YM ACEs

Funded by
Addressing
Adversity
Prioritising adversity and trauma-informed care

for children and young people in England
Edited by Dr Marc Bush

Foreword by Sarah Brennan OBE
This collection was published in Great Britain by The YoungMinds Trust
Suite 11 Baden Place, Crosby Row, London, SE1 1YW
Addressing Adversity
www.youngminds.org.uk
The publication of this collection was funded by Health Education England

1st Floor, Blenheim House, Duncombe Street, Leeds LS1 4PL
www.hee.nhs.uk 3
Editor: Dr Marc Bush
Prioritising adversity and trauma-informed care
Illustrators: Sophie Standing (Trauma is Really Strange) and Georgie Lowry (collection graphics) for children and young people in England
Authors: Victor Adebowale, Rebecca Adlington, Matilda Allen, Mario Alverez-Jimeneza,
Agnes Aynsley, Andy Bell, Sarah Bendalla, Lucy Bowes, Rick Bradley, Sarah Brennan OBE,
Lindsay Buchanan, Naomi Burrows, Dr Marc Bush, Carmen Chan, Sarah Clement, Jan Cooper,
Rosie Powell Davies, Betsy de Thierry, Angela Donkin, Beth Filson, Peter Fonagy, Steve Haines,
Corinne Harvey, Dawn Hewitt, Kristine Hickle, Nick Hindley, Russell Hurn, Henry Jackson,
Angela Kennedy, Eoin Killackeya, Pooky Knightsmith, Almudena Lara, Warren Larkin, Rob McCabe,
Lisa McCrindle, NHS England, Jo Prestidge, Public Health England, Kathryn Pugh, Claire Robson,
Katharine Sacks-Jones, Lucas Shelemy, Graham Simpson-Adkins, Angela Sweeney, Sue Sylvester,
Matthew Todd, Caroline Twichett, Sanjana Verghese, Clare Wightman.
The rights of the editor, illustrators and authors to be identified as authors of this work have been
asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
Print ISBN 978-1-5272-1946-5

Designed by Georgie Lowry
Printed in Great Britain by Blackmore Ltd
youngminds.org.uk
Foreword
Sarah Brennan OBE
“It is the experiences we find hardest to talk about in our society that have a
Addressing Adversity is licensed from 2018 by The YoungMinds Trust and Health Education England
lasting impact on the mental health and wellbeing of children and young people.
under a Creative Commons Attribution-ShareAlike 4.0 International License.
Be it bereavement, domestic violence, caring for a parent, or sexual abuse, we
must ensure that all services are better able to identify childhood adversity and
The following papers are exempt from the above Creative Commons License:
help to resolve the trauma related to it.”
Adverse Childhood Experiences (ACEs), Health outcomes and risk factors – extract from ‘The impact
of adverse experiences in the home on the health of children and young people and inequalities in
prevalence and effects’, first published in 2015, and reused under the Open Government Licence
v2.0, and with the permission of the authors. YoungMinds has compiled this collection to raise awareness about the
impact of adversity and trauma on the mental health of children and
Trauma Is Really Strange – first published by Singing Dragon in 2015, reproduced with permission
of Jessica Kingsley Publishers through PLSclear, and with the kind permission of the author and
young people.
illustrator.
4 Creating trauma-informed mental healthcare in the UK – extract from ‘Trauma-informed mental

healthcare in the UK: what is it and how can we further its development?’, first published in 2017 in
1in3
diagnosed mental health conditions in adulthood are
5
the Mental Health Review Journal, reused with the permission of Emerald Insight and the authors.
known to directly relate to adverse childhood experiences
Straight Jacket: the mental health consequences of LGBT+ prejudice – extract from ‘Straight Jacket’,
published in 2016 by Bantam Press, reproduced by permission of The Random House Group Ltd. The
conclusion to this paper is covered by the above Creative Commons licence. We know that one in three adult mental health conditions relate directly to
adverse childhood experiences, and that young people’s mental health and
Addressing adversity through alternative education – extracts from ‘Teaching the Child on the wellbeing can be significantly compromised by adverse environments, and the
Trauma Continuum’, first published in 2016 by Grosvenor Publishing; ‘The Simple Guide to Child experience of trauma.
Trauma and Addressing adversity through alternative education’ in D. Colley (ed) ‘Emotional
Development and Attachment in the Classroom’, both first published in 2017 by Jessica Kingsley Experience of adversity and trauma in childhood can significantly increase the
Publishing, reused with the permission of the author. risk of mental and physical ill health in adolescence and adulthood, and result
in these young people dying earlier than their peers later in life.
Annexes – permission has been granted by BioMed Central for the reproduction of the ‘National
household survey of adverse childhood experiences and their relationship with resilience to Yet too often services become fixated on what they see as challenging or risky
health-harming behaviors in England’, first published in 2014 in BMC Medicine, and ‘Relationships behaviour. These services can quickly stigmatise or criminalise young people’s
between adverse childhood experiences and adult mental well-being: results from an English national normal responses to adversity and trauma.
household survey’, first published in 2016 in BMC Public Health.
Uninformed services, interventions and professionals unnecessarily escalate
All statistics reproduced in this collection were correct at the time of writing in 2017. young people’s mental distress, put them off asking for, or engaging in, support,
Addressing Adversity youngminds.org.uk

Foreword
and ultimately have a profound impact on their social, psychological and

emotional development.
Authors and illustrators
It is, therefore, vital that we understand the impact that adversity and trauma Lord Victor Adebowale CBE is Chief Executive of the leading health and
can have on the mental health and wellbeing of young people, and how we can social care charity Turning Point. He is a Cross-bench Life Peer in the House
strengthen resilience and support recovery. of Lords, and a Visiting Professor and Chancellor at the University of Lincoln.
Lord Adebowale is President of the International Association of Philosophy
In Addressing Adversity, we bring together contributions from leading and Psychiatry, President of the Community Practitioners and Health Visitors
academics, clinicians, commissioners and frontline professionals who all share Association, a commissioner for the UK Commission for Employment and
a passion for ensuring that services and support for children and young people Skills, sits on the National Quality Board and is the incoming Chair of Social
in England is both adversity and trauma-informed. Enterprise UK. He is an associate of the Cambridge University Judge Business
School, and Birmingham University Centre for Health Service Management.
The papers present evidence, insight, direction and case studies for
commissioners, providers and practitioners. We hope that this collection will Dr Rebecca Adlington is a Clinical Psychologist and Manager of the
stimulate further growth in adversity and trauma-informed care, and spark Bereavement, Trauma and Crises Response Services at CHUMS. She has
innovation and good practice across England. worked at CHUMS since 2014 as a clinician in the Trauma Service and the
Emotional Wellbeing Service. Before this, she worked in adult Community
Mental Health and Clinical Health Psychology settings in Bedfordshire.
Rebecca completed her Doctorate in Clinical Psychology at the University
of Hertfordshire in 2012, during which time she published several articles
6 in the area of Problem Based Learning (PBL) and presented her thesis at 7
Sarah Brennan OBE the Paediatric Psychology Network UK Conference on the Narratives of
Chief Executive of YoungMinds Adolescents with Cystic Fibrosis. Rebecca completed a doctorate by research
in 2009 looking at category-specificity in people with Alzheimer’s Dementia.
Matilda Allen is a Public Health Consultant Trainee. She previously worked at

the UCL Institute of Health Equity as a senior researcher where she wrote a
number of publications relating to the social determinants of health and how
to improve them.
Associate Professor Mario Alvarez-Jimenez is Head of e-health at Orygen,

The National Centre of Excellence in Youth Mental Health. Associate
Acknowledgements Professor Alvarez-Jimenez leads a multidisciplinary team of 40 professionals
focused on bringing about long-term psychosocial recovery in youth mental
YoungMinds is grateful to: all of the authors and illustrators who have health through online social media-based interventions and new models of
contributed to this collection, the participants of the Beyond Adversity psychotherapy. Since 2010, Mario has attracted 24 competitive grants (12 as
clinical summits, the young people who shared their experiences and principal investigator), totalling $13.8 million in competitive research funding
helped to shape the principles for adversity and trauma-informed (over $5 million as principal investigator). In 2012, he was awarded the CR
care, and to Health Education England for part-funding the design, Roper Fellowship by the University of Melbourne, as well as the International
publication and dissemination of Addressing Adversity. Early Psychosis Association Young Investigator Award. In 2014, Mario was
awarded the Rising Star Award by the Society for Mental Health Research.

Authors and illustrators Authors and illustrators
Agnes Aynsley works within Addaction’s Kent Young Person’s drug and including so-called ‘legal highs’ and sits on the national clinical group that
alcohol services as the Specialist Treatment Team Leader. She oversees one monitors these substances. He was part of the Education and Prevention sub
to one interventions with young people involved in substance use. Agnes has group which informed the expert panel’s advice to the UK Government on
an additional specialism around wellbeing with a focus on nutrition and is the how to respond to New Psychoactive Substances trends, and also helped to
Child Sexual Exploitation (CSE) champion for the team. develop the Home Office resource pack for educators.
Andy Bell is the Deputy Chief Executive at the Centre For Mental Health and Sarah Brennan OBE is the Chief Executive of YoungMinds and has worked
recently won the President’s Medal for outstanding services for all with mental with vulnerable young people and families for over 30 years. She has acted
health conditions from The Royal College of Psychiatrists. He is a member of as an independent advisor on children and young people’s mental health to
the Mental Health Policy Group and was Chair of the Mental Health Alliance successive governments, and recently served as co-Chair of the Vulnerable
between 2006 and 2008. Andy has carried out research on the implementation Group and Inequalities task group of Future in Mind. Sarah currently Chairs
of national mental health policies, on local mental health needs assessments the London and South East CAMHS Collaborative, and serves the Mental
and writes a regular blog on mental health policy for the Huffington Post. Health Independent Advisory and Oversight Group, which oversees the
implementation of NHS England’s Five Year Forward View for Mental Health.
Dr Sarah Bendall is a clinical psychologist and senior research fellow at
Orygen: The National Centre of Excellence in Youth Mental Health, and the Lindsay Buchanan is the Addaction Mind and Body Coordinator for Cornwall’s
Centre for Youth Mental Health at the University of Melbourne, Australia. She ‘YZUP’ addiction service. She is a qualified youth worker and sociologist with a
has practiced as a clinical psychologist for over 20 years in a variety of settings keen interest in mental health issues and domestic abuse.
including adult and adolescent outpatient mental health. She leads research
into trauma in youth mental health and the development and trialing of new Naomi Burrows is the Team Leader at Young Addaction Lancashire. She is
8 psychological therapies for recovery in youth mental health. She is the author experienced in managing both substance misuse and mental health services, 9
of over 50 publications in these areas, including two psychological treatment and currently oversees the therapeutic and pharmacological substance misuse
manuals. She regularly trains mental health professionals in responding to team, local Mind and Body delivery and the CYP IAPT team. Naomi’s work
trauma in early psychosis. looks to reduce stigma associated with mental health conditions and aims to
educate and empower people to look after their own wellbeing.
Dr Lucy Bowes is a Leverhulme Early Career Research Fellow at the
Department of Experimental Psychology, University of Oxford. Lucy’s Dr Marc Bush is the Chief Policy Advisor at YoungMinds, and a Visiting
research focuses on the impact of early life stress on psychological and Professor in Public Health at the University of Northampton. He has an
behavioural development. In particular, Lucy has focused on the effects of extensive background in research, policy, and practice in the fields of disability,
victimisation on young people’s adjustment and wellbeing. Her research health, mental health, psychotraumatology, and childhood adversity. Marc
integrates methods from social epidemiology, developmental psychology is the editor of this collection, and authored YoungMinds’ Beyond Adversity
and behavioural genetics in order to understand the complex influences report.
that promote resilience to victimisation and early life stress. The aim of her
research is to guide interventions by identifying protective factors that Dr Carmen Chan is a clinical psychologist and Service Lead for Horizon, a
promote positive outcomes among vulnerable children. specialist CAMHS team working alongside professionals to support young
people and families affected by sexual harm. She is also a Visiting Tutor at the
Rick Bradley is the Operations Manager of the Addaction Mind and Body Oxford Institute of Clinical Psychology Training, University of Oxford. She has
programme which works with young people around self harming behaviours. specialised in working with interpersonal trauma and PTSD across the lifespan
He is a passionate advocate of early intervention support for young people, and she has extensive experience training professionals in this area. Her
encouraging open discussion of issues before they become more problematic. areas of research includes PTSD, trauma, shame, self-criticism and children’s
Rick also leads Addaction’s work around new psychoactive substances, experiences and disclosure of sexual abuse.

Dr Sarah Clement (PhD CPsychol) is a research psychologist and health Beth Filson (BA, MFA) is a US-based nationally recognised writer and trainer
services researcher. She has worked as an academic researcher and lecturer in Trauma-Informed Approaches (TIA). She works with diverse groups to
since 1993, and is now freelance. Her research on trauma and on mental integrate TIA in policy and practice, and co-authored Engaging Women in
health is informed by her lived experiences. Trauma-Informed Peer Support. She also contributes to the development
of Intentional Peer Support and peer support alternatives to the psychiatric
Jan Cooper is a qualified counsellor specialising in bereavement work and system. Her early experience of multiple hospitalisations informs her work.
currently sits on the advisory panel for the Childhood Bereavement Network
and also co-chairs the Hertfordshire and Bedfordshire Bereavement Alliance. Professor Peter Fonagy is a Professor of Contemporary Psychoanalysis and
She volunteered for CHUMS for several years before joining the staff Developmental Science and Head of the Research Department of Clinical,
team in 2009, coordinating referrals for bereaved children and families in Educational and Health Psychology at UCL, Chief Executive of the Anna
Bedfordshire. Jan managed the child bereavement service at CHUMS, and Freud National Centre for Children and Families, London, Consultant to the
more recently has taken on the role of bereavement and neonatal specialist. Child and Family Program at the Menninger Department of Psychiatry and
Jan provides individual and family pre-bereavement and bereavement support Behavioral Sciences at Baylor College of Medicine, Houston and holds visiting
and works with families where a baby has died. She regularly facilitates professorships at Yale and Harvard Medical Schools.
workshops and monthly ongoing groups for parents and carers, delivers
training to local professionals and facilitates training and supervision for Steve Haines has been working in healthcare for over 25 years and as a
bereavement volunteers. bodyworker since 1998. Understanding the science of pain and trauma has
transformed his approach to healing. He has studied Yoga, Shiatsu, Biodynamic
Betsy de Thierry (MA Psychotherapy and Counselling, B.Ed (hons)) has been Craniosacral Therapy and Trauma Releasing Exercises (TRE). He is a UK-
a qualified teacher and psychotherapist for over 20 years, and founded the registered chiropractor and teaches TRE and cranial work all over the world.
10 Trauma Recovery Centre (www.trc-uk.org) which has therapy centres and 11
alternative education centres in four cities across the UK. She has authored Corinne Harvey is a public health consultant at PHE Yorkshire and the
Teaching the child on the trauma continuum (Grosvenor Publishing) and also Humber, specialising in reducing health inequalities and improving health and
The Simple Guide To Child Trauma, published by Jessica Kingsley. She founded wellbeing. She has experience of working across the health system in a variety
the Therapeutic Mentoring Rooms which are within schools across the UK. of operational and strategic roles and continues to be a registered mental
She delivers training across the UK and is a consultant to many organisations, health nurse.
schools, Pupil Referral Units, virtual schools, therapy centres etc about the
impact of trauma on a child. Dawn Hewitt worked as a manager in the NHS for 11 years, and is responsible
for developing CHUMS’ Child Bereavement Service as a countywide service.
Dr Angela Donkin is the Joint Deputy Director of The Institute of Health In 2009 she was instrumental in setting up the charity Friends of CHUMS
Equity (IHE), leading their programmes to improve and disseminate evidence, to raise money to deliver a Trauma Service. Dawn led CHUMS through the
evaluate, monitor and provide strategic policy advice. Angela has worked in Department of Health’s Right to Request programme to become a social
applied social research for 25 years and is an expert on early years, health enterprise in 2011. As CEO of a social enterprise her focus changed from
inequalities, improving work and income for health, and sits on a number of clinical delivery to business development. With support from a committed
advisory and steering groups in this capacity. Before joining IHE Angela was team the service grew rapidly and now receives approximately 3000 referrals
a civil servant in ONS, DWP and the Cabinet Office. Towards the end of her annually. Dawn trained as a RGN (registered nurse) and later as a District
civil service career Angela managed the delivery of key government reports Nurse. She has an MSc in Leadership, as well as qualifications in management,
on Early Intervention and Health Work and Wellbeing and maintains research reflective practice, counselling and bereavement.
interests in sustainable international development and food and poverty.

Dr Kristine Hickle is a Senior Lecturer in Social Work at the University 20 book chapters and co-edited three books. Henry is a clinical psychologist
of Sussex. She received her PhD from Arizona State University in the who worked as a full-time public practice clinician for 13 years before entering
United States, where she was a practicing clinical social worker. Her social academia in 1991. From 2005–2007 Henry served as Head of the School of
work practice was primarily in the voluntary sector, working with sexually Behavioural Science (now renamed Psychological Sciences). In 2009, Henry
exploited young people and adults through the use of trauma-focused group was made a Fellow of the Academy of Social Sciences in Australia.
interventions. Her research interests include child sexual exploitation and sex
trafficking, developing and testing interventions that reduce trauma symptoms Dr Angela Kennedy (DClinPsych) is a clinical psychologist who has worked
among victims of exploitation and trafficking, group-work and group-based in the NHS since 1990. She is a trauma therapist and board member of the
interventions. She has written extensively about the experiences of adults and European Society for Trauma and Dissociation. Her focus is applying clinical
young people affected by sexual violence and trauma. knowledge towards system-wide change, including compassion focused
cultures and leadership.
Dr Nick Hindley is clinical lead for the Thames Valley Young People’s Forensic
Service, part of the Oxford Health NHS FT CAMHS provision, and specialises Professor Eóin Killackey is Head, Functional Recovery Research in Youth
in working with young people about whom there are concerns about risk of Mental Health at Orygen, The National Centre of Excellence in Youth
harm to others or who have particularly complex needs. The service includes Mental Health and the Centre for Youth Mental Health at The University of
the forensic CAMHS Thames Valley-wide, the Child and Adolescent Harmful Melbourne. He completed his doctorate at Deakin University in 2000. He has
Behaviour Service (CAHBS) which covers Oxon and Bucks, the Young People’s worked as a clinical psychologist in adolescent and adult public mental health
Liaison and Diversion Service for Oxon and the HORIZON Team which works settings. His research interests are functional recovery for young people with
with young people who have experienced sexual abuse in Oxfordshire. Dr mental illness, evidence-based interventions in mental health and barriers to
Hindley is involved locally and nationally in the development of support for, their implementation.
12 and meeting the needs of, high risk young people and those with complex 13
needs. He has experience of working in a number of custodial, secure and Dr Pooky Knightsmith is the Director of the Children, Young People and
community settings, and is the NHS England clinical lead for the national Schools Programme at the Charlie Waller Memorial Trust. She is also the Vice
implementation of community forensic CAMHS. Chair of the Children and Young People’s Coalition.
Dr Russell Hurn is a Consultant Counselling Psychologist and Clinical Almudena Lara joined the NSPCC in February 2017 as the Head of Policy
Director. Russell spent 11 years working for CAMHS in Hertfordshire before and Public Affairs. Prior to this, she worked at the Department for Education
leaving the NHS to join the Traumatic Bereavement Service at CHUMS. He where she held a variety of roles, including leading the social work reform
is the former Chair of the Child and Adolescent Section of EMDR UK and agenda, setting up the Innovation Programme and leading the children in care
Ireland. Russell has specialised in the treatment of trauma since 2005. His portfolio. Before joining the Department, Almudena worked at the Cabinet
recent roles have been to act as Clinical lead for the implementation of the Office and at the Prime Minister’s Strategy Unit leading the social investment
CYP IAPT programme within the service and form closer working links with and social action agenda. Almudena started her career as an economic
the local CAMHS teams. Russell has also been developing the trauma service consultant at Frontier Economics, where she worked for eight years.
over the last couple of years to widen its focus to the treatment of children and
young people presenting with non-bereavement trauma. Dr Warren Larkin is a Consultant Clinical Psychologist and Visiting Professor
at Sunderland University. He is also the Clinical Lead for the Department of
Professor Henry Jackson is Emeritus Professor in the Melbourne School Health Adverse Childhood Experiences programme and a Director at Warren
of Psychological Sciences at the University of Melbourne. Henry’s research Larkin Associates Ltd. He has a long-standing interest in the relationships
expertise is in clinical psychology with regards to youth mental health and between childhood adversity and outcomes later in life. He has spent most of
severe mental illness, especially in the fields of early psychosis and personality his career working in specialist early intervention services with service users
disorders. He has authored or co-authored 203 papers in refereed journals, who are experiencing psychosis. He has published numerous research articles

on the topic of trauma and psychosis and published an edited book with Rosie Powell-Davies began her career at the NSPCC as a Charityworks fellow
Tony Morrison in 2006 (now commissioned for a second edition) exploring in September 2016. Since completing the 12-month programme she has
this theme. Warren led one of the two national IAPT (Increasing Access to continued to work in the Policy and Public Affairs team as the Policy and Public
Psychological Therapies) demonstration sites for Psychosis and was a member Affairs Assistant. Prior to this, Rosie was studying at the University of Oxford
of the Children and Young People’s Mental Health Services National Task for undergraduate and postgraduate qualifications.
Force. Warren also developed the REACh approach (Routine Enquiry about
Adversity in Childhood) as a way of assisting organisations to become more Jo Prestidge is a project manager at Homeless Link, the national membership
trauma-informed and to support professionals to ask routinely about adversity body for the single homelessness and supported housing sectors in England.
in their everyday practice. She works on a portfolio of projects to bring innovation and improve practice
across the homelessness sector. Before joining Homeless Link, Jo worked
Georgie Lowry is a graphic designer working in the north of England. A in frontline homelessness services for several years, mostly with street
background in mathematics and statistics combined with a natural creative homeless people with multiple and complex needs. In 2014 Jo participated
flair led her to set up GS Lowry Design in 2012. She now works almost in a transatlantic practice exchange and spent time in the US learning about
exclusively in non-profit and education sectors, fulfilling infographic and trauma-informed practices. Having learned about trauma and the principles of
editorial design needs for many national charities and organisations. trauma-informed care, Jo was quickly able to change her own practice and see
an impact with the people she supported. Since then Jo has become a strong
Rob McCabe is the strategic lead for the Birmingham SEMH Pathfinder. advocate for the approach, developing and delivering training and speaking at
His experience includes 16 years as a senior education social worker and a number of events.
manager in the Criminal Justice System, based in Birmingham. Rob has
extensive frontline and strategic social work experience and has built up Kathryn Pugh MBE works at NHS England as the Deputy Head of Mental
14 specialist knowledge of young people and families with multiple complex Health, and leads the Children and Young People’s Mental Health Programme 15
needs. He also has substantial experience of multi-agency working with the which contributes to NHS England’s implementation of Future in Mind and the
many professionals and agencies involved in such complex cases. Rob has Five Year Forward View for Mental Health. Past roles include work in primary
undertaken research and development work for Birmingham Local Authority care, commissioning primary, secondary and specialist care in both acute and
to understand the profile and systemic processes of multiple and complex mental health and a role as Head of Policy and Innovation at YoungMinds.
needs cohorts in Birmingham. He is also working with the West Midlands She led the programmes to implement the children and young people’s
Combined Authority to inform the complex needs strand of Public Services amendments to the Mental Health Act, and to improve transition for the
Reforms. National CAMHS Support Service and National Mental Health Development
Unit, as well as the development of the CYP IAPT programme.
Lisa McCrindle was Policy Manager at the NSPCC before joining the
Centre of Expertise for child Sexual Abuse in the summer of 2017. She is Claire Robson is an experienced public health specialist in Public Health
an experienced public policy manager, researcher and evaluator with over England’s national Health Improvement Directorate. Claire’s experience
14 years’ experience working in public policy across the children and young spans local health improvement delivery, national and regional programme
people’s agenda. Lisa’s career has focused on the issues affecting, and the management, policy development and organisational design gained from
provision of services and support to, women, families, children and young working in a variety of roles across the NHS, the private sector and in regional
people. She has a particular focus on those from disadvantaged and and national government.
vulnerable groups.
Katharine Sacks-Jones is the inaugural Director of Agenda, the lliance
forwomen and girls at risk. She has 15 years’ experience working across policy,
campaigns, public affairs and parliament. She is an expert in social policy and
has a track record of influencing the policy, political and media agendas and

bringing about policy change for marginalised groups including securing new Sanjana Verghese is a student at King’s College London, and was a Policy
primary legislation to protect private tenants whose landlords are repossessed; and Parliamentary Engagement Intern at YoungMinds in 2017. Her interests
funding for homelessness services and programmes and the prevention of include public health, the environment and policy development.
specific benefit cuts. Before joining Agenda, Katharine led the Policy and
Campaign team at Crisis. She has written extensively on issues around social Clare Wightman is Chief Executive of Grapevine Coventry and Warwickshire.
exclusion including for the Guardian, Telegraph and New Statesman. She is an Associate of Lankelly Chase Foundation, advising and coaching on
systems change within the Pathfinder. She co-leads Ignite, a system change
Lucas Shelemy is a PhD Researcher at the University of Reading, specialising programme in Coventry, and Causes not Consequences, a social movement-
in child and adolescent mental health. inspired community for change in local public services.
Dr Graham Simpson-Adkins is a clinical psychologist in a specialist community

learning disability team in Mersey Care NHS Foundation Trust. Graham
previously acted as the subject area expert in Adverse Childhood Experiences
for Lancashire Care NHS Foundation Trust and project development lead and
co-developer of the Department of Health’s national programme to implement
Routine Enquiry about Adverse Childhood Experiences, Sexual Abuse and
Sexual Exploitation – an approach designed to assist organisations across the UK
to become more trauma-informed and to support professionals to ask routinely
about adversity in their everyday practice. Graham has published articles and
research on the topic of trauma, mental health and clinical practice approaches
16 and has a long-standing interest in the impact of trauma and adversity. 17
Sophie Standing is a London-based illustrator. Her interest in human anatomy
often inspires her work, including the popular comics Trauma is Really Strange
and Pain is Really Strange.
Dr Angela Sweeney (MA Hons (Cantab) PhD) is a trauma survivor and

researcher. She’s worked in mental health research since 2001 on a variety of
predominantly health services research studies. She has a particular interest
in perinatal mental health and trauma-informed approaches. Her current
research is aimed at understanding and improving assessment processes for
talking therapies.
Matthew Todd was editor of the UK’s best selling gay magazine, Attitude,
from 2008-2016 where he was the recipient of 3British Society of Magazine
Editor Awards and the Stonewall Journalist of the Year Award 2011. His play,
Blowing Whistles, has played in London, Australia and America. His first book,
Straight Jacket: How to be gay and happy, was published by Bantam Press
in June 2016 and has been described by readers as “game changing and life
changing”, as “utterly brilliant” by Owen Jones in The Guardian and as “an
essential read for every gay person on the planet” by Sir Elton John.

