeholder Consultation (improvementservice.org.uk)

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greater-manchester-mental-health-toolkit-2022.pdf (gmgoodemploymentcharter.co.uk)

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Trauma-informed care and health outcomes

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Trauma-informed care and health outcomes

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Tackling poor health outcomes: the role of trauma-informed care | The King's Fund (kingsfund.org.uk)

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Tackling poor health outcomes: the role of trauma-informed care

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People who have experienced trauma face a number of barriers to accessing health care. Deborah Fenney explains why a trauma-informed approach is essential for supporting a group that currently face poor health outcomes.

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https://www.riseuk.org.uk/resources/anti-racism-resources

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RISE is a feminist organisation, recognising the intersecting, structural inequalities, and layers of oppression that impact women from multivarious backgrounds that are the cause and consequence of violence and abuse.

ACEVO
Our CEO Jo Gough is a member of ACEVO (Association of Chief Executives of Voluntary Organisations), who offer advocacy and resources to support civil society leaders to make the biggest difference possible.

Jo has publicly committed to the following eight ACEVO principles to address the diversity deficit in charity leadership: Eight principles to address the diversity deficit in charity leadership - ACEVO
Anti-Racism in VAWG Working Group
RISE signed up to the Anti-Racism in VAWG Charter prior to its launch in 2020, and our staff regularly attend anti-racism training and workshops to tackle privilege, prejudice, and inequality within our sector.

Find the values and pledges we adhere to as an anti-racist organisation here: Anti-Racism Working Group (endingracisminvawg.org)

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"Every voice raised against racism chips away at its power. We can't afford to stay silent."― Reni Eddo-Lodge

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Conceptual framework for historical trauma

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Conceptual framework for historical trauma

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https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1350062

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Assessment approaches with pregnant individuals

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Assessment approaches with pregnant individuals

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Overview of trauma-informed approaches - Angela Kennedy

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Overview of trauma-informed approaches - Angela Kennedy