Adverse Childhood Experiences and Complex Trauma in Looked After Children

What is trauma?

A traumatic event or situation creates psychological trauma when it overwhelms the individual’s ability to cope, and leaves that person fearing death, or physical/psychological harm. The circumstances of the event often include abuse of power, betrayal of trust, helplessness, pain, confusion, and/or loss.

Exposure to trauma is relatively common in the general population. According to one worldwide study conducted by the World Health Organisation including over 68,000 participants, over 70% of those responded had experienced a traumatic event; 30.5% of those were exposed to four or more events (Benjet et al., 2015).

The Adverse Childhood Experiences (ACE) study investigated the link between childhood trauma and adult health in over 17,000 people. Childhood trauma was common:

  • 30% of respondents reported substance use in their household;
  • 27% reported physical abuse;
  • 25% reported sexual abuse;
  • 13% reported emotional abuse;
  • 17% reported emotional neglect;
  • 9% reported physical neglect;
  • 14% reported seeing their mother treated violently.

In vulnerable groups such as Looked After Children and young people, individuals are more likely to be exposed to deprivation, family breakdown, family mental illness and substance abuse by caregivers (Ford, Vostanis, Meltzer & Goodman, 2007). Approximately 69% of Looked After Children and young people have experienced neglect, 48% physical abuse, 37% emotional abuse and 23% sexual abuse (Chambers et al., 2010). However, the general consensus is that it should be assumed that all Looked After Children and young people have experienced trauma in some way.

What is Complex Trauma?

Complex trauma is a type of trauma that occurs repeatedly or cumulatively and may even increase over time. Complex trauma may impact/alter psychobiological and/or socioemotional development when it occurs at critical periods in childhood development.

Complex trauma is now captured within the ICD-11 (International Classification of Diseases, 11th Revision – The global standard for diagnostic health information), where it is defined as: “arising after exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (for example, torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse)”.

Looked After Children and Young People may experience a range of prolonged traumatic events such as physical and sexual abuse in their early development (Denton, Frogley, Jackson, John & Querstret, 2016). This is significant as the cumulative effects of frequent traumatic events are associated with poorer outcomes in adulthood, compared to one isolated event (Finklehor, Shattuck, Turner, Ormrod & Hamby, 2011).

Complex trauma can be associated with significant behavioural, cognitive and emotional difficulties among children in foster care (Jee et al., 2010; van der Kolk, 2005), including:

• Challenging behaviour in the home and at school;                                            
• Development of pathology (e.g. ADHD, anxiety, depression)
• Difficulty forming appropriate relationships with others;
• Feeling detached from their surroundings;
• Frequent entry and re-entry into care services;
• Harmful sexual behaviour;
• Lack of trust towards carers and professionals;
• Low self-esteem;
• Over-compliance and over-reliance within relationships;
• Poor management of emotions;
• Self-blame.

What are Adverse Childhood Experiences?

Adverse childhood experiences (ACEs) refer to a range of potentially traumatic events experienced by people in childhood that can have profound and lasting effects on health and well-being (Felitti et al., 1998). ACEs can include, but are not limited to:

• Emotional, physical or sexual abuse;
• Emotional and physical neglect;
• Household domestic violence;
• Household mental illness;
• Household substance abuse;
• Parental or caregiver incarceration;
• Parental or caregiver separation.

Given that ACEs can be experienced by many people and vulnerable groups including Looked After Children and Young People, research is interested in identifying physical and psychological changes that can happen across the lifespan. Studies (e.g. Fisher, Level, Delker, Roos & Cooper, 2016) have consistently shown that ACEs can be associated with:

• Challenging behaviour at school and in the community;
• Engagement in anti-social behaviour;
• PTSD symptoms – as high as 75% prevalence rate (Morris, Salkovskis, Adams, Lister & Meiser-Stedman, 2015);
• Self-harm and suicide;
• Substance use in adulthood;
• Unemployment;
• Vulnerability to developing mental and physical health problems;
• Vulnerability to experiencing further victimisation in the home or community.

What is Post Traumatic Stress Disorder (PTSD)?

PTSD is a trauma and stressor-related disorder that develops in some people who have experienced a traumatic event. Almost everyone will experience a range of reactions after trauma, yet most people eventually recover from initial symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened even when they are not in danger.

The clinical presentation of PTSD varies. Some clients may have more of the behavioural symptoms, whereas others may have more of the negative cognitions, which can be very distressing for them. Others may have a combination of symptoms. There is a separate diagnostic criterion for PTSD in children aged six and under, yet many children who have experienced trauma often do not meet the threshold for diagnosis (van der Kolk, 2011). Approximately 4% of Looked After Children and Young People meet the criteria for post-traumatic stress disorder (Bronsard et al., 2016).

How can CCATS support Looked After Children and Young People who have experienced Trauma?

The therapeutic model adopted by CCATS of working with traumatised children is grounded in current trauma theory and practice within the Good Lives Model (GLM; Ward & Gannon, 2006). The GLM is a leading approach focuses on a person’s strengths as a means to achieve positive change.

CCATS provides psychologically-informed treatments for trauma and PTSD, informed by the NICE guidelines [NG116], published in December 2018. Interventions can include cognitive-behavioural therapy, Eye Movement Desensitisation and Reprocessing (EMDR), and play therapy.

All treatment is individualised, but is often based around a three-phase model of treatment capturing the following:

Phase one: Stabilisation and Psychoeducation

Improving symptom management, self-soothing and addressing current life stressors to achieve safety and stability in the present.

Phase two: Trauma Processing

Trauma-focused work to process traumatic memories.

Phase three: Reintegration, Reconnection and Recovery

Re-establishing social and cultural bonds and enabling the client to develop greater personal and interpersonal functioning.