Contents
Contents
11. Trauma-informed care for children with complex needs in the youth
0. The impact of childhood adversity justice system
Summary infographic 22 Caroline Twichett and Sue Sylvester (NHS England) 160
1. Childhood adversity and trauma: an introduction 12. Meeting the mental health needs of looked-after children and care leavers
Dr Marc Bush 26 Prof. Peter Fonagy 170
13. Straight Jacket: the mental health consequences of LGBT+ prejudice

Section 1: Understanding adversity, trauma and resilience 57 Matthew Todd and conclusion with Dr Marc Bush 179

2. Adverse Childhood Experiences (ACEs), health outcomes and risk factors 14. Responding to the traumatic impact of racial prejudice
Matilda Allen and Dr Angela Donkin 58 Lord Adebowale CBE and Dr Marc Bush, with Sanjana Verghese 199

3. Trauma is really strange 15. Investing in gender and trauma-informed services
Steve Haines and Sophie Standing 81 Katharine Sacks-Jones 219

4. Childhood adversity and lifetime resilience 16. Tackling child abuse in local transformation planning
Dr Lucy Bowes 90 Lisa McCrindle, Almudena Lara and Rosie Powell Davies 228
18 19
5. Building resilience in the face of adversity 17. Up-skilling the housing sector
Lucas Shelemy and Dr Pooky Knightsmith 100 Jo Prestidge 236

Section 2: Addressing childhood adversity and trauma (a national view) 109 Section 3: Emerging good practice (a local view) 245

6. Moving Beyond Adversity 18. Enquiring about childhood adversity and trauma (Lancashire)
Dr Marc Bush and Sarah Brennan OBE 110 Dr Warren Larkin and Dr Graham Simpson-Adkins 246
7. Young people’s principles for adversity and trauma-informed care 19. Rethinking specialist and liaison services for young people who have
YoungMinds activists 123 experienced adversity or trauma (Oxfordshire)
Dr Nick Hindley and Dr Carmen Chan 256
8. Creating trauma-informed mental healthcare in the UK
Dr Angela Sweeney, Dr Sarah Clement, Beth Filson and Dr Angela Kennedy 125 20. Addressing adversity through alternative education
(South West England – Bath)
9. Adverse Childhood Experiences: a public health concern Betsy de Thierry 269
Claire Robson and Corinne Harvey (Public Health England) 140
21. Embedding a trauma-informed approach in the community and
10. What works in addressing childhood adversity voluntary sector (South East England – YMCA)
Kathryn Pugh MBE (NHS England) 152 Dr Kristine Hickle 279

Contents
Abbreviations
22. A youth-led approach to tackling adversity / street triage
(London – Camden and Southwark)
Andy Bell 290 Wherever possible the contributors to this collection have avoided using
abbreviations. There are some papers where the use of abbreviations makes
23. Trauma-informed commissioning for substance misuse amongst the content easier to read. We have included a short list of the most frequently
young people (Cornwall, Kent and Lancashire – Addaction) used here, so the reader has a place to refer back to if they need clarity.
Agnes Aynsley, Rick Bradley, Lindsay Buchanan, Naomi Burrows and
Dr Marc Bush 298
ACEs Adverse Childhood Experiences
24. Trauma-integrated psychotherapy for psychosis (TRIPP) (Australia) ASD Acute Stress Disorder
Dr Sarah Bendalla, Prof Mario Alverez-Jimeneza,
BAME Black and Minority Ethnic (sometimes expressed as Black, Asian or
Prof Eoin Killackeya and Prof Henry Jackson 313
Arab and Minority Ethnic)

25. Supporting children who experience loss and bereavement BESD Behavioural, emotional and social difficulties – recently renamed
(Bedfordshire) ‘social, emotional and mental health difficulties’
Dr Rebecca Adlington, Dr Russell Hurn, Dawn Hewitt and Jan Cooper 324 CAMHS Child and Adolescent Mental Health Services
CCG Clinical Commissioning Groups
26. Re-thinking family interventions from an ACE perspective (Birmingham)
20 Clare Wightman and Rob McCabe 336 CSE Child Sexual Exploitation 21
DSM – 5 Diagnostic and Statistical Manual of Mental Disorders (fifth edition)
DTD Developmental Trauma Disorder
An agenda for change 345
EHCP Education, Health and Care Plan
27. Addressing adversity – an agenda for change ICD 10 International Classification of Diseases (10th revision)
Sarah Brennan OBE 346 LGBT+ Lesbian, Gay, Bisexual and Transgender and the wider queer,
questioning, non-binary and intersex communities
LTPs Local Transformation Plans
Annexes 349
MHPs Mental Health Professionals
Annex A: ‘National household survey of adverse childhood experiences NHS National Health Service (in England)
and their relationship with resilience to health-harming behaviours in
PTSD Post Traumatic Stress Disorder
England’ Original paper. Various 350
SDH Social Determinants of Health
Annex B: ‘Relationships between adverse childhood experiences and adult SEND Special Educational Needs and Disability
mental well-being: results from an English national household survey’ STPs Sustainability and Transformation Plans
Original paper. Various 360
TIC Trauma-Informed Care (also used to refer to adversity and trauma-
informed care)

The impact of childhood adversity Key messages infographic
Addressing childhood adversity and trauma HOW COMMON ARE ACES?
WHAT IS ADVERSITY? Around half of all adults

living in England have experienced at least one
Adverse Childhood Experiences (ACEs) are highly stressful, form of adversity in their childhood or adolescence
and potentially traumatic, events or situations that
occur during childhood and/or adolescence Of all children and young people:
It can be a single event, or prolonged threats to, and breaches of, a young person’s safety, security,
trust or bodily integrity. These experiences directly affect the young person and their environment, 52% experienced 0 ACEs
23% experienced 1 ACE
and require significant social, emotional, neurobiological, psychological or behavioural adaptation.
Adaptations are children and young people’s attempts to:

Survive in Find ways of mitigating or Establish a Make sense of
16% experienced 2-3 ACEs
their immediate
environment
tolerating the adversity by
using available resources
sense of safety
or control
the experiences
they have had 9% experienced 4+ ACEs
22 WHAT KINDS OF EXPERIENCES ARE ADVERSE? HOW DOES IT IMPACT THE LIVES OF YOUNG PEOPLE? 23
Forms of ACEs include: ACEs impact a child’s development, their relationships with others,
and increase the risk of engaging in health-harming behaviours, and
experiencing poorer mental and physical health outcomes in adulthood.
Compared with people with no ACEs, those with 4+ ACEs are:
Maltreatment Violence & coercion Adjustment Prejudice

i.e. abuse or neglect i.e. domestic abuse,
gang membership,
being a victim of crime
i.e. migration, asylum
or ending relationships
i.e. LGBT+ prejudice,
sexism, racism or disablism 2x
more likely to
3x
more likely to
4x
more likely
5x
more likely
16
binge drink and be a current to have low levels to have had
have a poor diet smoker of mental wellbeing underage sex
& life satisfaction
Household or
family adversity
Inhumane
treatment
Adult
responsibilities
Bereavement
& survivorship 6x
more likely to
7x
more likely
11x
more likely
11x
more likely
i.e. substances misuse, i.e. torture, forced i.e. being a young i.e.traumatic deaths,
intergenerational trauma imprisonment or carer or involvement surviving an illness have an unplanned to have been to have used to have been
destitution, or deprivation institutionalisation in child labour or accident teenage pregnancy involved in violence illicit drugs incarcerated

The impact of childhood adversity Key messages infographic
WHAT PROTECTS YOUNG Flexible “Shape your support around me”

Positive provides services that young people
PEOPLE FROM ACES? and supportive can easily access, does not rely on a
ies
olic formal psychiatric diagnosis, and
ed p ddress family
a Sa “Find a way that we can both understand each other”
m t a ent targets children who live in adverse
Not all young people who ha assm n environments rela nd m
or safeguarding b syste -infor
fe tual
t and traumatic environments.
face childhood adversity ar satio with io
or v ing, h t
u ips
ully ms
support, therapeutic & Trauma
i
nsh ers
or trauma go on to “The way you “Know where
m
Safe and responsible
pe
icti
develop a mental treat me matters” I’m coming from”
Early intervention from

health problem. intervenes early, avoids
and understanding
wider supportive
re-traumatising or stigmatising
Access to a
community
services
There are personal, young people, and ensures staff
“Keep me safe and don’t betray my trust”
structural and are knowledgable, qualified,
trustworthy and well‐trained.
environmental factors
that can protect against “Include me in decisions “I want to talk
Collaborative and enhancing
Co m t t u ne
to someone
l d nage ns
about my life”
e m to
adverse outcomes, as
su p o m pr
si
pas
a tio
a t i ve
l
d a o n a te A bi e
it y
who has been
o
p or o
involves young people in decisions about

fr
e ss
shown in the protection res nd , lat
re g u a n d m a
their care and the design of services, adopts a
is t r
fes po A q u i s iti o n through the
wheel opposite. sio n s e s
ti o n
o f p ra c t i c a l strengths-based approach, and ensures services
n al
s emo recognise and harness community assets. “I’ve survived this long” same thing”
p ro b l e m -s o l v i n g
skills
Integrated “Don’t pass me from person to person”
WHAT CAN WE DO ABOUT IT? co-commissions services, and
24 ensures smooth transitions and “Stop asking me to repeat myself” 25
Commissioners can address childhood adversity and trauma by: communications between partners.
Making childhood Creating a common Investing

adversity and identification in adversity WHERE IS THE EMERGING GOOD PRACTICE?
trauma a local
commissioning
priority
1 and enquiry
framework for
identifying need
2 and trauma-
informed
models of care
3 • Enquiring about childhood adversity and trauma (Lancashire)
• Family-based interventions from an ACE perspective (Birmingham)
• Specialist and liaison services (Oxfordshire)
Adversity and trauma-informed models of commissioning and care are always:
• Youth-led approaches to tackling adversity (London)
Prepared “When you notice, or I tell • Embedding a trauma-informed approach in the community
ensures addressing ACEs is a strategic priority,
you that I need help, you and voluntary sector (Sussex and Surrey)
analyses the available data and anticipates need should already know what • Education and alternative approaches (Bath)
in local commissioning and service pathways. the next step is”
• Trauma-informed approaches in substance misuse (Cornwall)
Aware “Recognise all “Don’t label Sources:
understands childhood adversity and trauma, of my needs” me with the Bellis MA, Hughes K, Leckenby N, Perkins C and Lowey H. (2014) ‘National household survey of adverse childhood
has a common framework for identification and experiences experiences and their relationship with resilience to health-harming behaviors in England’ BMC Medicine 2:72.
routine enquiry, and responds appropriately to Hughes, K., Lowey, H., Quigg, Z. and Bellis, M. A. (2016) ‘Relationships between adverse childhood experiences and
the cultural and personal characterises of the “Understand my behaviour” I’ve had” adult mental well-being: results from an English national household survey’ BMC Public Health 16:222.
young person and their communities. You can read the full text of these articles in the Annexes of this collection, republished with the permission of BioMed Central.

Childhood adversity and trauma: an introduction
1. Childhood adversity and trauma: That said, many children and young people grow up in environments, or have
an introduction
experiences, that are more than emotionally distressing or difficult. These
environments and experiences are adverse, and have a potentially traumatic
and long-lasting impact on our development, health and way of life.
Dr Marc Bush
Adverse Childhood Experiences (ACEs) are more common than you might
think.
1. Introduction Almost half of all adults living in England have experienced at least
one form of adversity in their childhood or adolescence2.
Addressing Adversity aims to raise awareness about the impact of childhood
adversity and trauma on the mental health of children and young people in This broadly reflects the picture of childhood adversity in other developed
England. It contains papers from leading academics, clinicians, commissioners countries3. These adversities can include experiences of neglect, abuse and/
and frontline professionals who all share a passion for ensuring that services or violence within the home or local community, the unexpected loss of a
and support for children and young people are adversity and trauma-informed. caregiver or a sibling and taking on adult responsibilities4.
In this introductory paper, we have provided an introduction to childhood These ACEs are exacerbated by wider social conditions and circumstances
adversity and trauma, drawn out some of the key debates and focused on the that create inequalities in the ways that children and young people live, and are
impacts it has on the lifelong health outcomes of children and young people in treated by those around them5. These inequalities include levels of material
England. This introduction builds upon the Beyond Adversity report1 published deprivation or child poverty6 and institutional prejudice in state and support
26 by YoungMinds in 2016. services. 27
Navigation boxes For more on:

• the Social Determinants of Health see Paper 3.
We have included navigation boxes so the reader knows where in
the collection they can go for further detail and examples of good • institutional prejudice see Papers 14 and 15.
practice – just look out for this symbol.
The term Adverse Childhood Experiences was popularised through US studies

exploring the impact of adversity on people’s health and behaviours across the
lifecourse7. Since the original study, researchers have used various definitions8
2. Childhood adversity and measurement frameworks9 to describe what an ACEs is, and the impact it
can have on young people’s mental health, behaviours and wellbeing.
We all face emotionally challenging situations during our childhood and
adolescence. It is a normal part of growing up, and this emotional distress Inevitably, the papers in this collection draw on varying traditions and
can come from moving to a new area, feeling stressed revising for exams, definitions of childhood adversity. By way of bringing together all of these
falling out with friends or forming and experimenting with our identities and important contributions, YoungMinds builds on Dr Katie McLaughlin’s
sexualities. proposed definition10 and recent developments that aim to expand the more
restrictive conventional definition11.

Chapter 1 Childhood adversity and trauma: an introduction
Adverse Childhood Experiences

Prejudice: discrimination, victimisation, hate incidents
Adverse Childhood Experiences (ACEs) are highly stressful, and potentially and crime, other attitudes, chronic exposure to
traumatic, events or situations that occur during childhood and/or behaviours and institutional processes driven by LGBT+
adolescence. It can be single event, or prolonged threats to, and breaches prejudice, sexism, racism or disablism.
of, the young person’s safety, security, trust or bodily integrity. These
experiences directly affect the young person and their environment, and Household or family adversity: including living in a
require significant social, emotional, neurobiological, psychological or household with adults or adolescents who misuse
behavioural adaptation. substances, engage in criminal activities, are not
supported to manage their mental ill health, making
Adaptations represent children and young people’s attempts to: survive in sense of intergenerational trauma (such as experiences
their immediate environment (including family, peer group, schools and local of genocide). It also includes living in poverty,
community), finding ways of mitigating or tolerating the adversity by using destitution or facing significant social, material and
the environmental, social and psychological resources available to them, emotional deprivation. It also include being looked-
establishing a sense of safety or control, making sense of the experiences after, leaving care, being detained in a secure children’s
they have had, the community or family that they are growing up in and the service (i.e. young offenders institution) and family or
identity they are forming. placement breakdown.
To make this definition more tangible, we have listed below different Adjustment: including moving to a new area where
experiences that constitute childhood adversity under this definition. These there are no social bonds, migrating, seeking and gaining
28 examples draw on the feedback YoungMinds received from the publication of refuge or asylum and the ending of a socially significant, 29
Beyond Adversity, and the clinical summit we held in the Winter of 2017. or emotionally important relationship.
Adult responsibilities: including being the primary carer

Examples of Adverse Childhood Experiences (ACEs) of adults or siblings in the family, taking on financial
responsibility for adults in the household and engaging
Maltreatment: including physical, sexual, emotional and in child labour.
financial abuse and neglect.
Bereavement and survivorship: including death of care
Violence and coercion: including experiencing, or directly giver or sibling (including through suicide or homicide),
witnessing, domestic abuse, assault, harassment or miscarriage, acquiring or surviving an illness or injury
violence, sexual exploitation, sexually harmful behaviour, and surviving a natural disaster, terrorism or accident.
being the victim of crime or terrorism, experience of
armed conflict, gang or cult membership and bullying.
Inhumane treatment: including torture, forcible Sections 2 and 3 of this collection consider the specific
imprisonment, confinement or institutionalisation or mental health needs arising from many of these forms of
confinement, non-consensual and coercive scarification adversity.
and genital mutilation.

In reality there is significant overlap in children’s experiences of these Figure 1: ACEs Framework
adversities. One study from England shows 16% of adults experience two or
three ACEs, and almost one in 10 experience four or more12. This means that
many children experience the cumulative impact13 from different forms of
ACEs on their health and wellbeing outcomes in adolescence and adulthood14.
Conception
Illustrating this, a recent report of the National Confidential Inquiry into Suicide Experience of adversity and trauma
and Homicide by People with Mental Illness15 found that the "circumstances
that lead to suicide in young people often appear to follow a pattern of Disrupted neurodevelopment
cumulative risk”. The cumulative risk pattern involves a) traumatic experiences
in early life, b) a build up of adversity and high risk behaviours (as a response) Aquiring / exhibiting social,
in adolescence and early adulthood, and an adverse event (which may be emotional and cognitive problems
seemingly insignificant, but hold significance and importance for the young
person) precipitating the suicidal behaviour. Adoption of risky and
challenging behaviours
When children and young people are exposed to these adversities across their Increased
childhood and/or adolescence we can think of it as being developmental – in * living with physical
morbidity * and / or mental ill health
that it will have an impact on the ways in which the young person grows up,
experiences their environment, explores their identity, and not to mention the Premature ** dying earlier than would
delays and alterations it can cause in the way that they think and behave. mortality** otherwise be expected
30 31
For more statistics about ACEs in England see Paper 2.
Death
Source: adapted from the CDC-Kaiser ACE Study [1998]

3. The impact of childhood adversity
A major US study16 uncovered a strong relationship between ACEs and risk Research has clearly shown that experiencing adversity in childhood has a
factors for ill health and poor wellbeing. Research in England17, Wales18 and substantive impact across the lifecourse22. These experiences increase the risk
Scotland19 replicated these findings and suggest that ACEs are strongly of poorer physical23 and mental health outcomes in adulthood24.
associated with adverse behavioural, health and social outcomes in childhood,
adolescence, adulthood and later life. Furthermore, ACEs also result in higher rates of avoidable death25 from
natural causes 26, including from the leading causes of early adult deaths
All these studies were based on an evidence-based, conceptual framework (such as heart disease, respiratory disease and cancer)27. Women who had
for thinking about the impact of ACEs on a child over the course of their life20. experienced one adversity had a 66% increased risk of premature death, and
This model demonstrates that there is a progression of outcomes. Below is those who had experienced two or more adversities had a 80% increased
an adapted version of the ACEs framework, which we developed from our risk compared to their peers. In contrast, men who had faced two or more
Beyond Adversity report21. adversities in childhood have a 57% increased risk of early death28 compared
to their peers.

Additionally, ACEs are associated with a significantly higher risk of suicidality adolescence and adulthood40, as well as an increased risk of enduring mental
in adolescence29, adulthood30 and later life31. Sadly, these young people are health problems (including experiencing psychosis)41. Subsequently, children
also more likely to die from non-natural causes32 than would otherwise be who have faced adversity are more likely to use psychiatric medicines that
expected33. have an additional adverse impact on their physical health in the longer term42.
For more on the impact of childhood adversity across the lifecourse

see 2, 3, 9 and 10. 1in3
diagnosed mental health conditions in adulthood are
known to directly relate to adverse childhood experiences
4. Childhood adversity and mental ill health By way of illustration, we can clearly see increased emotional distress and
mental ill health among children and young people who have faced one or
Around one in 10 children and young people have a diagnosable mental health more of the forms of adversity described previously.
condition34. Many young people do not have a clinical diagnosis, but experience
a period of mental ill health or emotional distress during their childhood or
adolescence. The Government’s own measures of children’s wellbeing found
that almost one in four showed some evidence of mental ill health (including Examples of the mental health consequences of ACEs
anxiety and depression)35.
32 Bereavement: over three in 100 young people experience the death of 33
It has been suggested that over the last decade there has been an increase in a parent, primary care giver (such as a carer or grandparent) or sibling43
the number of children who are presenting with mental ill health36, and whose before the age of 16 years44. Bereaved children are 1.5 times more
needs are being identified by professionals37. It is hard, however, to say for likely than their peers to be diagnosed with a mental health condition45,
certain whether or not the actual number of children experiencing mental ill and have three times the risk of experiencing depression than their
health is increasing, or whether there has been an increase in identification peers (irrespective of the cause of death)46. Within this group, children
and diagnosis. who lose their parents or carers when they are very young, or to
death from external causes (such as suicide, accident or homicide),
It is vital that we identify adversities that children and young people face are at a higher risk of depression in childhood and adolescence47.
as early as possible to ensure we can mitigate the impact of this additional Understandably, children who experienced more than one death, or
complexity and prevent further escalation of emotional distress and mental ill consecutive death, of a close family member or friend have increased
health. The majority of enduring mental health problems manifest in teenage depressive symptoms as a result of the adversity they have faced48.
and young adulthood, and it is estimated that half of all mental health problems
manifest before the age of 14 years, with one in four enduring mental health Violence: it has been suggested that around two in five victims of Child
conditions being present by the age of 24 years38. Sexual Exploitation (CSE) experience mental health problems and are 17
times more likely to experience a psychotic episode than their peers49.
Research suggests that at least one in three diagnosed mental health An enquiry held by the Children’s Commissioner for England found that
conditions in adulthood are known to directly relate to adverse childhood around one in four children were exhibiting mental health problems, with
experiences that have subsequently impacted on their psychological almost a third having self-harmed as a result of their experience, rising to
development and wellbeing39. Furthermore, childhood adversity is over three quarters of those they interviewed directly50.
accompanied by lower levels of mental wellbeing and life satisfaction in

environment63. This is associated with problems with sleeping64 as the child

Household and family adversity: just under one in 100 children are grows older. As such, many children who experience trauma find it difficult to
looked after by the State, and are living in care51. Research suggests calm themselves, and return to a "window of tolerance”, which represents a
that children who are looked-after (including those who are fostered52), safe and optimum level of arousal65.
are around four times more likely to have a diagnosable mental health
condition than their peers53. The higher risk of poor mental health can An alternative response to trauma is disassociation, by which a child might try
be seen in the two in five looked after children that have a diagnosed to separate their emotions from the overwhelming feelings of distress they
behavioural condition54 and the three in five more that have some form experienced at the time of the adversity. These children may feel unconnected
of emotional and mental health problem55. As a consequence of their with their body or a specific body region or area associated with the trauma.
experiences, and the lack of support they frequently face during life They may also feel an emotional numbness and significant cognitive fatigue
transitions, looked-after children and care leavers are between four if they try to recall or remember66 anything related to the experience –this
and five times more likely to attempt suicide in adulthood56. is also known as being in a state of hypoarousal. Sometimes it seems as if the
child has spaced out or is emotionally absent67. Some of these young people
consequently are unable to experience pleasure as a result of activities that
would usually be pleasurable, such as music, social interaction or sexual
encounters (also called anhedonia)68.
5. Neurobiological and neurocognitive changes
Repeated adversity and trauma in childhood results in the overstimulation of
Experiencing childhood adversity fundamentally alters the course of a hormones (cortisol) that are intended to help mitigate stress. Over-exposure
child or young person’s development. Recent studies have found that these to these stress hormones can suppress the response of the hippocampus
34 experiences are ‘likely to influence fundamental biological processes and (affecting both memory and behavioural responses) and significantly impact 35
engrave long-lasting epigenetic marks, leading to adverse health outcomes the areas of a child’s brain that are still developing69.
in adulthood’57. In other words, experiencing ACEs can trigger genetic
predispositions towards mental ill health58. This includes impairing the prefrontal cortex, which continues to develop
during childhood and adolescence, and is responsible for making sense of
For example, witnessing domestic violence is the most frequently reported executive thought and cognition70. As such, children who experience adversity
form of childhood adversity59. Research using neuroimaging has shown that and trauma create new neural pathways in the brain that are highly sensitive to
experiences of domestic violence in childhood can change brain structures and threats and heighten children’s arousal.
increase the risk of mental ill health, in a way that is akin to soldiers who have
trauma following armed conflict60. As a result of trauma, children who face adversity and complexity are unable
to effectively engage in important learning experiences that help to shape
Experiencing adversity during childhood impacts our autonomic nervous child development71. For example, they may not feel safe enough to play with
system. These experiences can alter our neuroception, which is our automatic their peers, might feel ambivalent towards family, friends and siblings, or may
detection of whether or not there is a threat in our external environment61. be mistrustful of, and distressed by, authority figures in formal education. Dr
This means that these children and young people spend a significant amount Katie McLaughlin and colleagues found different alterations depending on
of time in a state of hyperarousal, facing significant emotional distress, which whether the adversity was threat or deprivation related72.
adversely changes a young person’s ability to regulate their emotions (also
known as affect dysregulation)62.
Experiencing psychological trauma can also create a hypervigilance, in which

the young person is continually looking to identify and detect threats on their

6. Childhood adversity and traumatic stress Mental Disorders (DSM-5) describes the symptoms and suggested treatment
for PTSD and includes a consideration of manifestations of PTSD in children
There is significant overlap between the terms ‘Adverse Childhood who are six years old, or younger75. There is also a new ‘dissociative subtype'
Experiences’ and ‘childhood trauma’. The Substance Abuse and Mental Health of PTSD, which focuses on feelings of disconnectedness and detachment from
Services Administration (SAMHSA)73, for example, defines trauma as ‘a single one’s body or experiences76. Furthermore, it notes that many young people
event, multiple events, or a set of circumstances that is experienced by an who experience PTSD will have at least another co-occurring diagnosable
individual as physically and emotionally harmful or threatening and that has mental health condition related to the adverse experiences they have had.
lasting adverse effects on the individual’s physical, social, emotional or spiritual This might include anxiety, eating disorders, adjustment disorders, conduct
wellbeing’. and personality disorders, somatic disorders or the problematic misuse of
substances.
Perhaps the greatest difference in the use of the terms is that while ACEs
describe the events or situations that children and young people face that Similarly, the International Classification of Diseases (ICD 10) contains a
lead to mental health problems (including traumatic stress), childhood specific classification of PTSD (with a similar aetiology and symptomology as
trauma describes experiences directly relating to traumatic stress. That said, the diagnosis in the DSM-5) and also references a second classification that
in reality many clinicians, policy makers and commissioners use the terms refers to a ‘transition to an enduring personality change’77. The ICD 10 is
interchangeably. As such children and young people who experience mental ill currently in the process of being revised for an eleventh time and it has been
health as a consequence of adversity (whether or not it manifests as traumatic suggested that this associated classification be renamed ‘complex PTSD’78,
stress) should be kept in mind when designing commissioning strategies and which has a higher threshold of adversity, including experience of disaster,
service interventions. prolonged possibility of death and exposure to life threatening situations.
36 While all children and young people will experience some form of emotional The DSM-5 also includes the diagnosis of Acute Stress Disorder (ASD), which 37
distress, and neurobiological, neuroceptive and neurocognitive changes as is seen as within a normal range of response to adversity. The symptoms of
a result of the trauma and adversity, not all of these will result in enduring traumatic stress usually develop within a month of a single adverse event or
mental health conditions, nor will they necessarily lead to a trauma-related situation. This can involve a wide range of trauma-related responses including
diagnosis. The majority of children and young people find ways of overcoming intrusive memories or thoughts, nightmares, flashbacks, psychological
the adversity they have faced by drawing on the internal or external resources distress when play resembles the traumatic event, a persistent negative
and support available to them, and it does not have a substantive nor long term mood, disassociation, problems sleeping or concentrating, unprovoked
impact on their everyday life, relationships with others or social functioning. aggressive behaviour, or continuous scanning for threats in the immediate
However, around one in three children and young people who have a traumatic environment. The main difference between ASD and PTSD is that you need
experience will go on to develop symptoms that could lead to a traumatic to be experiencing fewer symptoms to get an ASD diagnosis, and they tend to
stress-related psychiatric diagnosis74. subside after a month, whereas in PTSD they persist for a much longer period
of time.
Existing psychiatric diagnoses recognise the traumatic stress related to
children’s mental health and emotional wellbeing. The most well known is In both situations the psychiatric symptoms of traumatic stress can be delayed
Post Traumatic Stress Disorder (PTSD), which originates from exposure to or missed. This is especially true in situations where children or young people
adverse and traumatic events, and results in significant distress in recalling remain in an adverse environment. For example, Professor Eamon McCrory
the traumatic event(s), accompanied by behaviours and ways of thinking that and colleagues have found common neurocognitive alterations in adults who
avoids confronting the trauma, are self-destructive, or affect the mood of the have experienced adversity (whether or not they have a diagnosed mental
young person. health condition), and that they can be used to predict future psychiatric
symptoms and mental ill health79. As a result, they propose the idea of ‘latent
The latest version (fifth edition) of the Diagnostic and Statistical Manual of vulnerability’, arguing that more attention needs to be given to pre and sub-

clinical symptoms of mental ill health resulting from adversity80. They call 7. Behaviours seen as risky and challenging
for an indexing of latent vulnerability, which would include early indicators
of altered neurocognitive functioning, such as changes in threat and reward In the face of significant adversity and complexity, many children and young
processing, and to autobiographical memory. people adopt risky or challenging behaviours, for example highly sexualised
behaviour and substance misuse. For example, the study of ACEs in England
Despite relative clinical agreement about the nature and presentations found that those adults who had experienced four or more adversities in their
of traumatic stress, there are many children and young people who have childhood, were twice more likely to binge drink, and 11 times more likely
experienced significant adversity and trauma, however their need is not to have gone on to use crack cocaine or heroin87. The chances of developing
recognised as ASD or PTSD. As such, they do not always receive access to a dependence on substances doubles if a child has also experienced sexual
the mental health and support services they may require. It is estimated that abuse88 or other forms of violence89.
around one in six children and adolescents develop PTSD after being exposed
to a traumatic event (as defined in DSM-5)81. This means that the higher
proportion who experience pre- or sub-clinical traumatic stress symptoms do For more on childhood adversity and substance misuse see Paper 24.
not get a clinical diagnosis, or are left being misdiagnosed – primarily as their
presenting symptoms are not seen in the context of wider adverse experiences
in childhood82. For example, adversity and trauma-related hospital admission These behaviours can quickly become labelled as problematic by professionals
should act as a flag for further enquiry and intervention, however a recent and families. Some are seen as signs of being ‘anti-social’, having a problem with
study demonstrated that this is frequently missed83. one’s ‘conduct’, and being oppositional, defiant or disruptive towards a carer or
authority figure (i.e. a parent, teacher, doctor or social worker)90.
In response to these concerns, Dr Bessel van der Kolk and colleagues have
38 proposed the introduction of a new classification of ‘Developmental Trauma By way of illustration, there are just over 169,000 students in England with an 39
Disorder’ (DTD), which would specifically recognise trauma resulting from identified Special Educational Need or Disability (SEND) relating primarily to
Adverse Childhood Experiences84. Despite being considered for the most their social, emotional or mental health91. This represents one in six of students
recent revision of the DSM-585, and significant support from practitioners known to have a SEND92, and equates to 2% of the total student population
working with children who faced childhood adversity, it was not included as a of primary and secondary schools, including alternative provision (i.e. special
new classification86. schools and Pupil Referral Units)93.
While we agree with Dr Bessel van der Kolk’s proposal of DTD, we do not Not all children who experience mental ill health, or social or emotional
advocate in this paper either for or against introducing new clinical diagnoses. difficulties, will be identified as having a Special Educational Need, as they do
However, we do think that there is an important need to recognise the not meet the definition and threshold for additional support94. Furthermore,
traumatic stress and changes at a neurobiological and neurocognitive level some children who experience social, emotional or mental health problems
that result from ACEs. Furthermore, following Professor Eamon McCrory we will not have this classified as their ‘primary’ SEND need, and, as such, more
believe there is an urgent need to acknowledge that children and young people children in need are hidden within other ‘primary need’ classifications, for
are experiencing pre- or sub-clinical symptoms of traumatic stress that are example children with ‘speech, language and communication needs’’.
not being otherwise identified, or are being misdiagnosed. This is an important
part of ensuring that the care these children and young people receive is both There is, however, a wider population of students who require support. It has
adversity and trauma-informed. been estimated that around three children in every classroom in the country
have a diagnosable mental health condition95, with many teachers suggesting
that at least a quarter of their students are experiencing mental health
problems96. These children face disruptions and/or difficulties in their learning
because of the impact that adverse experiences have on their development97.

The highest rate for permanent school exclusions is for students with an and is a way of communicating something that is not yet conscious, or that
identified SEND, but ineligible for support (58.8%), compared to those perhaps cannot yet be verbalised105. Other behavioural responses might
with support (6.7%) and those with no known SEND (34.5%)98. Worryingly, include children attempting to self-calm and self-soothe, but in a self-harming
students with identified Behavioural, Emotional and Social Difficulties (BESD) or regressive way106. This might include violent rocking, chanting, scratching
are significantly more likely than other SEND groups to be excluded from their face or body or biting themselves, or banging their hands against walls or
school, with one in five students with identified BESD being excluded for at objects.
least one fixed period of time, and one in 100 being permanently excluded99.
While sometimes difficult for others to watch, challenging behaviour acts
as a method of reducing tension, and can play a role in the child attempting
For more on the role of alternative education see Paper 21. to protect themselves from, or avoid, what they perceive to be a threat or
a continuation of the trauma107. Presentations of anti-social behaviour in
relation to ACEs are more prominent among boys and young men108, possibly
In our schools and colleges, health services, and youth justice institutions we because of gendered ideas about displaying emotions109.
continue to misunderstand the behaviours and emotions that children and
young people present with. Many of the pre- and sub-clinical symptoms of For example, victims of Child Sexual Exploitation also exhibit increased risk-
traumatic stress are misinterpreted as behavioural problems or are based on taking behaviour and criminality as a way of making sense of the adversity they
prejudicial views about the morality or characteristics of the child or young have faced. Around two in five children develop a substance (drug and alcohol)
person. Ultimately the problem is seen as being the child’s, and much of the problem and girls who have experienced CSE are 2.5 times more likely to have
attention is focused on correcting their behaviours, rather than identifying the a criminal record, because their behaviour is criminalised rather than being
cause of it. Echoing this, the Royal College of Psychiatrists recently found that seen as an indicator of additional need110.
40 antipsychotics are being routinely prescribed for people who have behaviours 41
that challenge, but with no record of having an enduring mental illness100. The Similarly, many young people who have experienced or witnessed domestic
rate of prescription increased if the young person had a learning disability. violence do not engage in violence themselves111. Research shows that
domestic violence is strongly associated with offending and anti-social
Worryingly, there is a correlation between the specific form of adversity that a behaviour112. Some respond to the distress of experiencing domestic violence
child has experienced, and the kind of harmful behaviour they are more likely by exhibiting these behaviours with others in the family, or later on in their
engage in adulthood101. For example, children who had lived with someone young adult relationships. Finally, domestic violence is a shared risk factor for
who was suicidal were more likely to have tried to end their life; if they were poor mental health and gang-affiliation113.
sexually abused, they were more likely to engage in risky or underage sex and if
they lived in households with significant substance misuse102, they were more Children who engage in significant risk-taking should be seen as both finding
likely to misuse substances themselves103. ways to make sense of adversity and trauma they have experienced, as
well as avoiding the need to address and resolve the trauma. Such children
are at additional risk of being labelled as having a clinical disorder (such as
For more on intergenerational trauma and cycles of violence see ‘oppositional / defiant disorder’ and ‘conduct disorder’), rather than having
Papers 3, 16, 18, 24, 26. the adversity identified114. Additionally, these children are more likely to be
known to the authorities, because they are engaging in anti-social or criminal
behaviour115.
Clinical research suggests that it is common for children and young people
who have experienced adversity and trauma to ‘act out’ – exhibiting self- When we look at the needs of young people who offend there are clear
destructive, conduct disordered behaviours. These are attempts by the child mental health needs and childhood adversity that are not being addressed.
to make sense of their experiences104 and cope with trauma they have acquired The Chief Medical Officer noted that two in five children and young people

on Community Orders have emotional and mental health needs and in an adverse environment and make sense of their experiences. It is very
approximately the same proportion have experienced neglect or abuse been difficult to predict what a child or young person’s response to adversity and
homeless – and around half have been a victim of crime116. trauma might be (reflected in the wide range of trauma-stress symptoms for
example), and whether the behaviours and ways of thinking that they adopt
In the context of gang membership an evidence review for the Ministry will successfully mitigate the impact of the adversity they face.
of Justice noted that a ‘social value of violence’ was established among
membership in terms of utilising a history of family violence and to help
maintain a bond between young members117. As such, the aggressive a. building resilience
behaviour seen in gang initiation and gang membership may be an acting out
of gang loyalty, as much using the experience of violence as a template to Interacting with the risk factors discussed above are protective factors that
establish a bond with peers. reduce the likelihood of long-term mental ill health and emotional distress.
Lucas Shelemy and Dr Pooky Knightsmith (see Paper 6) identify four core
This sentiment is recognised in an evidence review for the Home Office, which protective factors that increase the resilience of children and young people in
notes that young people who become involved in gangs or violent lifestyles relation to adversity and trauma, including the relationship with nurturing care
are some of the most vulnerable young people in our society and may have givers120 (if they are not the origin of the adversity) and social connectedness
experienced adversity from a very young age. They should be seen and treated with a supportive peer group. The ability to problem solve and communicate
first and foremost as children and young people in need of support’118. can moderate risk factors, and an interest, hobby or skill that the child or
young person highly values in themselves.
It is vital to understand the meaning of both challenging and risk-taking
behaviours, as for many children they will represent a response to the
42 adversity, complexity and trauma they have experienced in childhood. For more on resilience and protective factors see Papers 5, 6 and 13. 43
Moreover, being further labelled, stigmatised and confronted by professionals
who are unaware of their adversity, can trigger memories and emotions
relating the trauma they have experienced. This can have the effect of The Center on the Developing Child at Harvard University describes resilience
escalating their behaviour and emotional distress, and risks re-traumatising as a ‘positive, adaptive response in the face of adversity’121. In direct contrast
the young person or sustaining a secondary trauma119. to the health-harming and risk-related adaptations, resiliency mitigates the full
impact of adversity, and transforms potentially traumatic stress into tolerable
stress, which can be subsumed into a young people's life and enables them to
grow and develop as would have been otherwise expected.
8. Adversity and trauma-informed care
At an individual level, building resilience allows the children to protect the
It is clear from the above discussion that the experience of adversity and developing brain and body from adverse neurobiological and neurocognitive
trauma in childhood or adolescence increases our risk of poorer social, changes. At a social level, it ensures the young person can re-establish the
emotional and health outcomes in adulthood. Some children and young people, safety, connection and support they will require to recover from the adverse
as we have seen, will go on to adopt behaviours and coping strategies that experience(s), and to mitigate the feelings of isolation, hopelessness and
may mitigate the impacts of these adversities, but they also have a long-term meaninglessness that can arise from adversity and trauma.
effect on their emotional wellbeing, social functioning and psychological
development. Professor Peter Fonagy (see Paper 13) proposes that we see this resilience as
an ‘outcome of the quality of the social network surrounding the child and the
These behaviours and ways of thinking should be regarded as creative child’s capacity to access that network’, rather than a quality or characteristic
adaptations and creative adjustments that the young person is using to survive of the individual child. From this standpoint, he makes a compelling case to

focus on the ‘systems of care' in the social environment around the child, as therapeutic interventions, involving professionals with specialist training and
well as providing the specialist support a young person will need to make sense skills. These services and interventions are based on detailed assessments of
of their trauma. the trauma and adversity that a young person has faced, and co-creates with
them an integrated treatment plan to address identified symptoms.
b. adversity and trauma-informed care In contrast, trauma-informed care can be delivered by all organisations and
professionals. Its core principles include building awareness of adversity and
Both Dr Judith Herman and Dr Sandra Bloom122 have been influential, and trauma (understanding of cultural, gender and sexuality contexts) into service
successful, in advocating for models of care that move beyond a purely protocols and staff culture in order to avoid re-traumatisation. Establishing
diagnostic model of trauma, and instead place greater emphasis on creating and maintaining safety is at the heart of all adversity and trauma-informed
safe environments and practices, building individual resources and wider models of care. Furthermore, these models focus on increasing levels of
resiliency, as well as restoring connection to supportive and safe communities. trustworthiness by being transparent with clients and investing in greater
Reflecting this, the Center on the Developing Child123 notes that learning collaboration, shared decision making, and mutuality between the people who
to cope with manageable threats to our physical and social wellbeing (and are using the services and receiving them.
practices of self-regulation) are critical for the development of resilience, and
enhance recovery. The papers included in Addressing Adversity will provide you with greater
clarity and insight into what adversity and trauma-informed care looks like in
Similarly, Dr Bessel van der Kolk suggests that these models of care can practice, how it can benefit children and young people who have experienced
powerfully demonstrate to the child or young person (as well as the family or different forms of adversity, and finally some of the challenges and successes
community they live with), that a) relationships can heal, b) through therapy from local areas across England.
44 and connection with others we can create meaning out of our experiences, 45
c) we can learn to regulate our own physiology and take greater care of The first section of this collection considers evidence and analysis of the
ourselves, and finally d) it is possible to create conditions and environments impact that adverse childhood experiences and trauma have on children
where these young people can thrive and receive the care they need. and young people’s mental health and wider outcomes across the lifecourse.
Building on this foundational analysis, section two provides insight into areas
Increasingly, these models of care are being described as adversity or trauma- for priority focus from leading policy makers, national organisations and
informed care. These models of care aim to mitigate the impact of adversity clinicians who work with children and young people who have experienced
on people’s lives, and to address the mental health and/or traumatic stress different forms of adversity and trauma. In section 3, we explore case studies
resulting from these experiences. Importantly instilling trauma-informed care and working examples of adversity and trauma-informed service models to
is now being seen as a priority public health concern throughout the UK124. identify emerging good practice from across England. Finally, the collection
ends with an agenda for change, calling on all commissioners and providers to
make adversity and trauma-informed care a priority in their locality.
More detailed discussions of adversity and trauma-informed care
are available in Section 2, with local good practice examples set out
in Section 3. For more on:
• the principles of adversity and trauma-informed care see
Papers 7, 8 and 9.
The Provincial Mental Health and Substance Use Planning Council of British
• adopting an LGBT+ affirmative commissioning and service
Colombia in Canada differentiates between trauma-informed and trauma-
models see Paper 14.
specific services125. Trauma-specific services are described as being delivered
in a trauma-informed environment and focus on treating trauma through

• adopting culturally sensitive trauma-informed models of care

References
see Paper 15. 1 Bush, M. (2016) Beyond Adversity: Addressing the mental health needs of young people who
• ensuring commissioning and services is gender-informed see face complexity and adversity in their lives: https://youngminds.org.uk/media/1241/report_-_
beyond_adversity.pdf
Paper 17.
2 Bellis, M. A., Hughes, K., Leckenby, N., Perkins, C. and Lowey, H. (2014) ‘National household
survey of adverse childhood experiences and their relationship with resilience to health-harm-
ing behaviors in England’ BMC Medicine: https://bmcmedicine.biomedcentral.com/arti-
cles/10.1186/1741-7015-12-72
3 Kessler, R. C. and McLaughlin, K. A. (2010) ‘Childhood adversities and adult psychopathology
in the WHO World Mental Health Surveys’ British Journal of Psychiatry 197(5): 378–385.
McLaughlin, K.A., Green, J.G., Gruber, M.J., Sampson, N.A., Zaslavsky, A., and Kessler, R.C.
(2012) ‘Childhood adversities and first onset of psychiatric disorders in a national sample of
adolescents’ Archives of General Psychiatry 69: 1151-1160.
4 Some organisations and services might describe these ‘vulnerabilities’, however this can lead
to more restrictive ways of identifying and quantifying need. See the following for an example
of a vulnerabilities framework: Children’s Commissioner (2017) On measuring the number
of vulnerable children in England: https://www.childrenscommissioner.gov.uk/wp-content/
uploads/2017/07/CCO-On-vulnerability-Overveiw-2.pdf
5 WHO (2014) Social Determinants of Mental Health: http://apps.who.int/iris/bitstre
am/10665/112828/1/9789241506809_eng.pdf
6 See for example Bellis, M.A., Lowey, H., Hughes, K. and Harrison, D. (2014) ‘Adverse Childhood
Experiences: Retrospective study to determine their impact on adult health behaviours and
health outcomes in a UK population’ Journal of Public Health 36(1): 81-91: http://jpubhealth.
46 oxfordjournals.org/content/36/1/81.full.pdf+html 47
McLaughlin, K. A. (2017) ‘The long shadow of adverse childhood experiences’ Psychological
Science Agenda: http://www.apa.org/science/about/psa/2017/04/adverse-childhood.aspx
The Children’s Society (2016) Poor Mental Health: The links between child poverty and mental
health problems: http://www.childrenssociety.org.uk/sites/default/files/poor_mental_health_
report.pdf
7 Felitti V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P.
and Marks, J. S. (1998) ‘Relationship of childhood abuse and household dysfunction to many
of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.’
American Journal of Preventative Medicine 14(4): 245-258: http://www.ncbi.nlm.nih.gov/
pubmed/9635069/
8 For a more detailed discussion read: McLaughlin, K. A. (2016) ‘Future Directions in Childhood
Adversity and Youth Psychopathology’ Journal of Clinical Child and Adolescent Psychology
45(3): 361-382.
9 c.f. Mersky, J. P., Janczewski, C. E. and Topitzes, J. (2017) ‘Rethinking the Measurement of
Adversity: Moving toward second-generation research on Adverse Childhood Experiences’
Child Maltreatment 22(1): 58-68.
A useful overview of measurement instruments for childhood adversity is contained in Burger-
meister, D. (2007) ‘Childhood Adversity: A Review of Measurement Instruments’ Journal of
Nursing Measurement 15(3):163-76: https://www.researchgate.net/publication/5618564_
Childhood_Adversity_A_Review_of_Measurement_Instruments
Whist the World Health Organisation propose the use of a somewhat ‘direct’ instrument for
measuring ACE – http://www.who.int/violence_injury_prevention/violence/activities/adverse_
childhood_experiences/en/ ACE International Questionnaire (ACE-IQ).
10 McLaughlin, K. A. (2016) Op. cit.

11 Cronholm, P. F., Forke, C. M., Wade, R., Bair-Merritt, M. H., Davis, M., Harkins-Schwarz, M., Ford, J. D. (2010) ‘Complex adult sequelae of early exposure to psychological trauma’ in Lanius,
Pachter, L. M. and Fein, J. A. (2015) ‘Adverse Childhood Experiences: Expanding the concept of R. A., Vermetten, E. and Pain, C. (eds)The Impact of Early Life Trauma on Health and Disease:
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and associations with health-harming behaviours in young adults: surveys in eight eastern
13 Sometimes these experiences get subsumed in the policy and commissioning literature within
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26 Bellis, M. A. et al (2014) Op. cit.
14 Schilling, E.A., Aseltine, R.H. and Gore, S. (2008) ‘The impact of cumulative childhood adversity
on young adult mental health: measures, models, and interpretations’ Social Science and Medi- Felitti, V. J. et al. (1998) Op. cit.
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Stress: Effects on the brain’ Dialogues in Clinical Neuroscience 8(4): 445–461.
51 There are 69,540 looked after children (including those adopted) in England as of 31 March
2015 – DfE / ONS (2015) Children looked after in England (including adoption and care leav- 67 Minton, K., Ogden, P., Pain, C., Siegel, D. J., Van Der Kolk, B. (2006) Trauma and the Body: A
ers): https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/464756/ sensorimotor approach to psychotherapy, NY: W W Norton and Co.
SFR34_2015_Text.pdf – this represents 0.9% of the child and adolescent population – based 68 Frewen, P. A.; Dean, J. A. and Lanius, R. A. (2012) ‘Assessment of anhedonia in psychological
on population estimates for ONS (2015) Population Estimates Summary for the UK, mid- trauma: development of the Hedonic Deficit and Interference Scale’ European Journal or
2014: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/ Psychotraumatology 3: 8585
populationestimates/datasets/populationestimatesforukenglandandwalesscotlandandnorth- DePierro, J. M., D’ Andrea, W. and Frewen, P. (2014) 'Anhedonia in Trauma Related Disorders:
ernireland The good, the bad and the shutdown’ in Ritsner, M. (ed) Anhedonia: A Comprehensive Hand-
52 Bruskas, D. (2013) ‘Adverse Childhood Experiences and Psychosocial Well-Being of Women book Volume II (Neuropsychiatric and Physical Disorders) London: Spinger.
Who Were in Foster Care as Children’ The Permanente Journal 17(3): 131–141. 69 Rothschild, B. (2000) The Body Remembers: The psychophysiology of trauma and trauma
treatment, NY: W W Norton and Co.

Van der Kolk, B. (2015) Op. cit. 86 Bremness, A. and Polzin, W. (2014) ‘Developmental Trauma Disorder: A Missed Opportunity
70 Perry, B. D. (2006) ‘Applying principles of neurodevelopment to clinical work with maltreated in DSM V’ Journal of the Canadian Academy of Child and Adolescent Psychiatry: http://www.
and traumatised children: the neurosequential model of therapeutics’ in Boyd Webb, N. (ed) ncbi.nlm.nih.gov/pmc/articles/PMC4032083/
Working with Traumatized Youth in Child Welfare. NY: The Guildford Press. 87 Bellis, M. A. et al (2014) Op. cit.
71 National Scientific Council on the Developing Child (2014) Excessive Stress Disrupts the 88 Simpson, T. L. and Miller, W. R. (2002) ‘Concomitance between childhood sexual and physical
Architecture of the Developing Brain (Working Paper No. 3 – updated version): http://develop- abuse and substance use problems: a review’ Clinical Psychology Review 22(1): 27–77.
ingchild.harvard.edu/wp-content/uploads/2005/05/Stress_Disrupts_Architecture_Develop- 89 Douglas, K. R., Chan, G., Gelernter, J., Arias, A. J., Anton, R. F., Weiss, R. D., and Kranzler, H. R.
ing_Brain-1.pdf (2010) ‘Adverse childhood events as risk factors for substance dependence: Partial mediation
72 McLaughlin, K.A., Sheridan, M.A., and Lambert, H.K. (2014) ‘childhood adversity and neural by mood and anxiety disorders’ Addictive Behaviors 35: 7-13.
development: deprivation and threat as distinct dimensions of early experience’ Neuroscience 90 see for example: SCE (2013) Managing Children’s Behaviour (guidance): https://www.gov.uk/
and Biobehavioral Reviews 47: 578-591. government/uploads/system/uploads/attachment_data/file/339074/Managing_Challeng-
73 SAMHSA (2014) Trauma-Informed Care in Behavioral Health Services: Treatment Improve- ing_Behaviour_Final-U.pdf
ment Protocol (TIP 57): https://store.samhsa.gov/shin/content//SMA14-4816/SMA14-4816. 91 DfE / ONS (2015) Special Educational Needs in England (national tables), January 2015:
pdf https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/446718/
74 For more information visit: http://www.nhs.uk/conditions/post-traumatic-stress-disorder/pag- SFR25-2015_TABLES_NATIONAL.xlsx
es/introduction.aspx 92 ibid.
75 APA (2013) Diagnostic and Statistical Manual of Mental Disorders (fifth edition – DSM-5) 93 As a percentage of student population derived from DfE / ONS (2015) Schools, Pupils and
Washington DC: American Psychiatric Publishing. Their Characteristics (national tables): January 2015: https://www.gov.uk/government/up-
76 also see Lanius, R. A., et al (2010) ‘Emotion Modulation in PTSD: Clinical and neurobiological loads/system/uploads/attachment_data/file/433685/SFR16_2015_national_tables.xlsx
evidence for a dissociative subtype’ The American Journal of Psychiatry, 167(6): 640–647. 94 For more information on thresholds for support, see DfE / DH (2015) Special Educational
77 World Health Organisation (2016 version) The International Classification of Diseases (ICD- Needs and Disability Code of Practice: 0 to 25 years: https://www.gov.uk/government/up-
10): http://apps.who.int/classifications/icd10/browse/2016/en loads/system/uploads/attachment_data/file/398815/SEND_Code_of_Practice_January_2015.
78 Maercker A., et al (2013) ‘Diagnosis and classification of disorders specifically associated with pdf
stress: proposals for ICD-11’ World Psychiatry 12(3):198-206. 95 Estimate derived from Green, H. et al (2005) Op. cit.
52 79 McCrory, E. J., Gerin, M. I. and Viding, E. (2017) ‘Annual Research Review: Childhood mal- 96 ALT (2015) School Children's Mental Health at Serious Risk: https://www.atl.org.uk/media-of- 53
treatment, latent vulnerability and the shift to preventative psychiatry – the contribution of fice/2015/Schoolchildrens-mental-health-at-serious-risk.asp
functional brain imaging’ Journal of Child Psychology and Psychiatry 58(4): 338-357. 97 for further discussion on the difficulty of assessing impact on educational attainment see John-
80 McCrory, E. J. and Viding, E. (2015) ‘The theory of latent vulnerability: Reconcetualizing the ston, D., Propper, C., Pudney, S. and Shields, M. (2011) Child Mental Health and Educational
link between childhood maltreatment and psychiatric disorder’ Development and Psychopa- Attainment: Multiple observers and the measurement error problem: https://www.iser.essex.
thology 27: 495-505. ac.uk/research/publications/working-papers/iser/2011-20.pdf
81 Alisic, E., Zalta, A. K, van Wesel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K. and Smid, G. E. 98 DfE / ONS (2015) Permanent and Fixed-period Exclusions in England (national tables):
(2014) ‘Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: 2013 to 2014: https://www.gov.uk/government/uploads/system/uploads/attachment_data/
meta-analysis’ The British Journal of Psychiatry 204(5): 335-340. file/449439/SFR27_2015_National_Tables.xlsx
82 NICE (2005) Post-traumatic stress disorder: management (clinical guideline 26): https:// 99 DfE (2014) Children With Special Educational Needs: Absence and exclusions 2014:
www.nice.org.uk/guidance/cg26/resources/posttraumatic-stress-disorder-manage- https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/350130/
ment-975329451205 SFR31_2014_Absence_Exclusions_Tables.xlsx
NICE (2013) Post-traumatic stress disorder (PTSD): Evidence update December 2013: 100 RCPsych (2016) Psychotropic drug prescribing for people with intellectual disability, mental
https://www.nice.org.uk/guidance/cg26/evidence/evidence-update-193438333 health problems and/or behaviours that challenge: practice guidelines: www.rcpsych.ac.uk/pdf/
83 Webb, R. T., Antonsen, S., Carr, M. J., Appleby, L., Pedersen, C. B. and Mok, P. L. H. (2017) ‘Self- FR_ID_09_for_website.pdf
harm and violent criminality among young people who experienced trauma-related hospital 101 Felitti, V. J. at al (1998) Op. cit.
admission during childhood: a Danish national cohort study’ The Lancet Public Health 2(7): 102 Hughes, K., Lowey, H., Quigg, Z. and Bellis, M. A. (2016) ‘Relationships between adverse
314-322. childhood experiences and adult mental well-being: results from an English national household
84 van der Kolk, B. (2005) ‘Developmental Trauma Disorder: Toward a rational diagnosis for survey’ BMC Public Health 16: 222.
children with complex trauma histories’. Psychiatric Annals 35(5): 401-408: http://www. 103 Dube, S., Felitti, V., Dong, M., Chapman, D., Giles, W. and Anda, R. (2003) ‘Childhood abuse,
traumacenter.org/products/Developmental_Trauma_Disorder.pdf neglect and household dysfunction and the risk of illicit drug use: the adverse childhood expe-
85 for wider discussion of limits and merits see: Schmid, M., Petermann, F. and Fegert, J. M. (2013) rience study’ Pediatrics 111: 564- 572.
‘Developmental trauma disorder: pros and cons of including formal criteria in the psychiat- Dube, S. R., Anda, R. F., Felitti, V.J., Edwards, V. J. and Croft, J.B. (2002) ‘Adverse childhood
ric diagnostic systems’ BMC Psychiatry 13(3): http://www.ncbi.nlm.nih.gov/pmc/articles/ experiences and personal alcohol abuse as an adult’ Addictive Behaviors 27: 713-25.
PMC3541245/pdf/1471-244X-13-3.pdf

104 Singer, M. I., Anglin, T. M., Song, L. Y. and Lunghofer, L. (1995) ‘Adolescents’ exposure to 120 A recent report by Generations United demonstrates the protective role that grandparents
violence and associated symptoms of psychological trauma’ Journal of the American Medical and inter-generational families can play in the lives of children who experience trauma, see:
Association 273: 477-482. Generations United (2017) In Loving Arms: the protective role of grandparents and other
105 Nicholson, C., Irwin, M. and Dwivedi, K. N. (2010) Children and Adolescents in Trauma: Crea- relatives in raising children exposed to trauma: https://dl2.pushbulletusercontent.com/uhD-
tive therapeutic approaches, London: Jessica Kingsley Publishers. Y7UgdGYnOod6G7VFkdKnuzE3yALmr/17-InLovingArms-Grandfamilies.pdf
106 Greenwald, R. (2015) Child Trauma Handbook: A guide for helping trauma-exposed children 121 Center on the Developing Child (2015) Supportive Relationships and Active Skill-Building
and adolescents, London: Routledge. Strengthen the Foundations of Resilience (Working Paper 13): http://46y5eh11fhgw3ve3ytp-
wxt9r.wpengine.netdna-cdn.com/wp-content/uploads/2015/05/The-Science-of-Resilience2.
107 Hollins, S., Esterhuyzen, A. and Sinason, V. (2000) ‘Psychotherapy, learning disabilities and trau- pdf
ma: new perspectives’ British Journal of Psychiatry, 176: 32–36.
122 Herman, J. (2015 [1992]) Trauma and Recovery: The aftermath of violence – from domestic
RCPsych, BPS, RCSLT (2007) Challenging Behaviour: A unified approach (clinical and service abuse to political terror. PA: Basic Books.
guidelines for supporting people with learning disabilities who are at risk of receiving abusive
or restrictive practices): http://www.bps.org.uk/sites/default/files/documents/challenging_be- Bloom, S.L. (2013) Creating Sanctuary: Toward the evolution of sane societies (revised edition)
haviour_-_a_unified_approach.pdf NY: Routledge.
108 Schilling, E.A., Aseltine, R.H. and Gore, S. (2007) ‘Adverse childhood experiences and mental 123 Center on the Developing Child (2015) Op. cit.
health in young adults: a longitudinal survey’ BMC Public Health 7: 30. 124 c.f. Sara, G. and Lappin, J. (2017) ‘Childhood trauma: psychiatry's greatest public health
109 Timimi, S. (2005) Naughty Boys: Anti-social behaviour, ADHD and the role of culture, Basing- challenge?’ The Lancet Public Health 2(7): 300-301: http://www.thelancet.com/pdfs/journals/
stoke: Palgrave Macmillan. lanpub/PIIS2468-2667(17)30104-4.pdf
110 Phoenix, J. / The Howard League for Penal Reform (2012) Out of place: The policing and crim- 125 BC Provincial Mental Health and Substance Use Planning Council / BC Centre of Excellence
inalisation of sexually exploited girls and young women: https://d19ylpo4aovc7m.cloudfront. for Women’s Health (2013) Trauma-Informed Practice Guide: http://bccewh.bc.ca/wp-con-
net/fileadmin/howard_league/user/pdf/Publications/Out_of_place.pdf tent/uploads/2012/05/2013_TIP-Guide.pdf
111 UNICEF (2006) Op. cit.

112 CAADA (now SafeLives) (2014) In Plain Sight: The evidence from children exposed to domestic
abuse: http://www.safelives.org.uk/sites/default/files/resources/In_plain_sight_the_evidence_
from_children_exposed_to_domestic_abuse.pdf
54 113 CPH / PHE (2015) The Mental Health Needs of Gang-Affiliated Young People: A briefing 55
produced as part of the Ending Gang and Youth Violence programme: https://www.gov.uk/
government/uploads/system/uploads/attachment_data/file/398674/The_mental_health_
needs_of_gang-affiliated_young_people_v3_23_01_1.pdf
114 Greenwald, R. (2015) Op. cit.
115 For wider description of groups of children who may be known to authorities because of an ad-
ditional risk of harm, see: HM Government (2015) Working Together to Safeguard Children: A
guide to inter-agency working to safeguard and promote the welfare of children: https://www.
gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Togeth-
er_to_Safeguard_Children.pdf
116 CMO (2012) Our Children Deserve Better: Prevention pays: https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/255237/2901304_CMO_complete_low_res_
accessible.pdf
117 Harris, D., Turner, R., Garrett, I. and Sally Atkinson (2011) Understanding the Psychology of
Gang Violence: Implications for designing effective violence interventions (Ministry of Justice
Research Series): https://www.gov.uk/government/uploads/system/uploads/attachment_data/
file/217379/research-gang-violence.pdf
118 Early Intervention Foundation (2015) Preventing Gang and Youth Violence: Spotting signals
of risk and supporting children and young people: http://www.eif.org.uk/wp-content/up-
loads/2015/11/Final-R1-Overview-Preventing-Gang-Youth-Violence.pdf
119 For more details on secondary trauma see: NCTSN (2011) Secondary Traumatic Stress: A fact
sheet for child-serving professionals. LA: http://www.nctsn.org/sites/default/files/assets/pdfs/
secondary_traumatic_tress.pdf

Chapter 1
Section 1
Understanding
adversity, trauma
and resilience
56 57

Adverse Childhood Experiences, health outcomes and risk factors
2. Adverse Childhood Experiences,

health outcomes and risk factors
Household adversity:
• Domestic violence (this... encompasses physical, psychological,
sexual, financial and emotional abuse and includes controlling and
Matilda Allen and Dr Angela Donkin coercive behaviours)
• Substance misuse (there are adults within the home with drug
misuse or addiction problems, including alcoholism)
This extract is from ‘The impact of adverse experiences in the home on the health
of children and young people, and inequalities in prevalence and effects’ report • Mental ill health (there are parents or other adults within the home
and has been re-used under the Open Government Licence v2.0 with the with diagnosed or undiagnosed mental illness)
permission of the authors. • Criminality (parents or others who usually live in the home are
either in prison or on probation)
• Separation (parents are separated or divorced, or one or both
parents are dead)
1. Adverse Childhood Experiences • Living in care (children are looked after by the state in a care setting
or elsewhere – sometimes referred to as ‘looked-after children and
Childhood and adolescence are key periods for development, growth and
young people’)
education, and are of critical importance in shaping adulthood. It is widely
recognised that just as supportive, nurturing, safe and happy childhoods
are necessary for later health and wellbeing, if individuals live in damaging
58 circumstances, or are exposed to adverse conditions early in life, this can have 59
negative short- and long-term effects, including for health.
2. ACEs and Social Determinants of Health (SDH)
The term ‘Adverse Childhood Experiences’ was originally coined in an
American study on the impact of adversities across the lifecourse1. Adverse The term ‘social determinants of health’ (SDH) refers to the conditions and
childhood experiences have since been defined as: ‘intra-familial events circumstances in which we are born, grow, live, work and age. These conditions
or conditions causing chronic stress responses in the child’s immediate are shaped by inequalities in power, money and resources and therefore are
environment. These include notions of maltreatment and deviation from unequal in their distribution3. This inequality in the social determinants of
societal norms’2. health contributes to inequalities in health outcomes. In England, between
the most and least deprived local areas there is a difference of 17 years in the
number of years that people live in good health.
When we refer to Adverse Childhood Experiences, or adverse
experiences, within this paper, we are referring to: Fair Society Healthy Lives (known as the Marmot Review)4, set out the
evidence of inequalities in health and the social determinants of health in
Maltreatment: England, and proposed six high level policy objectives in order to take action on
• Physical abuse the social determinants of health. These were:
• Emotional abuse
1. Give every child the best start in life
• Sexual abuse
• Neglect 2. Enable all children, young people and adults to maximise their
capabilities and have control over their lives

Chapter 2 Adverse Childhood Experiences, health outcomes and risk factors
3. Create fair employment and good work for all Figure 1: ACE conceptual framework
4. Ensure a healthy standard of living for all

Intergenerational transmission
5. Create and develop healthy and sustainable places and communities
6. Strengthen the role and impact of ill health prevention Adverse childhood
experiences
These relate to ACEs and health in three ways. Firstly, tackling the presence Context Parent
in which & family
and impacts of ACEs is an important component of some of these policy families live factors
objectives – such as giving children the best start in life and maximising e.g. e.g. Health- Social
Household harming determinants
capabilities and control. Secondly, inequalities in the SDH could be poverty, parenting
adversities Maltreatments
social behaviours of health
contributing to inequalities in the prevalence of ACEs. Deprived areas and isolation, e.g. e.g.
e.g. e.g.
families living in poverty (who do not have a healthy standard of living) are social
domestic abuse and
education, education,
protection income income
likely, on average, to have a higher prevalence of ACEs. Thirdly, the presence violence violence
policies
of ACEs could impact on the SDH, so that children and young people who are
exposed to ACEs are more likely than those who are not to grow up to live
in conditions (such as in poverty, or with damaging employment) that have a
Health – morbidity (physical and mental) and early mortality
negative impact on their health.
60 61
The conceptual framework (opposite) provides an outline of the topic areas
that are discussed in this paper and how they relate to each other. The arrows
represent correlations, connections or possible pathways, but do not show vulnerability of children to poor health and wellbeing outcomes as a result of
evidenced causation, because in many areas the current evidence is suggestive adversity6. However, although protective factors can increase resilience, this
of causation but it is not proven. does not make children and young people ‘invulnerable’ or impervious to harm –
experiencing severe or multiple adverse experiences is likely to be damaging to
children and young people regardless of how high their resilience levels are7.
3. Associations between ACEs and health One UK-based study has found that those who experience neglect at an older
age are likely to experience worse outcomes compared with their younger
Not everyone who is exposed to one or more ACEs will experience negative counterparts8. This is supported by American evidence, which finds that
health outcomes: a review of children and young people who had experienced maltreatment experienced during adolescence had a “stronger and more
ACEs found that a “large proportion do appear to be functioning adequately or pervasive effect on later adjustment”, including in areas such as criminality,
well”5. The type of ACEs, the number of ACEs experienced, and the length of substance misuse and other health damaging behaviour9.
time over which they are experienced, can impact on the risk of negative health
outcomes.
a. Injury and death during childhood
In addition, contextual factors can increase resilience – the ability to ‘bounce
back’ from adverse experiences. Supportive peer relationships, the impact At their most extreme, the presence of ACEs can result in death during
of schools, potentially family wealth and a range of other factors can reduce childhood. In 2012/13, there were 69 homicides of children aged 0–15 across

the UK10. The presence of ACEs can also increase self-harm and suicide among A different study of the same birth cohort (1958), examined what risk factors
children and young people. There were 170 suicides of 15–19 year olds in were present at age seven that predicted later suicide. The authors found
the UK in 2013, 135 of which were in England and Wales. This was split into that emotional adversities such as parental death or separation and living in
112 male and 23 female11. Self-harm, suicide and injury rates among children care had an association with risk of suicide. This risk was graded: “the highest
and young people are likely to reflect, in part, the presence of ACEs. However was for persons with three or more adversities”13. Surveys conducted from
there is a lack of clear data on this relationship. 2010–2013 in eight Eastern European countries found that respondents who
reported at least four ACEs had increased odds of 49 for attempting suicide14.
This is a particularly high figure, which may not be reflected in the English
b. Premature mortality and suicide context – but it does demonstrate the potentially disastrous impacts of ACEs.
A British study published in 2013 used longitudinal data of a set of over

15,000 individuals born in 1958 to determine mortality rates by 50. The c. Disease and illness
authors found that: “in men the risk of death was 57% higher among those
who had experienced two or more ACEs compared to those with none. The US ACEs study found a relationship between the number of ACEs and the
Women with one ACE had a 66% increased risk of death and those with presence of diseases in adulthood, including ischemic heart disease, cancer,
two or more ACEs had an 80% increased risk versus those with no ACEs”12. chronic lung disease, skeletal fractures and liver disease. Other studies have
The definition of ACEs used included maltreatment, living in care and some also found relationships with a risk of stroke, and the development of cancer,
household adversity measures (offenders, parental separation, mental illness hypertension, diabetes, asthma, arthritis, angina pectoris and osteoporosis.
or alcohol abuse in the home). Figure 2 shows these rates, for men and for US research has also found a three-fold increased risk of lung cancer for
women. Although the overall proportions are small, the relationships between those with six or more ACEs and found that this cohort were roughly 13 years
62 mortality and prevalence of ACEs are clear. younger on average when first detecting symptoms than those without ACEs. 63
A 2013 survey of 4,000 English adults found increased odds of developing a
Figure 2: All-cause mortality rate by age 50 according to prevalence of range of diseases, and particularly high risks associated with experience of four
adverse childhood experiences, British men and women, 2008 or more ACEs. Moreover, the study shows that those with more ACEs have a
higher rate of diagnosis of a major disease at a younger age. By the age of 69,
among those who experienced four or more adversities during childhood, only
8% Male Female
approximately two in 10 people have not been diagnosed with a major disease.
7%
6%
d. Mental ill health
Percentage dead by 50
5%
4% Research has shown that the presence of ACEs can increase the chances of
3% children and young people experiencing mental illness or a low level of mental
wellbeing, including low self-esteem, depression and relationship difficulties15.
2%
In addition, WHO Euro reports that post-traumatic stress disorder has been
1% reported in as many as a quarter of abused children16. Not only can experience
0%
of ACEs impact on childhood, but also there can be a lasting impact on adult
0 1 2 or more
mental health. The WHO World Mental Health Surveys estimate that 30% of
Number of adverse childhood experiences adult mental illness in 21 countries could be attributed to physical abuse in
childhood or other adverse childhood experiences17.

Some groups are more at risk of adverse mental health impacts than others: 4. Link from ACEs to health-harming behaviours
for example, a British cohort study found that looked-after children and
young people were significantly more likely to be depressed, dissatisfied with It is possible that exposure to ACEs during childhood and adolescence
life and have low self-efficacy (which relates to feelings of control over one’s increases the likelihood of an individual later adopting health-harming
life)18. After adjusting for family socioeconomic status, residential care was behaviours, including substance misuse, alcohol misuse, smoking, sexual risk
associated with an increased odds ratio of four for depression19. behaviour, violence and criminality or behaviours leading to obesity.
A study of the 1958 British birth cohort study estimated the impact of An English study published in 2014 found a correlation between the number
childhood adversities on psychopathology across the lifecourse20. This is one of ACEs experienced and health-harming behaviours. The increased odds
of the few studies that focus on older children rather than the 0–5 age range. ratios associated with four or more ACEs varied from two for poor diet to
Figure 3 summarises some of the results related to adversity in the home. The 11 for incarceration. Heroin or crack cocaine use also showed a significantly
graph shows varying impacts of different ACEs over time. For example some increased odds ratio of 11. The authors conclude that, “resistance to
ACEs, such as divorce of parents and being looked-after, have a higher impact commercial, cultural, and other environmental pressures to adopt health-
on mental illness at younger ages, which then declines over time. harming behaviours appears to be related to childhood stressors, with
nurturing, ACE-free childhoods increasing personal resilience”21.
Figure 3: Increased odds ratio of psychopathology associated with various Results from the US ACE study22 have shown the association between ACEs
types of ACE, by age, UK, 2008 and later smoking: for example, 16% of smokers reported verbal abuse in
childhood compared with 8% of non-smokers, and 14% reported physical
abuse compared with 7% of non-smokers23. English evidence supports these
64 Psychopathology, 16 years Psychopathology, 23 years Psychopathology, 45 years US findings24: for example, those with four or more ACEs have been found to 65
have odds ratios of three for smoking25.
6.0
5.5 A study using longitudinal data from the 1970 British Cohort Study also found
Odds ratio (where no experience = 1)
5.0 that those who were looked-after as children were significantly more likely to
4.5 smoke and have criminal convictions Generally, admission to care at a later age
4.0 tends to result in increased risk of negative outcomes – for example, admission
3.5 to care after the age of 10 was associated with an increased odds ratio of three
for smoking and six for adult criminal convictions26.
3.0
2.5
Studies of the association between ACEs and obesity in the 1958 British birth
2.0
cohort show that, “the risk of obesity increased by 20% to 50% for several
1.5 adversities”27. English evidence has also showed adjusted odds ratios of six for
1.0 unintended teenage pregnancy among those who experienced four or more
Illness Paternal Maternal Parental Divorce by Neglected/ Parental In care Culmulative ACEs (compared with those who experienced none), and eight for violence
in the absence absence physical 16 years underfed sexual adversity:
household abuse appearence abuse
(7–16)
3 or more perpetration28.
(7–16) (7–16)
(7–16) Reported (7–11) Reported (7–16)
at 33 years at 33 years
The adoption of these behaviours can be seen in the short term (mostly during
adolescence but sometimes before) and in the longer term, during adulthood.
Adversity type (age of measures available)
They impact on health directly, through an increased likelihood of disease,
accidents or violence, and, in some cases (for example, criminality), impact on

the wider conditions in which people live – the social determinants of health. 6. Neurobiological and genetic pathways
There may also be a link between ACEs and health that occurs through the
direct impact of ACE on neurobiological and genetic functioning. Studies have
5. Link from ACEs to the social determinants of health suggested a relation between trauma (which can result from maltreatment),
other ACEs, and brain dysfunction or neurobiological impacts that can affect
The social determinants of health (SDH) are the conditions in which we are later health37. It is likely that part of this link is due to increases in damaging
born, grow, live, work and age, and the impact that these conditions have responses to stress38. These alterations to stress-responsive neurobiological
on our health. Experiencing ACEs may have an impact on three key social systems can impact emotional regulation, somatic signal processing, substance
determinants of health: educational attainment, employment and income. abuse, sexuality, memory, arousal and aggression39.
For example, a US study found lower rates of success in employment and
education among those who were maltreated in childhood. Of men in the The areas of genetics and epigenetics also may provide links between ACEs
sample maltreated as children29, 45% graduated from high school compared and health. It has been suggested that, “exposure to prolonged activation
with 65% of non-maltreated men; for women this was 52% compared with of physiological stress responses due to events chronically unsupported by
71%. There is evidence that ACEs can impact on future employment and positive and secure relationships causes deleterious modifications to biological
earning potential30. Evidence also shows that maltreated children are more systems (neuroendocrine, inflammatory, immune) involving epigenetic
likely to have menial or semi-skilled jobs as young adults and are more likely to modifications, that may or may not be reversible”40. This then increases
be unemployed than their non-maltreated peers31. morbidity and early mortality as individuals are less able to adapt to negative
exposures and more likely to engage in damaging health behaviours.
There is significant evidence linking childhood maltreatment with poor
66 educational outcomes32. This includes evidence that verbal abuse contributes 67
to lower language test scores for 10 year olds33, and that abused children have
lower grades, lower educational attendance and more placements in special 7. The intergenerational transmission of ACEs
education programmes34. Evidence has also shown that maltreated children,
particularly those who were neglected, had lower test scores and grades In general, those children who experience ACEs are more likely to have a
in reading and maths35. Other studies have shown an impact of household parent who has also experienced ACEs. This perpetuation of disadvantage,
adversities on the SDH – for example, data from the 1970 British Cohort from one generation to the next, contributes to societal inequalities as it
Study has shown a clear association between maternal mental health and places an extra burden on those children who come from disadvantaged
children’s educational attainment and future household income36. backgrounds, increasing the risk of ACEs across generations.
Evaluating the full impact of the pathway from ACEs to health via the social This ‘intergenerational transmission’ of adversity has been reported in
determinants is complex, as many studies of the impact of ACE control for relation to child abuse41, mental ill health42 and substance misuse43. Exposure
educational attainment, socioeconomic status or other SDH, which therefore to domestic violence and other forms of violence increases the risk of
makes it harder to isolate these as pathways. In general, a greater relationship becoming both a victim and perpetrator of violence in adolescence and later
can be seen between ACE and health outcomes when these factors are life44, sometimes called the ‘cycle of violence’45. One study has suggested
included (often as ‘unadjusted figures’). However, this may be due to common that approximately a third of parents who were maltreated in childhood will
causes – for example, family poverty in childhood can increase the chances of maltreat their own children46. In part this may be due to children modelling
experiencing ACEs and increase the chances of being unemployed later on in the behaviour of their parents when they grow up and not having a ‘positive’
life. experience to learn from and replicate. Parenting programmes that teach
about good parenting could help to break this cycle47.

A 2015 US study examined the pathways by which ACEs experienced in For example, there is evidence that women from poorer childhood homes were
childhood increase the risk of intimate partner aggression in adulthood48. twice as likely to have suffered from abuse or neglect and three times as likely
The study found that among men, post-traumatic stress disorder mediated to have suffered from more than one form of abuse than those from more
the relationship between sexual abuse and intimate partner aggression, affluent childhood homes52. US research has found that children in households
and substance abuse mediated the relationship in men and women. It with an annual income below $15,000 (in 1993) were 22 times more likely to
concluded that, “programs geared towards aggressors should address abuse experience harm as a result of maltreatment compared with those in families
(sexual, physical and psychological), which occurred during childhood and with incomes over $30,00053.
recent substance abuse and PTSD (post-traumatic stress disorder). These
programmes should be implemented for men and women”49. More recent US research has also found a clear relationship between material
factors and child maltreatment54. This includes a random-assignment study
However, experiencing one or more ACEs in childhood or adolescence is not where a gain in income resulted in a reduction in child abuse and neglect,
fate – it does not mean that the individual is destined to perpetuate these compared with a control group55. While random-assignment is rare, other
conditions in relation to their own children. Most people who are maltreated studies have shown a correlation between reductions in income and increases
do not go on to maltreat their own children and most of those who were in child maltreatment56.
exposed to violence do not go on to perpetrate or be a victim of violence. More
research is needed on the factors that enable these people to ‘break the cycle’ UK longitudinal research has found that an indicator of deprivation (derived
– although it appears that having a higher socioeconomic status and sufficient from measures of paternal unemployment, overcrowding, living in rented
economic resources may help. For example, English evidence has found that or council accommodation and not having access to a car) had the strongest
father’s mental illness ceased to have an impact on their children’s attainment association with child maltreatment out of all the risk factors included in the
and development where the family had higher socioeconomic resources50. study57. The majority of parents who live in poverty, disadvantage, or are of low
68 socioeconomic status, do not mistreat their children58. However, UK research 69
has found that being in a lower socioeconomic group is associated with a
more significant level of abuse59 and data from England and Wales from the
8. Risk factors of ACEs 1980s and 90s showed a steep social class gradient in intentional injury among
children and young people: for example, the homicide rate for children aged
0-15 in the lowest social class was 17 times that for those in the highest social
a. the context in which families live class60. A Scottish study found that 82% of families with higher incomes (over
£33,571) had no instances of poor maternal mental health, while this dropped
Difficult and challenging social, economic and cultural factors impact on to 54% for families in the lowest quintile (under £8,410)61.
families and increase the stress on parents and families. All of these will likely
increase the risk and likelihood of ACEs. The association between poverty and maltreatment is most commonly
explained by stress factors linked to unemployment, low income and depleted
resilience, including social isolation, mental ill health, domestic abuse and
i. poverty, low socioeconomic status and disadvantage substance misuse62. For example, parents with a low income are four times
more likely to feel ‘chronically stressed’ than parents with higher incomes63.
Most parents who live in poverty, are disadvantaged or have low The NSPCC states, in relation to social status and child maltreatment, “the
socioeconomic status do not maltreat their children. However there is most common explanation centres on the stress factors that are associated
evidence that low economic status and having insufficient economic resources with unemployment and low income, such as social isolation and mental ill
can act as a risk factor for child maltreatment51. health. Poverty can also erode parents’ resilience to deal with these stress
factors”64.

ii. unemployment b. parental and family factors

Studies that find a relationship between ACEs and unemployment rarely
control for income, in order to ascertain the effect that unemployment might i. parenting
have over and above, or separate from, the increased risk of low income.
However, some studies do mention unemployment specifically as a risk There is some evidence that links parenting style with child maltreatment. For
factor65, and it may be the case that unemployment increases the chances of example, a retrospective study in the UK found that incompetent parenting
children experiencing ACEs, perhaps due to increased stress in the home. by mothers (such as being impatient, irritable or giving too little time and
attention) was associated with their offspring reporting maltreatment during
childhood75. Parents who maltreat their children are also more likely to use
iii. deprived communities harsh discipline strategies, less likely to use positive parenting strategies, and
more likely to respond to negative but not positive behaviours76.
The WHO states that, “maltreatment tends to be more common in families in
deprived communities. These areas can lack ‘social capital’ – the institutions, One element of knowledgeable parenting is having appropriate expectations
relationship and norms that shape a society’s social interaction – and may have and accurate understanding of children’s development. Some studies have
many alcohol outlets”66. found links between higher (unsuitable) expectations of children and lower
understanding of developmental processes, and child maltreatment77.
The impact of local deprivation has also been seen in UK studies67: children
who live in the most deprived 10% of neighbourhoods have a 10 times greater While some of these findings refer specifically to younger children, it is likely
chance of being on a child protection plan and an 11 times greater chance of that damaging parental relationships with children over the age of 5, and some
70 being taken into care than children in the least deprived 10%. This may have parenting practices, may be related to ACEs. One study also found that poor 71
an impact separate from the likely lower incomes and increased poverty of parenting was a background factor for adolescent physical abuse78. However,
families in this area – in part through a lack of local services or community in some cases, parental behaviours that may have been abusive or neglectful
conditions which increase stress for families and do not provide sufficient for a younger child are not so damaging for older children79.
social support. There is also evidence linking violent neighbourhoods to an
increased risk of child maltreatment68. There is some evidence that younger parents may be more likely to maltreat
their children than older parents80. For example, a longitudinal study of British
parents found that parents who were younger than 20 had a three times
iv. social isolation greater risk of having a child placed on the child protection register before
the child’s 6th birthday81. It may be the case that younger parents are more
There is some evidence that parents who maltreat their children are more likely to be exposed to other risk factors – such as poverty and unemployment
isolated, more lonely and have less social support than those who don’t69. This – compared with their older counterparts, and that this increases the risk of
may be in part because social isolation increases stress, and those who are child maltreatment82 and likelihood of poor parenting.
isolated have a lack of positive parenting role models, or a lack of pressure
from others to conform to positive parenting behaviours70.
ii. family structure
Evidence on the protective nature of parental social networks has found that
they protect against poor outcomes for children71 and increase the amount Children living in single parent families have been shown to be at increased
of positive interactions mothers have with their children72. Social networks risk of maltreatment83. A UK cohort study of more than 14,000 individuals
provide a shared understanding of parenting73 and a buffer to the challenges also found a relationship between family structure and child maltreatment
of parenting74.

– single parent and reordered (with step-parent) families both had a higher received much publicity recently. Overall prevalence across the population
risk of children becoming placed on local child protection registers. The odds is not possible to ascertain with certainty but one study from 1992 found
ratio was three times higher in these families. However, the authors report that out of 1,000 children in institutionalised care in the UK, 158 reported
that this odds ratio drops substantially when other factors are controlled that they had been sexually abused91. This figure is now out of date, however,
for, suggesting that, “while important, the effects of family structure are and prevalence may have changed significantly since then. A 2013 National
modified by the confounding roles of parental background and socioeconomic Crime Agency report found that children cared for by institutions were more
environment”84. Having larger numbers of children in the household has also vulnerable to abuse due to the structure and status of institutions and the
been linked to an increase risk of neglect85. power of the adults working in them92.
It is not clear whether living with only one parent is the actual risk factor
for child maltreatment, or whether this is indicative of poverty or low
socioeconomic status (since one-parent families are more common lower 9. Taking action to address ACEs risk factors
down the social gradient), which are also risk factors. In some cases, for
example in which there is domestic violence or other conflict in the home, Taking preventive action to reduce the prevalence of ACEs, and thereby
separation may be beneficial for the child and reduce the chances of improve population health, therefore requires acting on the risk factors
maltreatment. In addition, while factors such as family structure can increase identified. Some current policies, for example the Troubled Families
the risk of child maltreatment, the absolute risk is still low: for example, in the Programme93, aim to do this. However this and many other interventions are
UK longitudinal study cited above, only 3.5% of all single mothers had children only available for those with the very highest levels of need.
registered for child abuse or neglect86.
It may be the case that many children who are exposed to ACEs, but are not
72 identified by local safeguarding systems, would benefit from a ‘proportionate 73
c. household adversity universalism’ approach – universal in scope, but recognising the increased
burden faced by those lower down the social gradient. This could act on the
In England, an examination of the household conditions present in cases three risk factors as follows:
of child death or serious injury shows the presence of domestic violence in
more than 60% of cases, parental mental illness in 60% of cases, and parental • Improving the context in which families live – local programmes that
substance misuse in 42% of cases87. However, deaths and serious injuries tackle social isolation, increase community coordination and mitigate
represent a very small fraction of all child protection cases – there are many the negative impact of poverty, the recession and austerity measures
less serious or immediate impacts, which also reveal household adversity as a on families may help to reduce stress, increase resilience and therefore
risk factor. For example, further research shows that more than 34% of under- reduce ACEs prevalence.
18s who have lived with domestic violence have been abused or neglected
by a parent or guardian88, and parental abuse of drugs or alcohol, or both, has • Tackling parental and family risk factors – parenting programmes
been detected in more than half of parents who neglect their children89. US have a range of benefits, and some have been found to reduce child
research supports these findings: parental substance abuse has been found maltreatment94. Making these available to a wider range of parents,
to be a contributing factor for between 30 and 60% of maltreated children and implementing them with the involvement of a range of sectors,
in the welfare system and children whose parents abused alcohol were could reduce ACEs prevalence.
approximately three times likelier to be abused and over four times more likely
to be neglected when compared with those whose parents were not substance • Reducing household adversity – local organisations and practitioners
misusers90. can work in multi-agency teams to provide integrated responses that
recognise multiple needs and adversities, and act holistically and
Child maltreatment, particularly sexual abuse, in institutional care settings has flexibly to better detect and respond to those facing adversity at home.

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68 Cicchetti, D., Manly, J. T. and Lynch, M. (1998) An Ecological Developmental Perspective on the 86 Sidebotham, P. (2006) Op. cit.
Consequences of Child Maltreatment (1995-1996) NY: Cornell University. 87 Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C., et al. (2012) New
69 Whitney, D. M., Morello, L. M., Reed, A. K. and Urquiza, A. J. (1999) ‘Depression, distress, and learning from serious case reviews: a two year report for 2009-2011. Warwick: University of
social isolation in physically abusive and nonabusive parents’. Paper presented at the meeting East Anglia and University of Warwick.
of the American Professional Society on the Abuse of Children, TX: San Antonio. 88 Radford, L., Aitken, R., Miller, P., Ellis, J., Roberts, J., Firkic, A. (2011) Meeting the needs of
Marryat, L. and Martin, C. (2010) Op. cit. children living with domestic violence in London. London: Refuge / NSPCC.
70 Harrington, D. and Dubowitz, H. (1999) ‘Preventing child maltreatment’ in Hampton, R. L. (ed) 89 Dunn, M. G., Tarter, R. E., Mezzich, A. C., Vanyukov, M., Kirisci, L. and Kirillova, G. (2002) ‘Ori-
Family Violence: prevention and treatment (second edition). London: Sage. p. 122-47. gins and consequences of child neglect in substance abuse families’ Clinical Psychology Review
71 Garmezy, N. (1993) ‘Children in Poverty: resilience despite risk’ Psychiatry: interpersonal and 22(7): 1063-90.
biological processes 56(1): 127-36. 90 Guy, J., Feinstein, L. and Griffiths, A. (2014) Early intervention in domestic violence and abuse.
London: Early Intervention Foundation.

Chapter 2
91 Nunno, M. A. (1992) Factors Contributing to Abuse and Neglect in Out of Home Settings.
Paper presented NSPCC conference on the International Abuse of Children. 3. Trauma is really strange
TRAUMA IS REALLY STRANGE.
92 National Crime Agency (2013) The Foundations of Abuse: A thematic assessment of the risk of
child sexual abuse by adults in institutions. London: NCA. Steve Haines and Sophie Standing (illustrator)
93 Buchholz, E. S. et al (1993) Op. cit.
94 DCLG (2014) Understanding Troubled Families: https://www.gov.uk/government/uploads/sys-
tem/uploads/attachment_data/file/336430/Understanding_Troubled_Families_web_format.
The original text and illustrations are from Trauma Is Really Strange, published
pdf
and reproduced with permission of Jessica Kingsley Publishers through
For more information see: www.canparent.org.uk
PLSclear.
UCL Institute of Health Equity (2014) Good quality parenting programmes and the home to
school transition. London: Public Health England.
Learn more about Steve and Sophie’s work at:
www.traumaisreallystrange.com and www.sophiestanding.com
80 81

Chapter 3 Trauma is really strange
THE GOAL OF THIS BOOK IS TO BE A NON-SCARY MOST OF THE BITS OF THE BRAIN THAT DEAL WITH
INTRODUCTION TO TRAUMA. FOR MANY PEOPLE, OVERWHELMING EVENTS ARE VERY OLD. SOME OF
UNDERSTANDING WHAT THE BRAIN IS TRYING TO DO THE REFLEXES WE USE TO RESPOND TO DANGER
TO PROTECT THEM HELPS HEALING. ORIGINATED IN REPTILES.
TRAUMA IS REALLY STRANGE.
IN FIGHT-OR-FLIGHT, RESOURCES SUCH AS FIGHT-OR-FLIGHT OR DISSOCIATION SWITCH ON

OXYGEN, BLOOD AND SUGAR ARE DIVERTED TO REALLY REALLY REALLY QUICKLY. UNLESS THEY ARE
THE BIG MUSCLES AND THE BRAIN. PRIMITIVE DISCHARGED, THE BRAIN CAN DEFAULT TO THESE
REFLEXES TAKE OVER. LIFE AND DEATH SCENARIOS LONG AFTER THE
DANGER HAS PASSED.
THIS IS THE BIG PROBLEM OF TRAUMA.
‘GET ME OUT
OF HERE NOW!’
82 83
THE EXCITING NEWS IS THAT THEY CAN ALSO SWITCH WE ALL HAVE WITHIN US
OFF REALLY QUICKLY - EVEN IF THEY HAVE BEEN STUCK THE ABILITY TO ENDURE,
IN PLACE FOR YEARS. RECOVER AND LEARN
FROM OVERWHELMING
EVENTS.
A common response is contracting to make ourselves small, ultimately into Running away from a lion is life or death. All non-essential activity is switched
an immobile, fetal position. We are left bracing ourselves against life, off, there is no need for digestion, libido and reproduction, immune system,
disconnected from our internal and external worlds. ‘Trauma occurs when or growth and repair (Sapolsky 2004). Health can dramatically improve
an event creates an
A common unresolved
response impact on to
is contracting an make
organism’ (Levine
ourselves 1997).
small, when
Runningthe away
‘defense cascade’
from a lion isis reset
life or(Kozlowska
death. Alletnon-essential
al 2015).
ultimately into an immobile, fetal position. We are left bracing activity is switched off, there is no need for digestion, libido and
ourselves against life, disconnected from our internal and reproduction, immune systems or growth and repair (Sapolsky
external worlds. ‘Trauma occurs when an event creates an 2004). Health can dramatically improve when the ‘defense
unresolved impact on an organism’ (Levine 1997). cascade’ is reset (Kozlowska et al 2015).

WE LOSE CONNECTION WITH OUR BODY OR PARTS OF OUR BODY. IT IS HARD TO STAY PRESENT AND GROUNDED.
LET’S LOOK AT SOME STATEMENTS FROM
CLINICAL PRACTICE THAT DEMONSTRATE
THE STRANGENESS OF TRAUMA.
DISSOCIATION CAN BE TERRIFYING, BUT IT CAN

‘MY LEGS ARE TINY AND FAR AWAY.’ DISSOCIATION IS DIFFICULT TO IDENTIFY AS
‘I FEEL AS IF I AM OUTSIDE MY BODY.’ ALSO BE VERY HARD TO SPOT. THE CENTRAL
‘WE DON’T KNOW WHAT WE DON’T KNOW.’
FEATURE IS THAT BRAIN IS IN THE HABIT OF NOT
OLD PARTS OF THE BRAIN ARE TRYING TO
FEELING.
STOP US SENSING, DISTANCING US FROM
THE BODY AND LIMITING OUR PERCEPTION.
84 85
FEEL ME
ALSO, DISSOCIATION... CAN MAKE US... A BIT CLUTZY!
PEOPLE CAN RELY ON THINKING

AND FUNCTION PRETTY WELL,
BUT OFTEN REPORT THEY FEEL
CUT OFF, LIKE AN OBSERVER.

‘I’M SHAKING, IS SHAKING AFTER A DRAMATIC EVENT IS OFTEN

THIS NORMAL?’ ASSOCIATED WITH FEAR. SHAKING UNCONTROLLABLY
FEELS BIZARRE AND TOO MUCH.
‘I CAN’T GET ENOUGH AIR IN.’ ‘THERE IS A KNOT OF ANXIETY IN MY BELLY.’

LETTING OURSELVES SHAKE CAN BE A VERY
POWERFUL TOOL AND CAN BE USED LIKE A SAFETY
VALVE TO CLEAR EXCESS ENERGY. WE CAN LEARN
TO INTERACT WITH SHAKING, RATHER THAN TRYING
TO DAMPEN IT DOWN ALL THE TIME. SHAKING CAN
BE UNCOUPLED FROM EMOTIONAL INTENSITY.
86 87
RESTLESS LEGS AND TENSION SHAKES ARE VERY
COMMON WHEN WE ARE OVERWHELMED.
‘THOUGHTS KEEP INVADING ME, IT’S AN ‘I CAN’T KEEP STILL, MY MIND IS RACING.’
OBSESSION I CANNOT LET GO OF.’
THESE STATEMENTS DESCRIBE THE BODY FEELS AS THOUGH

BEING STUCK IN THE GO EVERYTHING IS GEARED UP
QUICK, FIGHT-OR-FLIGHT FOR ACTION. ALL THE TIME.
MODE. NON-STOP. PANIC ATTACKS
AND/OR RAGE ARE THE LAST
STOPS ON THIS ROUTE.
SHAKING IS BEST UNDERSTOOD
AS A WAY OF EXTINGUISHING
FEAR AND DISCHARGING ALL THE
ENERGY MOBILIZED FOR FIGHT-
OR-FLIGHT.
(MORE ON THE STRANGENESS OF

SHAKING LATER.)
Classic post-traumatic stress disorder (PTSD) symptoms include involuntarily Being stuck in fast forward can be very productive. There are many The ‘I’m shaking, is this normal?’ quote is from a young girl after watching The amount of people who experience restless leg syndrome (RLS) is
re-experiencing aspects of the traumatic event in a very vivid and successful executives whose internal state drives them forward. But the her first deer be killed. Her dad does an amazing job of reassuring her and surprisingly high: ‘RLS affects 5%–10% of adults in the general population,
distressing way, avoidance behaviour, hyperarousal and emotional numbing imperative from the body is ultimately very draining and frequently helping her discharge, check YouTube: ‘Savannah’s first deer hunt’. and is associated with various chronic conditions’ (Li et al 2013).
(NICE Classic
2005). post-traumatic stress disorder (PTSD) symptoms include associated
Being stuckwith massive
in fast anxiety.
forward can be very productive. There are The ‘I’m shaking, is this normal?’ quote is from a young girl The amount of people who experience restless leg syndrome
involuntarily re-experiencing aspects of the traumatic event many successful executives whose internal state drives them after watching her first deer being killed. Her dad does an (RLS) is surprisingly high: ‘RLS affects 5%–10% of adults in
in a very vivid and distressing way, avoidance behaviour forward. But the imperative from the body is ultimately very amazing job of reassuring her and helping her discharge, the general population and is associated with various chronic
hyperarousal, and emotional numbing (NICE 2005). draining and frequently associated with massive anxiety. check YouTube: ‘Savannah’s first deer hunt’. conditions’ (Li et al 2013).

Chapter 3
4. Childhood adversity and lifetime resilience

WE CAN USE THREE STATEMENTS TO
HELP UNDERSTAND WORKING WITH AND
1. ‘THERE IS TRAUMA.’ TERRIBLE THINGS
HAPPEN TO HUMAN BEINGS.
Dr Lucy Bowes
OVERCOMING TRAUMA.
Summary
Childhood adversity increases children’s risk of poor educational,

social, mental and health outcomes. However, many children display
‘resilience’ in the face of adversity, and function at least as well as the
average non-exposed child. A great deal of research has focused on the
role of children’s individual characteristics such as cognitive appraisal
and coping strategies. However resilience is not, and should not, be
viewed as an issue of individual resources and capabilities.
Resilience arises through children’s interactions with their social

and physical ecologies, from families through to schools, and
neighbourhoods. Scaffolding child development by supporting families,
3. ‘HEALING TRAUMA IS ABOUT MEETING THE BODY.’ building healthy and happy school environments and communities,
88 2. ‘WE CAN OVERCOME TRAUMA.’ IN TRAUMA, OLD PARTS OF THE BRAIN CHANGE
HOW THE BODY WORKS. BY PAYING ATTENTION TO
and addressing social inequalities in access to resources is crucial for 89
FEELINGS IN THE BODY AND LEARNING TO SELF-
REGULATE WE CAN REBOOT THE BRAIN.
enabling vulnerable children exposed to adversity to navigate their way
to success. Resilience therefore depends on the structures and social
policies that determine availability and access to resources.
Adverse childhood experiences, including child maltreatment, bullying

(including bullying by siblings), and other forms of violence and
victimisation in the home or community place children at increased risk
for a broad range of mental health, social and educational difficulties1.
WE ARE ‘WIRED TO
Despite this increased risk, there is plenty of evidence to suggest that
SURVIVE’. WE WOULD
NOT BE HERE AS A HUMAN
many children function at least as well as the average, non-exposed
SPECIES UNLESS WE child. Some researchers have gone on to suggest that ‘resilience’ – or
HAD EVOLVED WAYS OF
RECOVERING FROM THAT the process by which children maintain or regain normative functioning
LION ATTACK (OR SUDDEN
LOSS OF A LOVED ONE, OR following exposure to significant adversity – is the norm, not the
BEING ABUSED, OR BEING
IN AN ACCIDENT…). exception2. Research on resilience has progressed from an early
focus on the particular characteristics of ‘invulnerable youth’ to an
‘As I learned more about how people manage to withstand extremely These three statements are drawn from the work of Dr David Berceli, creator
aversive events, it became all the more apparent to me that humans are of Trauma Releasing Exercises (TRE). The body is central to healing, as understanding that resilience is a dynamic process involving a complex
wired to survive. Not every-body manages well, but most of us do’ (Bonanno often ‘there are no words to describe the depth of human experience the
2010).‘As I learned more about how people manaage to withstand trauma survivor
These three has beenare
statements plunged
drawninto’
from(Berceli 2008a).
the work of Dr David interplay between individuals and their particular life circumstances3.
extremely aversive events, it became all the more apparent to Berceli, creator of Trauma Releasing Exercises (TRE). The body
me that humans are wired to survive. Not everybody manages is central to healing, as often ‘there are no words to describe
well, but most of us do’ (Bonanno 2010) the depth of human experience the trauma survivor has been
plunged into’ (Berceli 2008a).

Chapter 4 Childhood adversity and lifetime resilience
1. Individual characteristics that foster resilience adversity – cognitive behaviour therapy (CBT)10. There are numerous different
models and treatments that build on the core principles of CBT; CBT-based
Much research has focused on the individual-level factors that help determine treatments for post-traumatic stress disorder, social anxiety, obsessive
whether an experience is associated with severe symptoms or recovery. The compulsive disorder and depression to name but a few. The key process
‘kindling hypothesis’ describes how early adverse experiences may sensitise remains consistent across treatments: identifying and challenging patterns of
children to subsequent life stress, increasing vulnerability to psychological negative thinking and avoidance behaviours. Though CBT-based approaches
disorders such as depression and anxiety4. However, exposure to stress early are not the only form of psychological therapy, they are among the most
in life is not always a source of risk; studies of ‘stress inoculation’ or ‘steeling effective, particularly for the treatment of depression and anxiety11.
effects’ point to the beneficial effects of exposure to mild forms of stress5. It is
thought that the experience of successfully coping with milder forms of stress
may give children an opportunity to develop adaptive strategies that can be
utilised to change future stressful situations where possible or modify their 2. The social ecology of resilience
emotional response6. In a recent study of 1,584 teenagers in the Netherlands,
it was found that for some adolescents, the experience of childhood Resilience in the face of adversity is not – and should not – be considered an
adversity was associated with a lower probability of later depression under issue in terms of individual resources and capabilities however. While cognitive
stressful situations compared to adolescents without a history of adversity7. vulnerability and other individual-level characteristics may be a predisposing
It is thought that such individuals become more ‘adapted’ to stressful factor to psychological difficulties, one must also consider protective factors
environments than teenagers without a history of childhood adversity. at the family and social level, the wider school and community-level resources
However, this may come at a cost – the same adolescents may display an in place and how these are shaped by national policies and practices. It has
overall lower sensitivity to all environmental experiences, meaning they may been argued that resilience is better construed as “The capacity of individuals
90 also benefit less from more positive environments. to navigate their way to health-sustaining resources, including opportunities 91
to experience feelings of wellbeing, and a condition of the individual’s family,
The way we attend to stimuli in our environment, and how we process community and culture to provide these health resources and experiences in
information, is thought to play an important role in risk and resilience to culturally meaningful ways”12. Thus the onus moves away from the individual,
psychological disorders. In the cognitive model of psychological disorders, a but rather acknowledges the responsibility of society to support vulnerable
complex interaction between one’s genetic make up and early life experiences individuals and build the resources necessary to enable individuals who have
are thought to give rise to particular cognitive schemas – dysfunctional experienced adversity to navigate their way towards wellbeing. Practically,
cognitive attitudes that, when activated by stressful life events, serve to bias what might that entail?
our attention towards negative stimuli, to cause us to interpret ambiguous
stimuli negatively, and biases our memory towards more negative events8.
While research originally focused on the impact of significant life events
such as the death of a loved one or loss of a job, more recent research has 3. Strengthening social support for vulnerable children
emphasised that relatively milder forms of stress may precipitate depression
in those with cognitive vulnerability. For example, students who showed Availability and access to social support – both in terms of supportive
evidence of cognitive vulnerability in terms of negative attitudes and biases relationships with family members, but also with friends and peers beyond
about the self were more likely to become depressed following negative the family – are an important source of resilience in at-risk youth13. The
outcomes on college applications compared to students without such cognitive importance of forming positive attachments, particularly for children exposed
vulnerability9. to abuse and maltreatment, has underpinned much of the recent changes in
the child welfare system.
The cognitive model has given rise to one of the most effective forms of
treatment for the psychological difficulties associated with childhood There has been an overall decline in the use of residential care for children in

high-income countries since the 1980s, in large part due to concerns about There is a substantial body of evidence that school-based bullying is a key risk
the lack of attachment in young children, and the risk of abuse14. In 2005, factor for the development of psychological disorders including depression,
68% of children in care were fostered15. However, a survey by Fostering anxiety and self-harm. School bullying may also exert long-term effects on
for the Future16 found that five out of seven councils had difficulties finding children’s educational and social outcomes26. Systematic reviews provide
suitable matches between child and carers. As a consequence, out of area evidence that there are effective interventions that serve to reduce bullying,
placements for children are not reducing, and placement stability may even particularly those that target the whole school27. Recent research highlights
be worsening17. Such instability reduces the opportunities for vulnerable the importance of changing bystander responses – shifting attitudes and
youth to build and maintain positive relationships with supportive adults, actions away from providing implicit support for bullying behaviours such as
and thus reduces opportunities to promote resilience. Strong sibling bonds through laughing or sharing online messages towards a discouraging stance28.
have also been shown repeatedly to be associated with greater resilience to
stressors such as maltreatment and bullying18. The importance of keeping By UK law, all state schools (not private schools) must have a behaviour policy
siblings together during foster care or adoption has been well-documented in place that includes measures to prevent all forms of bullying among pupils.
in research19. Increasing availability of foster carers able to care for sibling However, policies are decided by schools, and there is great variation in policy
groups and providing enhanced support is likely to be of great benefit. content and implementation29. Increasing awareness on best practices for
Likewise, the importance of school ties – both in terms of peer friendships and tackling bullying and provision for schools to implement evidence-based anti-
positive teacher-student relationships – plays an important role in children’s bullying programmes is greatly needed. Finland provides an excellent example
resilience to adversity20. Too often, looked-after children are forced to move here. The evidence-based whole-school intervention program ‘KiVa’ developed
schools, disrupting these ties and reducing the likelihood of resilience. in Finland has now been adopted as the national anti-bullying programme,
with over 90% of schools registered as implementing the KiVa programme30.
Access to social support is not just important for children exposed to A similar approach in the UK would help reduce the prevalence of a key risk
92 maltreatment, but rather promotes resilience to multiple forms of adversity. factor for children and young people’s mental health and wellbeing. 93
Increasing opportunities for socially isolated youths to develop support
systems is one way to maximise opportunities for resilience. While the risks The rise in cyberbullying presents a new challenge for families, schools and
associated with online social networks is often highlighted21, online resources society. While evidence may suggest that cyberbullying may represent a new
to support health and social care are becoming increasingly popular. Online tool through which bullying can take place rather than a new phenomena
support groups and forums have potential to provide an important source of per se31, the very fact that the bullying does not take place within school
protection, with studies suggesting beneficial effects in terms of increased grounds, and that the bullies may remain unknown, means existing anti-
emotional support, self-disclosure, reduced social anxiety and belongingness22. bullying interventions will need to be modified to address cyberbullying at the
very least. New interventions are being developed, many utilising effective
components from traditional anti-bullying interventions such as psycho-
education and changing bystander behaviour32. However as yet, systematic
4. The school environment evidence of their efficacy is lacking.
Children spend some fifteen thousand hours at school from the start of school
until GCSEs23. In addition to supporting children’s educational outcomes, the
physical, social and cultural environment in which staff and students spend so 5. Addressing the adverse experiences in the round
much of their time may impact profoundly on their wellbeing, mental health
and their opportunities to choose healthy lifestyles24. A systematic review Bullying also provides an example of the silos in which we conduct research
of school-based interventions that promote student social and emotional and improve practice. Children’s experiences of trauma and victimisation in the
development and mental health also promote better attainment25. However, home are closely connected with their experiences with their peers outside
schools may also impart risk for child mental health and wellbeing. of the home environment. Children who are maltreated are twice as likely

to be bullied at school for example33; more than half of children victimised 6. An integrated view of resilience
by their siblings also report being bullied by their peers34. This is not to say
that all bullied children have experienced some form of maltreatment at Resilience encompasses children’s individual strengths and capabilities as
home – far from it – but rather raises the point that victimisation experiences well as their social and physical environments. Protective factors range from
tend to co-occur. Research and practice often neglects the fact that children proximal, individual characteristics of children and their families to broader,
who experience one form of victimisation are at significantly greater risk of distal (remote) factors that together promote successful development under
experiencing other forms of violence35. In a survey of children’s victimisation adversity. Resilience is not an individual trait, or something that children
experiences in the home, school and wider community, the average number of are born with. Rather, children’s interactions with their social and physical
victimisation experiences reported was 336. Children who experience multiple environments build resilience. Resilience is therefore dependent on the
forms of adverse experiences are particularly vulnerable to developing structures and social policies that help scaffold children and make resources
psychological difficulties37. available.
Exposure to multiple types of adversity substantially decreases the chances of

children and young people navigating their way to resilience38. Unfortunately,
most interventions are designed to target specific forms of adversity: family
nurse partnership programmes and other parenting programmes are designed
to support parents at risk of harsh parenting practices; bullying interventions
are almost wholly confined to the school domain, despite strong evidence of
an overlap between experiences at home and at school39. This separation of
research and intervention misses the chance to provide better, integrated
94 support for children exposed to multiple forms of adversity. Protective factors 95
at the family level including parental warmth, positive sibling relationships
and a supportive home environment have the power to promote resilience to
bullying, yet such family factors are often overlooked in school-based anti-
bullying interventions40.
Schools too may play an important role in supporting children exposed to

family maltreatment, with evidence that school education programmes
increase child self-protective skills and knowledge41. A better integration of
family and school services and interventions is likely to be of great benefit in
reducing risk and promoting resilience. Alongside this, there is strong evidence
that when adolescents are able to access mental health services, they are
better able to manage their mental ill health, and make sense of the trauma and
adversity they have faced42.

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break the intergenerational cycle of abuse: a prospective nationally representative cohort of Psychology 18: 372-90.
children in the United Kingdom’ The Journal of Adolescent Health 53(4): 4-10. Bonell, C., Humphrey, N., Fletcher, A., et al. (2014) ‘Why schools should promote students’
Bowes, L., Maughan, B., Caspi, A., et al. (2010) ‘Families promote emotional and behavioural health and wellbeing’ BMJ 348(7958): 3078.
resilience to bullying: evidence of an environmental effect’ Journal of Child Psychology and 26 Bowes, L., Joinson, C., Wolke, D., et al. (2015) ‘Peer victimisation during adolescence and its
Psychiatry 51(7): 809-17. impact on depression in early adulthood: prospective cohort study in the United Kingdom’
BMJ 350: 2469.

Chapter 4
Copeland, W. E., Wolke, D., Angold, A., et al. (2013) ‘Adult psychiatric outcomes of bullying and
being bullied by peers in childhood and adolescence’ JAMA Psychiatry 70(4): 419-26. 5. Building resilience in the face of adversity
27 Ttofi, M. M. and Farrington, D.P. (2011) Effectiveness of school-based programs to reduce
bullying: a systematic and meta-analytic review’ Journal of Experimental Criminology 7: 27-56. Lucas Shelemy and Dr Pooky Knightsmith
Vreeman, R. C. and Carroll, A. E. (2007) ‘A systematic review of school-based interventions to
prevent bullying’ Archives of Pediatrics and Adolescent Medicine 161(1): 78-88.
28 Salmivalli, C. (2014) ‘Participant Roles in Bullying: How Can Peer Bystanders Be Utilized in
29
Interventions?’ Theory Into Practice 53(4): 286-92.
Smith, P. K., Kupferberg, A., Mora-Merchan, J. A, et al. (2012) ‘A content analysis of school an-
Introduction
ti-bullying policies: a follow-up after six years’ Educational Psychology in Practice 8(1): 47-70.
30 Karna, A., Voeten, M., Little, T. D., et al. (2011) ‘Going to scale: a nonrandomized nationwide In reviewing what the academic and practice literature says about how
trial of the KiVa antibullying program for grades 1-9’ Journal of Consulting and Clinical Psy- children and young people build resilience in the face of adversity, several
chology 79(6): 796-805.
themes emerged as key factors in protecting and promoting children and
Salmivalli, C. and Poskiparta, E. (2012) ’Making bullying prevention a priority in Finnish
young people’s resilience – what we call the ‘4Ps’:
schools: the KiVa antibullying program’ New Directions for Youth Development 133: 41-53.
31 Waasdorp, T. E. and Bradshaw, C. P. (2105) ‘The overlap between cyberbullying and traditional
bullying’ The Journal of Adolescent Health 56(5): 483-8. • Parents – a nurturing, caring, rule-enforcing relationship with a parent,
Olweus, D. (2012) ‘Cyberbullying: an overrated phenomenon?’ European Journal of Develop- carer or adult figure
mental Psychology 9(5): 520-38.
32 Bastiaensens, S., Vandebosch, H., Poels, K., et al. (2014) ‘Cyberbullying on social network sites: • Peers – social connectedness with a supportive peer group
an experimental study into bystanders’ behavioural intentions to help the victim or reinforce
the bully’ Computers in Human Behavior 31: 259-71.
33 Bowes, L., Arseneault, L., Maughan, B., et al. (2009) ‘School, neighborhood and family factors
• Problem solving – ability to problem solve and communicate can
are associated with children’s bullying involvement: a nationally-representative longitudinal moderate risk factors
98 study’ Journal of the American Academy of Child and Adolescent Psychiatry 48: 545-53. 99
34 Wolke, D. and Samara, M. M. (2004) ‘Bullied by siblings: association with peer victimisation and • Passion – an interest, hobby or skill that the child highly values in
behaviour problems in Israeli lower secondary school children’ Journal of Child Psychology
and Psychiatry 45(5): 1015-29.
themselves
35 Finkelhor, D., Ormrod, R. K., Turner, H. A. (2007) ‘Poly-victimization: a neglected component in
child victimization’ Child Abuse and Neglect 31(1): 7-26. In this paper we explore each of these ‘Ps’ in turn and consider their practical
36 Finkelhor, D., Ormrod, R. K., Turner, H. A. (2009) ‘Lifetime assessment of poly-victimization in a application in the current context.
national sample of children and youth’ Child Abuse and Neglect 33(7): 403-11.
37 Edwards, V. J., Holden, G. W., Felitti, V. J., et al. (2003) ‘Relationship between multiple forms of
childhood maltreatment and adult mental health in community respondents: results from the
adverse childhood experiences study’ American Journal of Psychiatry 160(8): 1453-60. Figure 1: Key factors that protect and promote resilience in children and
38 Jaffee, S. R. and Gallop, R. (2007) ‘Social, emotional, and academic competence among children young people in the face of adversity and trauma
who have had contact with child protective services: prevalence and stability estimates’ Jour-
nal of the American Academy of Child and Adolescent Psychiatry 46(6): 757-65.
39 Bowes, L. et al (2009) Op. cit.
Person-centred factors Social factors
40 Sapouna, M. and Wolke, D. (2013) ‘Resilience to bullying victimization: the role of individual,
family and peer characteristics’ Child Abuse and Neglect 37(11): 997-1006.
41 Walsh, K., Zwi, K., Woolfenden, S., et al. (2017) ‘School-based programmes for prevention of
Parents Peers Problem-solving Passion
child sexual abuse: A Cochrane systematic review and meta-analysis’ Research on Social Work
Practice (in press). Nurturing, caring, Social Ability to An interest,
rule-enforcing connectedness problem solve hobby or skill that
42 Neufeld, S. A., Jones, P. B., Dunn, V. J., et al. (2017) ‘Reduction in adolescent depression relationship with with a supportive and communicate the child highly
following contact with mental health services: a longitudinal cohort study in the United a parent, carer or peer group values in
adult figure themselves
Kingdom’ The Lancet Psychiatry: http://www.thelancet.com/journals/lanpsy/article/PIIS2215-
0366(17)30002-0/fulltext

Chapter 5 Building resilience in the face of adversity
1. Parents greatly enhanced by having a “warm and supportive mother”5. The quality of
the relationship between parents or carers greatly affects the resilience of the
The role of early attachment and a strong, nurturing relationship with a child6 and the presence of a compassionate and active father can also improve
parent or carer is highlighted by much of the literature. The fulfilment of this resilience in children who may be facing trauma7.
role by a trusted adult away from the home environment such as a teacher
can also boost resilience. All children benefit from at least one stable caring This effect extends beyond emotional health: children are more protected
relationship from a supporting adult. Where there is no existing relationship at from crime and drugs when parents or carers are more affectionate and
home or school, the allocation of an adult mentor may be beneficial. supportive, regardless of other external factors such as neighbourhood8. In
one Australian study it was found that children from disadvantaged areas view
In order to build the resilience of a vulnerable child, the supporting adult can1: their parents as central to helping them do well when met with a “tough life”9.
• Offer a warm and nurturing environment As well as creating a nurturing relationship, parents also have an important
role in the creation and maintenance of community support factors for the
• Spend quality time with the young person young person. In some communities, strong extended family connections can
heavily influence young people’s sense of resilience and coping strategies
• Provide clear guidance, structure and rule-setting (e.g. African-American families10). When met with illness-related trauma,
children showed improved coping in families with close and constructive
• Encourage and support participation in leisure activities relationships11.
• Act as a role model that the young person can look up to Where there is an absence of a home-based attachment figure in the form of
100 a parent or carer, the ability to form a trusting relationship with at least one 101
• Incite goals and inspire ambition adult outside of the home environment is also a factor that can boost resilience
when met with trauma or risk12. These trusted, supporting adults may be from
a school or other community environment; the allocation of an adult ‘mentor’
For children and young people who experience adversity, one of the most for a child has been demonstrated to be beneficial in boosting resilience13.
effective protective factors that can enhance resilience is having a stable and Resilience is improved if the adult mentor is caring and supportive, and incites
caring parental person in their life. Parents can protect and ‘buffer’ children goals and ambition in the child14. For some children, a faith community can
from some of the worst effects of environmental adversity and can also provide that relationship that may not be found at home15.
nurture the characteristics in children that help them to cope with problems.
For younger children, it is usually the parent or carer that is best placed to
Previous studies have highlighted the importance of a supportive and provide such a relationship. As adolescents grow older, the tendency to rely
nurturing relationship between the young person and a parent to improve more on peer relationships is an important one in helping foster resilience.
resilience in adverse circumstances2. Traumatised children are more likely
to recover when in a “healthy, nurturing, consistent, repetitive, rewarding,
persevering, emotionally literate relationship”3.
2. Peers
A supportive, stable and consistent family environment provides a strong basis
for increased resilience. De Haan found that children aged 10 with supportive Peer relationships become increasingly important as children grow older, or
mothers were more resilient to everyday stressors than to those with less where there is an absence of a positive relationship with a parent. Positive
supportive mothers4, while La Fromboise and colleagues found that in the peer relationships describe those where the young person:
face of prejudice and violence, American-Indian adolescents’ resilience was

• Feels a sense of belonging and acceptance the same high-risk adversity environment25. For example, in a longitudinal
study of New Zealand adolescents it was found that resilient teenagers had
• Identifies with a group, sharing likes, dislikes and opinions significantly higher IQ scores than their peers26. Flouri and colleagues analysed
data from over 16,000 children in the UK, studying the relationship between
• Feels supported and respected and reciprocates these feelings family risk factors and emotional outcomes27. They found that higher general
intelligence by age five was a significant protective factor. Children in adverse
• Has a few high-quality friendships rather than many superficial conditions with high intelligence were less likely to experience behavioural
friendships and emotional problems compared to those with lower intelligence. Perhaps
most relevant of all is Kwok and colleagues’ study of adolescents living in
China which concluded that rational problem-solving ability was a significant
A group of supportive peers and friends around a young person can play moderator in suicidal ideation following physical abuse in females28.
an important role in boosting resilience16. This is the case especially in late
adolescence, where support from adults is replaced by those of a similar age. Improvements in intelligence can be gained through an encouraging family
Good peer relationships can improve the wellbeing, social skills and problem- and school environment29. Likewise, schools are an ideal environment to
solving ability of young people17. A friendship group enables protection teach problem-solving skills from an early age and throughout adolescence
from negative risk factors and the opportunity to ‘escape’ from high-risk discretely through timetabled Personal, Social, Health and Economic
environments18. (PSHE) education lessons, or across the curriculum, as part of an embedded,
developmental curriculum.
In one study of over 1000 adolescents, it was found that peer acceptance
was a significant protective factor for young people with low closeness with
102 parents19. Support from the social environment and social attachment are 103
the highest predictors of emotional recovery following child sexual assault20. 4. Passion
Graber and colleagues studied adolescents from a low socio-economic area
in Britain and found that psychological resilience was positively correlated Young people who have a passion or hobby that interests them and which
with the quality of friendships21. One study found that good peer relationships gives them a feeling of belonging, self-efficacy, self-worth and self-esteem may
moderated the negative effects caused by parental separation22. have greater resilience than their peers. A young person’s perceived efficacy in
‘something’ can moderate risk factors, regardless of whether that ‘something’
is creative, physical, academic, social etc. This is true of children from high risk
as well as low risk environments30 both in the short term and in the longer
3. Problem-Solving term; a young person succeeding in something that they value highly has a
positive effect on future psychological resilience when faced with childhood
When discussing resilient families, Walsh writes that the ability for a family trauma31.
to communicate and problem-solve together is vital to ensuring protective
factors to resilience23. Children show improved coping with domestic abuse The ability for children to participate in activities in their local area is
when they are part of the decision-making process and are informed about correlated with improved self-esteem and self-efficacy32. Self-belief (the
what is happening around them (e.g. whether to leave home)24. confidence that one is good at something) and self-efficacy (an understanding
of one’s own strengths and limitations) may be crucial factors for improving
In fact, intelligence and the ability to problem-solve has been consistently self-esteem and subsequently resilience.
indicated as a protective factor for children facing trauma and adversity with
studies indicating that more resilient children have higher intelligence and Robbie Gilligan writes about a series of case studies in which resilience is
problem-solving ability compared to peers, despite being surrounded by greatly enhanced in young people following attention to cultural and sporting

activities33. The engagement with mentors through these activities could • Does this child have good problem-solving skills?
be an effective way of helping a young person form a positive relationship
with parents or peers and can expedite and enhance the development of a • Does this child have an interest, hobby or skill?
protective social network within which the child identifies.
One case study described by Gilligan showing the power of strong interests as Where we answer no to one or more of these questions, there is a clear
a protective factor is of a boy in foster care. His strong interest in dancing and indication of practical steps we might take in order to support the growth, and
performance enabled him to become resistant to “sexist mockery”. Following a development of their resilience.
performance, he felt much more self-confident and positive about his future.
The encouragement of young people to find interests and activities is one of
the most effective means in boosting their self-esteem and resilience.
Schools are an ideal environment to offer development in skills and hobbies.

Likewise, parents or carers are effective in sparking an interest in the child
that helps divert attention away from negative life events34 and in many
cases, passionate engagement with an activity or hobby will also support
the development of other resilience boosting skills such as problem-solving,
intelligence and communication.
104 105
5. Practical implications
The literature we have reviewed suggests a role for our ‘4Ps’ (parents, peers,
problem-solving and passion) in the development of resilience in children and
young people protecting them from the effects of trauma and adverse events,
indicating a role for both person-centred and social factors.
The most important takeaway is that it appears that it is possible for us to

support children and young people in developing resilience and the ability to
cope both before and after the onset of trauma or adverse effects and that
there are a wide range of means that may be effective – and possibly more so
in combination as there are clear interactions between the four Ps.
In simple terms, the literature indicates that for every child or young person
who is faced with adversity we should ask the following questions:
• Does this child have a supportive relationship with a trusted adult?
• Does this child have quality relationships with a group of friends?

References 14
15
Hill, M. et al (2007) Op. cit.
Werner, E. (2000). Op. Cit.
16 Fergusson, D. and Lynskey, M. (1996) ‘Adolescent resiliency to family adversity’ Journal of
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21 Graber, R., Turner, R. and Madill, A. (2015) ‘Best friends and better coping: facilitating psycho-
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22 Bugental, D. B. (2003). Op. cit.
Khan, L. (2017) Fatherhood: the impact of fathers on children’s mental health: www.centrefor-
mentalhealth.org.uk/briefing-50-fatherhood 23 Walsh, F. (1998) Strengthening Family Resilience. New York: Guilford Press.
Seifer, R., Sameroff, A., Baldwin, C. and Baldwin, A. (1992) ‘Child and family factors that 24 Hague, G., Mullender, A., Kelly, L., Imam, U. and Malos, E. (2002) ‘How do children understand
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3 Thierry, B. (2015) Teaching the Child on the Trauma Continuum. London: Grosvenor House to multiple risk exposure in early life: the role of parenting’ European Child and Adolescent
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4 De Haan, L., Hawley, D. and Deal, J. (2002) ‘Operationalizing family resilience: a methodologi- 28 Kwok, S., Yeung, J., Low, A., Lo, H. and Tam, C. (2015) ‘The roles of emotional competence and
cal strategy’ The American Journal of Family Therapy 30(4): 275-291. social problem-solving in the relationship between physical abuse and adolescent suicidal
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Community Psychology 34(2): 193-209.
30 Wener E. (2000) Op. Cit.
6 Khan, L. (2017) Op. cit.
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13 Williams, N., Lindsey, E., Kurtz, P. and Jarvis, S. (2001) ‘From trauma to resiliency: lessons from
former runaway and homeless youth’ Journal of Youth Studies 4(2): 233-253.

Section 2
Addressing childhood
adversity and trauma
(a national view)
108 109

Moving Beyond Adversity
6. Moving Beyond Adversity For example, analysis of LTPs by the NSPCC in 2016 found that a third
contained no recognition that children and young people who have been
Dr Marc Bush and Sarah Brennan OBE abused or neglected present a very high risk of developing mental health
issues, or gave any detail about the provision of services to meet their needs5.
Just one in three of these plans were seen by the NSPCC as containing
In this paper we propose three urgent actions that local commissioners could an adequate needs assessment for the mental health needs arising from
take to begin to address childhood adversity and trauma in their local area. experience of childhood abuse and neglect.
These actions include:
This is contra to the guidance to local areas from NHS England, which states
1. making childhood adversity and trauma a local commissioning priority that “the scope of Local Transformation Plans should cover the full spectrum
of service provision and address the needs of all children and young people
2. creating a common identification and enquiry framework for including the most vulnerable, making it easier for them to access the support
identifying need they need when and where they need it”6. Clearly more needs to be done at
a national level to support local areas to prioritise a transformation agenda,
3. investing in adversity and trauma-informed models of care. which is adversity and trauma-informed.
Sections 2 and 3 of Addressing Adversity provide additional ideas on how to put For more on the NSPCC analysis of Local Transformation Plans see
these three actions into practice, and give insight and case studies about how Paper 17.
this has been achieved across different local areas in England.
110 111
While Local Transformation Plans are the focal planning document for the
transformation of children and young people’s mental health services, they are
1. Make childhood adversity and trauma a local priority located within a larger NHS geographical footprint of the Sustainability and
Transformation Plans (STP)7. The 44 larger plans describe the transformation
YoungMinds was part of the Government’s independent taskforce, which strategy for the implementation of the NHS Five Year Forward View across
made important recommendations about the transformation of children the wider sub-regional health economies in England, and for all areas of health.
and young people’s mental health through the Future in Mind report1. The
recommendations were accepted by government and subsequently embedded We believe that all STPs and LTPs must include a priority committed to
in the NHS England Five Year Forward View for Mental Health2, NHS planning ensuring that all new and transformed local services supporting children and
guidance3 for 2016/17 – 2020/21 and guidance for Local Transformation young people should be adversity and trauma-informed. This could easily
Plans (LTPs)4. be incorporated into existing commitments or be included as a new strategy
priority through the annual refreshing of the LTPs.
Most local areas have captured their priorities for the transformation of
children and young people’s mental health in their LTPs, which have been The refreshed LTPs should include addressing pre- and sub-clinical symptoms
developed by Clinical Commissioning Groups (CCGs) in partnership with of (post) traumatic stress within the design and implementation of a local,
local agencies. However, within these there remains discrepancies in the generic children and young people mental health pathway. This is recognised
recognition and identification of children who face adversity and trauma. within Public Health England’s Prevention Concordat for Better Mental
Moreover, the scale of the transformation challenge facing local areas, has Health, which places a renewed focus on the wider determinants of mental
resulted in significant variation across the country. ill health (including experiences of adversity and trauma) within psychosocial
pathways8. Additionally, the adversity and trauma-informed models of

Chapter 6 Moving Beyond Adversity
care should be embedded within crisis care pathways and local Crisis Care
Concordats9 (where these arrangements are in place). Furthermore, a number • Ensure approaches are evidence-based and proportional,
of local areas have already put this in practice through their response to tragic flexible and timely to respond to the needs of the children
incidents, and in anticipation of future need arising from these experiences. and young people affected.
• Provide clear and consistent messages and communication

to partners, children, young people and families.
The London Incident Support Pathway for Children and Young
People • Ensure professional practitioners and staff providing
support have access to training, consultation and
The London Incident Support Pathway for Children and Young People10 supervision relating to adversity and trauma.
was developed in response to the London Bridge terrorist incident in
June 2017. The pathway built upon the existing transformation and The continuity of care offered through the multi-agency stepped model,
crisis care plans11 for children and young people, the NICE guidance on first offers universal advice and resilience building, using familial and
PTSD12, and the THRIVE model13 developed by The Anna Freud Centre community resources. If symptoms escalate or persist the child or
and The Tavistock and Portman NHS Foundation Trust. The NHS young person can access targeted psychosocial support and mental
Healthy London Partnership also created a pathways for adults14. healthcare (if required).
The pathway for children and young people provides clarity on the CYP will be identified following specialist consultation with either the
support that local agencies have made available to those children referrer (professional) or family. Specialist consultation will also identify
112 and young people who have been exposed to the distressing terrorist CYP with additional risk factors (pre-existing history of trauma, co- 113
incidents (including those who have acquired an injury and/or existing mental health needs and secondary stresses).
experienced bereavement). Importantly, it recognises that some
children and young people may have a delayed distress response, and Finally, the offer is extended for those children and young people who
describes pre- and sub-clinical behaviours and ways of thinking that are experiencing moderate-severe needs where the symptoms are
would be considered normative responses to trauma. persistent or increasing, which is having an impact on their day-to-
day living, and in situations where they lack familial or a network of
At the heart of the key principles of the pathway is adversity and emotional and social support. This focuses on more incentive provision
trauma-informed care. The principles for the models of care offered of mental healthcare being led by, and with input from, a specialist
within the pathway are to: clinical team.
• Acknowledge the importance of anticipated reactions These targeted and specialist services (the latter via additional
(stress response) to a major incident. consultation) have been made available for those children and young
people who have a ‘pre-existing greater risk, or complexity’ relating
• Support children and young people to develop and sustain to trauma and who have co-existing mental health needs. Within the
their ability to cope (including the wider role of care givers THRIVE model, these children are located in the ‘Getting More Help’
and community resources). and ‘Getting Risk Support’ domains.
• Utilise a multi-agency stepped model of care that provides a

continuum of care that is holistic.

2. Create a common identification and enquiry framework The Children Act of 2004 requires local authorities to make arrangements
to promote cooperation between local statutory partners to identify, assess
Creating and sustaining a local transformation priority of adversity and and meet the needs of children who require additional support. As part
trauma-informed care requires us to bring together the different ways in of the implementation of the Children Act of 2004 and the former Every
which local agencies recognise and identify adversity, trauma and related Child Matters policy23, local authorities adopted a Common Assessment
mental health needs. The wider variation in terminology and clarification Framework24, which standardised processes across agencies so that they
even within forms of service creates confusion about populations that are could identify the needs of children, including those who faced additional risk
being supported, and can unwittingly fail to recognise forms of adversity and adversity in their lives. A core intention of the new assessment framework
that can have a significant impact on a young person’s mental health and was to give local agencies a common language to identify and describe the
wellbeing. For example, an analysis by the Children’s Society of 36 specialist needs of these children. This is why many local authorities (despite the
child and adolescent mental health (CAMHS) providers, found significant financial implications25), and their partners, have continued to use Common
inconsistencies in the way that providers described and identified ‘vulnerable’ Assessment Frameworks beyond the lifespan of the Every Child Matters
children and young people15. policy, and the end of a national pilot to collate local data26.
These inconsistencies are replicated at a local level through the legislative Common Assessment Frameworks are now frequently used by local
focus of different statutory agents. At present, local authority safeguarding authorities as a tool for identifying the needs of children and families who
teams in England focus on identifying and assessing the needs of children and would benefit from “early help”27 as set out by the revised statutory guidance
young adults who are at risk of, or experiencing, abuse, maltreatment or harm. for safeguarding children28 and requirements in the Ofsted inspection
They also are responsible for coordinating inter-agency working (including framework29. Ofsted’s definition of early help is targeted at “those children
education) to promote the welfare for children16 and young (vulnerable) and young people at risk of harm (but who have not yet reached the ‘significant
114 adults17. These responsibilities are enhanced by the recent passing18 of the harm’ threshold (as set out in the statute) and for whom a preventative service 115
Children and Social Work Act 2017, and there is additional statutory guidance would reduce the likelihood of that risk or harm escalating)”30.
for children who experience specific forms of abuse, including Child Sexual
Exploitation. Similarly, the Education, Health and Care Plans (EHCP)31 introduced as part
of the Children and Families Act32 of 2014, put an emphasis on multi-agency
Local authorities also have a broader responsibility to identify and assess identification and coordination of services to meet the needs of children
‘children in need’, including those who are at risk of poor mental health who have a SEND. Beyond this, children who have a level of need that is not
and emotional development19. Likewise, tools are used by local authorities deemed eligible for an EHCP, are meant to be given access to a local offer that
to identify the mental health and emotional wellbeing of specific groups, enables their families to navigate the support that is available for them in the
including looked-after children, through the use of a Strengths and Difficulties local community. This should include signposting to relevant children’s mental
Questionnaire (SDQ)20. health services, if a need has been identified.
A similar approach is taken in youth offending, with teams specifically More recently, local authorities have been incentivised by central government
considering the risk of serious harm21 and mental ill health, where an adverse to focus on the needs of children living in families who experience significant
childhood experience has been identified as a contributing factor, and would complexity. The national Troubled Families Programme33 aims to support
increase the likelihood, of poor outcomes22. In areas where there is a known families who meet three of the following criteria34: 1) contain a child involved
social problem in the community, both local authorities and Youth Offending in youth crime or anti-social behaviour; 2) have children who are regularly
Teams have programmes of work to identify those children who are at risk of a truanting or not in school; 3) have an adult on out of work benefits; 4) cause
prevalent childhood adversity or additional complexity in their community, for high costs35 to the taxpayer (because of the complexity of their need or
example gang membership or substance misuse. interaction with services).

Over 117,910 families have been identified in this way and all receive multi- Future in Mind recognised the value of routine enquiry. NHS England has
agency interventions to support their needs36. Within this group of families subsequently been supportive of its roll-out, and the government has
are children who will have faced multiple adverse childhood experiences, incorporated it into measures to tackle sexual exploitation, domestic violence
which is further compounded by the complexity of their family life and and abuse of young people aged over 16 years43. Routine enquiry is now being
interactions with local services. Moreover, the criteria used for the programme extended into child and adult mental health, sexual health and adult substance
focuses on presenting factors or symptoms of underlying adverse childhood misuse services44.
experiences37.
In contrast Directors of Public Health can take a more broader perspective, For more on identification of need and routine enquiry see Papers
considering the social and environmental factors that contribute to higher risk 10, 11, 12, 19, 20, 24, 25, 27.
of mental ill health and determinants of premature mortality. Reflecting this,
both the Public Health Outcomes Framework38 and the Children and Young
People’s Mental Health and Wellbeing Profiling Tool39 created by Public Health
England contain proxy measures relating to childhood adversity. The latter has
been updated to include three domains that enable local areas to explore data 3. Invest in adversity and trauma-informed models of care
relating to childhood adversity, vulnerability and protective factors.
Finally, in order to commission and deliver adversity and trauma-informed care
Building on the reforms of the Health and Social Care Act of 2012, most areas for children across England, we need a common set of guiding principles.
now hold a shared profile of children’s health and care needs in their area40.
These are usually contained or summarised within their Joint Strategic Needs
116 Assessment or Health and Wellbeing Plans, many of which derive from data Throughout sections 2 and 3 of this collection, you will find a number 117
compiled by Public Health England in their annual Child Health Profiles41. of proposed principles that provide a clear direction of travel for
Some Clinical Commissioning Groups (CCGs) and NHS mental health the transformation of services (in particular we recommend reading
providers specifically target groups of children who are at additional risk, such those set out in Paper 9).
as those involved in gangs, those who have life-limiting health conditions or
those with learning disabilities.
Here, we have set out the guiding principles from Future in Mind45 that would
More recently, health commissioners and providers have followed the lead of enable local services to be commissioned and provided in a more adversity
Blackburn with Darwen Local Authority and Lancashire Care NHS Foundation and trauma-informed way, which we identified in our Beyond Adversity
Trust by embedding a routine enquiry about childhood adversity into service report46. These principles are based on the work of a Vulnerable Groups and
models and assessment processes. This follows measures taken by the Inequalities Task and Finish Group47, and have been subsequently refined with
devolved nations, including the Scottish Government’s early adoption as part insight and reflections from the clinical summits YoungMinds held in 2017, and
of its National Domestic Abuse Delivery Plan for Children and Young People42. the contributions we have included in Addressing Adversity. The principles are
While routine enquiry is still in its infancy, and requires further development, it summarised in short-form on the next two pages.
is beginning to signal the need for a common way of describing and enquiring
about childhood adversity within non-specialist services. Furthermore, it
offers a form of enquiry that can be used in relation to pre- and sub-clinical
symptoms of traumatic stress, as well as acting as a basis for identifying
adverse situations and circumstances in the child or young person’s life.

Table 1: The Six Principles of Adversity and Trauma-informed Care
Adversity and trauma-informed models of commissioning and care Adversity and trauma-informed models of commissioning and care
should be: should be:
1. Prepared • creates and maintains a priority in addressing the causes 4. Safe and • ensures that safeguarding procedures are in place, are seen as
and mental health consequences of childhood adversity and responsible* part of interventions in childhood adversity, and work in a way
trauma. This includes having this priority embedded in local (continued) that supports the child or young person to recover from the
commissioning, service and transformation plans. adversity or trauma they have faced.
• analyses available data on prevalence, and possible local need, • ensures that children and young people receive coordinated
at both a pre- / sub-clinical and clinical level. support from knowledgable, qualified, trustworthy and
• anticipates mental health needs arising from childhood well-trained professionals who have suitable supervision and
adversity and trauma, by embedding knowledge, expertise workforce support that can address vicarious or secondary
and informed interventions in local commissioning and service trauma that may occur.
pathways.
5. • meaningfully engages and involves children and young people
• ensures local agencies and partners have a good Collaborative who have faced adversity and trauma in decisions about their
2. Aware treatment, care and the design of interventions.
understanding of childhood adversity and trauma, and the and
associated symptoms and responses. enhancing • adopts a strengths-based approach, recognising the resources
• has a common framework for identification and routine and resilience that children and young people have drawn
enquiry about adversity and trauma in childhood and upon in the past, and creating positive and additional
adolescence. strategies for symptom mitigation and recovery – including
self-soothing, emotional and regulation and the promotion of
118 • understands and responds to the cultural, identity and self-care.
119
gendered contexts of the young people and the community in
which they live – including situations where a child continues • ensures models of care recognise and harness (where
to live in adverse circumstances. possible) families, care-giving, peer and community assets as
part of treatment and recovery.
3. Flexible • provides stepped support to children and young people who

face adversity or trauma at both a pre- / sub-clinical and 6. Integrated • enables effective communication and data-sharing between
clinical level. agencies to ensure that the whole of the child’s needs are
identified and met.
• provides models of care that enable alternative and more
flexible forms of access and engagement (i.e. through street • co-commissioned (possibly with a lead agency) to ensure
triage). that there is a continuity of care and consistency of pathways
across, and within, the services and interventions that children
• provides targeted models of care to excluded groups of and young people will receive.
children and young people who live in adverse and traumatic
environments. • ensuring smooth transitions between stepped care models,
providing timely referral and treatment to specialist services,
and proving access to enhanced mental health, adversity and
4. Safe and • intervenes early to prevent an escalation of need and avoid
trauma knowledge and expertise when required (i.e. through
preventable exposure to additional adversity and trauma in
responsible* outreach and liaison models of care).
children and young people’s lives.
• puts in place policies, practices and safeguarding
arrangements that avoids re-traumatising the young people
and stigmatising their behavioural or emotional response to
trauma. * We would recommend readers consult NHS Education for Scotland’s framework for core
components of the required knowledge and skills-base. NHS EfS / Scottish Government (2017)
Transforming Psychological Trauma: A skills and knowledge framework for the Scottish workforce:
Continued... http://www.nes.scot.nhs.uk/media/3983113/NationalTraumaTrainingFramework-execsummary-web.pdf

References 17 For more information about safeguarding of children see the statutory guidance: DH (2014)
Care and Support Statutory Guidance: Issued under the Care Act 2014 https://www.gov.uk/
government/uploads/system/uploads/attachment_data/file/315993/Care-Act-Guidance.
1 DH / NHS E (2015) Future in Mind: Promoting, protecting and improving our children and pdf or the text of the relevant statute: Care Act [2014]: http://www.legislation.gov.uk/ukp-
young people’s mental health and wellbeing: https://www.gov.uk/government/uploads/system/ ga/2014/23/contents/enacted and Mental Capacity Act [2005] http://www.legislation.gov.uk/
uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf ukpga/2005/9/contents .
2 MH Taskforce / NHS E (2016) Op. cit. 18 Children and Social Work Act [2017]: http://www.legislation.gov.uk/ukpga/2017/16/contents/
enacted/data.htm
3 NHS E (2015) Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21:
https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf 19 A ‘child in need’ is defined under the Children Act [1989]: http://www.legislation.gov.uk/
ukpga/1989/41/contents
4 NHS E (2015) Local Transformation Plans for Children and Young People’s Mental Health and
Wellbeing: Guidance and support for local areas: https://www.england.nhs.uk/wp-content/ 20 DfE / DH (2015) Promoting the health and well-being of looked-after children: Statutory
uploads/2015/07/local-transformation-plans-cyp-mh-guidance.pdf guidance for local authorities, clinical commissioning groups and NHS England: https://www.
gov.uk/government/uploads/system/uploads/attachment_data/file/413368/Promoting_the_
5 NSPCC (2016) Transforming mental health services for children who have experienced abuse: health_and_well-being_of_looked-after_children.pdf
A review of Local Transformation Plans: https://www.nspcc.org.uk/globalassets/documents/
research-reports/transforming-mental-health-services-children-experienced-abuse.pdf 21 For more detail on Asset Core Profiles see: https://www.gov.uk/government/publications/
asset-documents and Onset see: https://www.gov.uk/government/publications/onset-docu-
6 Wellbeing: Guidance and support for local areas: https://www.england.nhs.uk/wp-content/ ments
uploads/2015/07/local-transformation-plans-cyp-mh-guidance.pdf
22 MoJ (2012) Prisoners’ Childhood and Family Backgrounds: Results from the Surveying
7 The 44 STPs are available here: www.england.nhs.uk/stps/view-stps Prisoner Crime Reduction (SPCR) longitudinal cohort study of prisoners https://www.gov.uk/
8 PHE (2017) Prevention Concordat for Better Mental Health: Prevention planning resource government/uploads/system/uploads/attachment_data/file/278837/prisoners-childhood-fam-
for local areas: https://www.gov.uk/government/uploads/system/uploads/attachment_data/ ily-backgrounds.pdfm
file/640749/Prevention_Concordat_for_Better_Mental_Health_Prevention_planning.pdf 23 HM Government (2003) Every Child Matters: https://www.education.gov.uk/consultations/
9 For more information on the national and local Mental Health Crisis Care Concordats see: downloadableDocs/EveryChildMatters.pdf / HM Government (2003) Every Child Matters:
www.crisiscareconcordat.org.uk Change for children: http://webarchive.nationalarchives.gov.uk/20130401151715/http://
10 NHS Health London Partnership (2017) London Incident Support Pathway for Children and www.education.gov.uk/publications/eOrderingDownload/DfES10812004.pdf
120 Young People: Multi-agency support pathway for children, young people and families affected 24 The policy and practice documents for the Common Assessment Framework are archived 121
by the London Bridge terrorist incident: https://www.healthylondon.org/sites/default/files/Lon- here: http://webarchive.nationalarchives.gov.uk/20100915033844/http://www.dcsf.gov.uk/
don%20incident%20support%20pathway%20for%20children%20and%20young%20people.pdf everychildmatters/resources-and-practice/TP00004/
11 c.f. NHS Healthy London Partnership (2016) Improving care for children and young people 25 Holmes, L., McDermid, S. Padley, M. and Soper, J. (2012) Exploration of the Costs and Impact
with mental health crisis in London: Recommendations for transformation in delivering of the Common Assessment Framework (research report for DfE): https://www.gov.uk/gov-
high-quality, accessible care: https://www.healthylondon.org/sites/default/files/Improving%20 ernment/uploads/system/uploads/attachment_data/file/184025/DFE-RR210.pdf
care%20for%20children%20and%20young%20people%20with%20mental%20health%20 26 ‘Loughton confirms abolition of national eCAF system’ Children and Young People Now
crisis%20in%20London.pdf 14.12.11: http://www.cypnow.co.uk/cyp/news/1071441/loughton-confirms-abolition-nation-
12 NICE (2016) Post-traumatic Stress Disorder: Management (clinical guideline CG26): www. al-ecaf#sthash.cmnRRc3r.dpuf [retrieved March 2016].
nice.org.uk/guidance/cg26 27 A brief overview of Early Help is available at: LGA (2013) Must Know 5: What you need to
13 Wolpert, M., Harris, R., Jones, M., Hodges, S., Fuggle, F., James, R., Wiener, A., McKenna, C., know about early help: http://www.local.gov.uk/c/document_library/get_file?uuid=50e58128-
Law, D. and Fonagy, P. (2014) THRIVE: The AFC–Tavistock Model for CAMHS: http://www. e1e3-4e66-bfaa-7cdd852a98d8&groupId=10180
annafreud.org/media/2552/thrive-booklet_march-15.pdf 28 HM Government (2015) Working Together to Safeguard Children: A guide to inter-agency
14 NHS Healthy London Partnership (2017) London Incident Support Pathway for Adults: Mul- working to safeguard and promote the welfare of children: https://www.gov.uk/government/
ti-agency support pathway for adults affected by the London Bridge terrorist incident: https:// uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_
www.healthylondon.org/sites/default/files/London_incident_support_pathway_for_adults.pdf Children.pdf
15 Abdinasir, K. and Pona, I. (2015) Access Denied: A teenager’s pathway through the mental 29 Ofsted (2015) Early Help: whose responsibility?: https://www.gov.uk/government/uploads/
health system: https://www.childrenssociety.org.uk/sites/default/files/AccessDenied_final.pdf system/uploads/attachment_data/file/410378/Early_help_whose_responsibility.pdf
16 For more information about safeguarding of children see the statutory guidance: HM Gov- 30 ibid.
ernment (2015) Working Together to Safeguard Children: A guide to inter-agency working 31 DfE / DH (2015) Special Educational Needs and Disability Code of Practice: 0 to 25 years
to safeguard and promote the welfare of children (revised): https://www.gov.uk/government/ (revised): https://www.gov.uk/government/uploads/system/uploads/attachment_data/
uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_ file/398815/SEND_Code_of_Practice_January_2015.pdf
Children.pdf or the text of the relevant statute: Children Act [1989]: http://www.legislation.
gov.uk/ukpga/1989/41/contents , Education Act [1996]: http://www.legislation.gov.uk/ukp- 32 Children and Families Act [2014]: http://www.legislation.gov.uk/ukpga/2014/6/contents/en-
ga/1996/56/contents , Education Act [2002] http://www.legislation.gov.uk/ukpga/2002/32/ acted
contents , Children Act [2004]: http://www.legislation.gov.uk/ukpga/2004/31/contents ,
Education and Skills Act [2008]: http://www.legislation.gov.uk/ukpga/2008/25/contents

Chapter 6
33 DCLG (2012) The Troubled Families Programme: Financial framework for the Troubled
Families programme’s payment-by-results scheme for local authorities: https://www.gov.uk/ 7. Young people’s principles for adversity
and trauma-informed care
government/uploads/system/uploads/attachment_data/file/11469/2117840.pdf
34 DCLG (2012) Working with Troubled Families: A guide to the evidence and good prac-
tice: https://www.gov.uk/government/uploads/system/uploads/attachment_data/
file/66113/121214_Working_with_troubled_families_FINAL_v2.pdf
35 DCLG (2013) The Cost of Troubled Families: https://www.gov.uk/government/uploads/sys-
tem/uploads/attachment_data/file/68744/The_Cost_of_Troubled_Families_v1.pdf During 2016 and 2017 YoungMinds worked with a small group of children
36 Total correct as of latest statistical release DfE (2015) Troubled Families: Progress infor- and young people to explore their experiences of care and support during and
mation by December 2014 and families turned around by May 2015: https://www.gov.uk/ following adversity and trauma. We supported them to co-create their own
government/uploads/system/uploads/attachment_data/file/436508/final_table_for_publica-
principles for adversity and trauma-informed care.
tion_May_results.xlsx
37 Casey, L. / DCLG (2012) Listening to Troubled Families: https://www.gov.uk/government/up-
loads/system/uploads/attachment_data/file/6151/2183663.pdf
38 For the searchable data see: www.phoutcomes.info Table 1: The Six Principles of Adversity and Trauma-informed Care
DH (2016) Improving outcomes and supporting transparency (Part 2: Summary technical
specifications of public health indicators): https://www.gov.uk/government/uploads/system/
uploads/attachment_data/file/545605/PHOF_Part_2.pdf Adversity and trauma-informed models of commissioning and care
39 For more information see: https://fingertips.phe.org.uk/profile-group/mental-health/profile/ should be:
cypmh
40 Health and Social Care Act [2012]: http://www.legislation.gov.uk/ukpga/2012/7/contents/ “When you notice, or I tell you that I need help, you should
enacted
1. Prepared
already know what the next step is” – sometimes I feel like
41 Child Health Profiles are available by local authority area and CCG at: http://www.chimat. people are making it up as they go along.
org.uk/profiles , the data is also available through searchable, interactive content on the PHE
122 Children and Young People’s Health Benchmarking (FingerTips) Tool: http://fingertips.phe.org.
uk/profile/cyphof/data#page/0
123
42 SG (2008) National Domestic Abuse Delivery Plan for Children and Young People: http://www.
gov.scot/resource/doc/228073/0061720.pdf
2. Aware “Don’t label me with the experiences I’ve had” – I’m not a label,
43 NICE (2014) Domestic violence and abuse: multi- agency working (Public health guideline 50):
I am me. Everyone’s experiences are different, and it doesn’t
https://www.nice.org.uk/guidance/ph50/
define who I am.
44 HM Government (2015) Tackling Child Sexual Exploitation: https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/408604/2903652_RotherhamResponse_acc2. “Recognise all of my needs” – I don’t think of my life as school,
pdf family, medication, all of the different parts of my life are
45 DH / NHS E (2015) Future in Mind: Promoting, protecting and improving our children and connected, see me as a whole person.
young people’s mental health and wellbeing: https://www.gov.uk/government/uploads/system/
“Understand my behaviour” – when I’m shouting, crying, hiding,
uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf
stealing, hitting out at myself or others I’m just trying to make
46 Bush, M. (2016) Beyond Adversity: Addressing the mental health needs of young people who sense of everything I’ve gone through. I’m not ‘wrong’, ‘damaged’,
face complexity and adversity in their lives: https://youngminds.org.uk/media/1241/report_-_ ‘mad’ or ‘bad’.
beyond_adversity.pdf
47 CYPMHW Taskforce (2015) Vulnerable Groups and Inequalities Task and Finish Group Re- “Find a way that we can both understand each other”- we might
port: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/414326/ 3. Flexible
communicate in different ways, make sure you use a way that
Vulnerable_Groups_and_Inequalities.pdf
works for me.
“Shape your support around me” – getting care is already hard
work, so don’t make it harder by giving me the wrong person, in
a place I don’t feel comfortable in, or at a time that doesn’t work
for me.
Continued...

Chapter 7
Adversity and trauma-informed models of commissioning and care

8. Creating trauma-informed mental
should be:
healthcare in the UK
4. Safe and “Keep me safe and don’t betray my trust” – tell me what you will
responsible need to do next and who you will be talking to, and make sure Dr Angela Sweeney, Dr Sarah Clement,
you include me in the process and keep me updated. Beth Filson and Dr Angela Kennedy
“Know where I’m coming from” – I may not be or feel safe back
where I live. If people know about what is going on, they could
use it against me. This extract is from Trauma-informed mental healthcare in the UK: what is it and
“The way you treat me matters” – to recover I need you to treat how can we further its development? first published in 2016 in the Mental Health
me with respect and understand why I’m behaving this way. Review Journal re-used with the kind permission of Emerald Insight, and the
Make sure I’m not in the care of someone who will make things authors.
worse. I want someone who is on my side.
5. • “Include me in decisions about my life” – ask me what I want

Collaborative to happen, I have the right to be involved in decisions about
and my life. 1. Re-traumatisation in the mental health system
enhancing • “I’ve survived this long” – build on my strength and help me
find new ways to recover. Re-traumatisation essentially means to be traumatised again. It occurs when
• “I want to talk to someone who has been through the same a person experiences something in the present that is reminiscent of a past
thing” – it helps me make sense of what I’ve experienced and
traumatic event. This current event or trigger often evokes the same emotional
shows me I am not alone.
124 and physiological responses associated with the original event. People are not 125
6. Integrated • “Stop asking me to repeat myself” – it’s a hard thing for me to always aware that their current distress is rooted in past events, nor do all
talk about, and if it’s going to help me I’d rather you told the people relive the original event in a logical, coherent manner1.
right professional so that I don’t have to.
• “Don’t pass me from person to person” – I have to start The mental health system can re-traumatise survivors through its fundamental
from scratch each time. I don’t want to be thrown between
services, and it’s going to screw with my recovery.
operating principles of coercion and control2. Re-traumatisation includes
overt acts, such as restraining and forcibly medicating a rape victim, as well as
less palpable re-traumatisation, such as pressure to accept medication which
mimics prior experiences of powerlessness. Empirical research indicates
that traumatic experiences (e.g. physical assault, seclusion, restraint) are
widespread in inpatient settings3. Mental health services can also contribute
to historical and cultural trauma by recasting responses to racism as individual
pathology4, recasting women’s attempts to resist domestic control as
hysteria5 and recasting homosexuality as sexual deviance in need of corrective
treatment6.
Jennings believes that while re-traumatisation can be unintentional and

unanticipated, it will remain while mental health systems fails to acknowledge
the role of trauma in people’s lives and their consequent need for safety,
mutuality, collaboration and empowerment7. Current services and supports
that do not take these impacts into account may inadvertently re-traumatise,

Chapter 8 Creating trauma-informed mental healthcare in the UK
further reinforcing survivors’ needs for coping strategies such as illicit drug 3. The principles of trauma-informed approaches
use or self-harm.
The development of Trauma-Informed Approaches (TIAs) can be traced to
the USA and to Harris and Fallot’s seminal text13, Using Trauma Theory to
Design Service Systems. Bloom14, also from the USA, who developed the
2. The impact of re-traumatising systems on staff Sanctuary Model outlines the development of TIA from the era of moral
treatment, through social psychiatry and finally the concept of the Therapeutic
The policies, procedures and practices that staff may be required to perform Community15 which includes developments in the UK. TIAs can be defined as
in “trauma-organised systems”8 can conflict with personal and ethical codes “a system development model that is grounded in and directed by a complete
of conduct. For example, the use of seclusion and restraint as an institutional understanding of how trauma exposure affects service user’s neurological,
practice erodes the very meaning of compassion and care, the primary reasons biological, psychological and social development”16. Consequently, TIAs are
most staff enter their chosen field. Staff who experience conflicts between informed by neuroscience, psychology and social science as well as attachment
job duties and their moral code are under chronic stress for which they must and trauma theories, and give central prominence to the complex and
learn to cope and adapt. Those coping strategies may include “shutting off” pervasive impact trauma has on a person’s worldview and interrelationships.
the ability to empathise, and viewing people receiving services as “other”
thereby disqualifying their humanity and basic human rights. Pessimism – TIAs are applicable to all human services, including physical health, education
rather than enthusiasm and hope – may buffer staff from their own feelings of and schools, forensic, housing and social care17. In a trauma-informed service,
helplessness9. it is assumed that people have experienced trauma and may consequently
find it difficult to develop trusting relationships with providers and feel
Staff may also engage in “power over” relationships when organisations place safe within services. Accordingly, services are structured, organised and
126 a higher priority on risk management than human relationships. A nurse who delivered in ways that engender safety and trust and do not re-traumatise. 127
is required to perform a personal search may become frustrated by a service Thus, trauma-informed services can be distinguished from trauma-specific
user’s resistance, failing to recognise that she/he is a stranger who is placing services which aim to treat the impacts of trauma using specific therapies and
hands on the body of another who may be a rape survivor. Organisational other approaches. The key principles underlying TIAs can be found in Table 1,
cultures may become corrupted, paving the way to power over relationships adapted from SAMHSA18, Elliot and colleagues19 and Bloom20.
that reinforce people’s helplessness and hopelessness. In these “corrupted
cultures”, the basic values of the organisation are no longer driving practice; While it may seem that principles such as safety and collaboration define any
instead, the needs of service users become secondary to the needs of staff, good service for any service user, Elliot and colleagues21 have argued that if
and restraint and coercion may be used widely even when less restrictive these principles are not adhered to, trauma survivors may be unable to use
options are available. This and other working practices and routines (such as services. It is striking that these general principles have strong resonance with
rigid professional hierarchies and a lack of supervision) can dehumanise both the values that psychiatric survivors have historically called for, and underpin
staff and service users and lead to human rights violations10. The National much peer support practice22.
Institute for Clinical Excellence (NICE) has expressed frustration at first resort
to coercive practices even where other approaches are indicated11. The impact
of trauma-organised services on workers is analogous to the impact of trauma
on survivors – it reshapes and re-constructs self-identity and can shatter 4. What are the potential benefits of TIAs?
individual meaning and purpose12.
The potential benefits of TIAs to survivors are myriad, including hope,
empowerment, support that does not re-traumatise and access to trauma-
specific services. Moreover, the medicalisation of human suffering has created
a divide between people receiving services and those offering support; this

divide can create tenuous bonds that are inadequate, at times, to protect the 7. Safety Trauma engenders feelings of danger. Give priority to
human and civil rights of people viewed as other23. But trauma is something ensuring that everyone within a service feels, and is,
that many of us experience, and indeed, a small number of studies suggest emotionally and physically safe. This includes the feelings of
safety engendered through choice and control, and cultural
that workers in human services have a high prevalence of ACEs scores24. In and gender awareness. Environments must be physically,
recognising trauma as a shared event, healing too becomes something we do psychologically, socially, morally and culturally safe.
together.
8. Survivor Understand that peer support and the coproduction of
partnerships services are integral to trauma-informed organisations. This
is because the relationships involved in peer support and
Table 1: The key principles of trauma-informed approaches coproduction are based on mutuality and collaboration.
1. Recognition Recognise the prevalence, signs and impacts of trauma. This 9. Pathways to Survivors should be supported to access appropriate trauma-
is sometimes referred to as having a trauma lens. This should trauma-specific specific care, where this is desired. Such services should be
include routine enquiry about trauma, sensitively asked and care provided by mental health services and be well resourced.
appropriately timed. For individual survivors, recognition can
create feelings of validation, safety and hope.
2. Resist Understand that operational practices, power differentials

retraumatisation between staff and survivors, and many other features of Because TIAs are premised on the understanding that most of the people who
psychiatric care can re-traumatise survivors (and staff). Take
steps to eliminate re-traumatisation.
come into contact with mental health services have been impacted by trauma,
training, supervision and support for staff are seen as essential. This attention
3. Cultural, Acknowledge community-specific trauma and its impacts. to staff support has the potential to decrease burnout and reduce staff
128 historical and Ensure services are culturally and gender appropriate. turnover. For example, research suggests that supervisors who feel that their 129
gender contexts Recognise the impact of intersectionalities, and the healing organisation values them and cares about their wellbeing are more likely to be
potential of communities and relationships.
supportive towards the people they are responsible for25.
4. Services should ensure decisions taken (organisational and
Trustworthiness individual) are open and transparent, with the aim of building There are complex interactions between service users, practitioners
and transparency trust. This is essential to building relationships with trauma and organisations that can come to mirror one another through “parallel
survivors who may have experienced secrecy and betrayal.
processes”26. Trauma survivors’ lives may be organised around the trauma
experience, just as systems can come to be organised around models that
5. Collaboration Understand the inherent power imbalance between staff
and mutuality and survivors, and ensure that relationships are based are inadequate for responding to survivors. This means that, for example,
on mutuality, respect, trust, connection and hope. These in trauma-organised systems, survivors may feel and be unsafe, leading to
are critical because abuse of power is typically at the aggression towards staff. Experiencing aggression from survivors may cause
heart of trauma experiences, often leading to feelings of
disconnection and hopelessness, and because it is through staff to become wary and hostile, with organisations responding with greater
relationships that healing can occur. punitive and risk-averse measures. This increases survivors’ sense of unsafety
and aggression. Becoming trauma-informed has the potential to break these
6. Empowerment, Adopt strengths based approaches, with survivors supported negative parallel processes and create positive interactions.
choice and to take control of their lives and develop self-advocacy. This is
control vital as trauma experiences are often characterised by a lack
of control with long-term feelings of disempowerment. Trauma carries a heavy economic cost. Dolezal and colleagues27 have reviewed
US research evidence on the economic impacts of violence and abuse and
estimate a cost of between 17 and 37.5% of the total spend on healthcare.
They believe that a compassionate healthcare system that understands the
Continued... impacts of violence and abuse and offers appropriate support may avoid many

of these costs. In the UK, the Department of Health has estimated that: “costs In a trauma-informed mental health service, all staff – clinical and non-clinical –
include the costs of providing public services for victims, the lost economic understand the impact of trauma on a person’s ability to survive in the present
output of women and the human and emotional costs of violence for victims. moment. Crucially, this entails a shift from thinking “what is wrong with you?”
An indicative figure for the minimum cost of violence against women and to “what happened to you?”31. The critical roles of racism, sexism, homophobia,
children is £36.7 billion”28. There is also some evidence that a reduction in ageism, poverty and their intersectionalities are recognised. Survivors in crisis
seclusion and restraint has large cost savings (e.g. a 92% reduction in the costs are not viewed as manipulative, attention-seeking or destructive, but as trying
linked to restraint29). to cope in the present moment using any available resource.
Providers do not fear asking about trauma, yet do so in ways that are
respectful of potential re-traumatisation; the power of telling one’s story but
5. Applying trauma-informed principles to mental health also the impotence of telling it where nothing changes32; the need to move at
the survivor’s pace; the need to truly listen and the need for post-disclosure
Trauma-informed mental health services are strengths based: they reframe support. Survivors are forewarned about trauma questions, and can choose
complex behaviour in terms of its function in helping survival and as a response not to answer. Trauma information is integrated into treatment plans so that
to situational or relational triggers. Reframing refers to looking at, presenting, people can be referred to trauma-specific services (if wanted)33.
and thinking about a phenomenon in a new and different way, and replaces
traditional individual/medical model approaches to madness and distress The basic safety of environments is prioritised – physical, psychological, social
with a social perspective, somewhat akin to the Social Model of Disability30. and moral – with organisations making a commitment to non-violence34. Staff
Reframing behaviour as meaningful allows providers to address underlying receive support to help them focus on trauma, and steps are taken to build a
needs and utilise less intrusive strategies. We have fictionalised a trauma- sense of community and shared responsibility between staff and survivors.
130 informed response to a woman who self-harms in the box below. This means that services prioritise building trusting, mutual relationships 131
between staff and survivors. When relationships are prioritised, policies and
procedures (such as time limited sessions with a therapist) can be re-evaluated
Jenny’s Story in light of whether or not they support TIAs.
Jenny has had numerous hospital admissions over four years, usually TIAs in mental health aim to reduce or eradicate coercion and control, including
through self-harming events, including swallowing foreign objects and medication as restraint, verbal coercion, threats of enforced detention,
cutting her arms. Previously, some staff described Jenny as “attention- withholding information, restrictive risk-aversive practices, disrespectful
seeking” and “manipulative”, and responded by trying to control or and infantilising interactions and Community Treatment Orders35. Clinicians
stop the behaviour. This included ignoring Jenny, giving PRN (‘when understand the re-victimisation that “power over” relationships reinforce.
required’) medication or forcibly medicating her. This has changed Training and supervision provide staff with the tools to attend to potential
since the organisation began training its staff on trauma and trauma- relational and situational triggers and to use trust-based, collaborative
informed approaches. Now, when Jenny tells staff she wants to hurt relationships to support people.
herself, staff respond to Jenny’s pain, recognising that past strategies
added to Jenny’s sense of powerlessness. While Jenny’s safety is no less Survivors often encounter numerous human services across their lives. To
important, validating Jenny’s pain and her attempt to cope with it, along be trauma-informed, each service within and beyond the local mental health
with using harm reduction strategies around her self-injury, has greatly system should operate according to TIA principles. This includes primary
helped her. Jenny is now using art to bring voice to her experiences, and care, A&E, talking therapies, mental health teams, crisis care, the police,
her treatment team have referred Jenny to a therapist who will work social services and voluntary sector services (such as trauma-specific service
with her on the issues arising from her experiences of abuse. providers).

6. TIAs in the UK
dissociation. TEWV has promoted experts by experience to deliver
One of us, (AK), has played a key role in introducing TIAs to Tees, Esk and Wear much of this. Finally, trauma specific supervision groups are supporting
Valleys NHS Foundation Trust, and describes her experiences in the box below. therapists to respond to issues of complex trauma.
Case study: introducing TIA to an NHS Trust It is clear that TIAs are beginning to reach the UK, although often in settings
beyond mental health. However, the two conferences on trauma-informed
Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) is a mental healthcare in 2014 – with speakers from psychology, mental health
large mental health provider in the North of England which serves a nursing, psychiatry and the survivor movement – indicate the beginnings
population of 1.6 million people and employs over 5,000 staff. TEWV of a sea-change. Scotland’s Mental Health Strategy 2012-2015 includes
is embarking on a programme to develop trauma-informed services psychological trauma as a key priority36. The strategy states that “General
throughout its adult division. Its TIA has been to develop a pathway of Services should be Trauma Aware”, and aims to improve recognition and
care and to train staff to implement this pathway. Training is undertaken awareness of trauma in Primary Care and Mental Health Services, encourage
as a team and it has been well received with staff reporting it relevant staff to make appropriate referrals for trauma survivors, and roll out trauma
to their work and increasing their confidence afterwards. The resource training. Although TIAs are not named, this is nevertheless a welcome
set incorporates a number of elements: it has a variety of information development.
leaflets for clients; resource links and summaries for staff; a treatment
algorithm; service skills matrix; good practice guidance for managing Similarly, the National Mental Health Development Unit37 and the Department
132 trauma disclosures; information on screening for dissociation and of Health (DH)38 have released strategy documents on gender sensitive 133
how to manage it; a section on staff wellbeing and a framework for services that include trauma awareness. The DH published recommendations
understanding risk issues. regarding routine enquiry of abuse in mental health settings over a decade
ago39 and a programme of work was undertaken to train staff, which
The pilot project on an acute adult mental health ward included all staff demonstrated changes in skill40. This focused on changing the emphasis from
from senior medics to health care assistants. They found that three “What is wrong with this person?” to “What has happened to this person?”.
quarters of the people admitted could directly link trauma with their Asking the basic question: “Have you ever experienced physical, sexual or
current difficulties. In total, 80% had substance misuse issues, and the emotional abuse at any time in your life?” has now become mandatory for
same proportion self-harmed. In total, 40% were experiencing some UK services. However, current evidence that staff do this in practice is scant
psychosis. Ward staff felt empowered to have meaningful discussions and this suggests that good practice that goes beyond this question is not
about trauma and used this to inform formulation based care plans. widespread41. One significant change that may prompt responses from
They were able to implement some core skills in grounding and emotion services is the inclusion of trauma in some NICE guidelines, for example, the
regulation, which resulted in a reduction in the use of PRN medication. recently updated guidance for the management of schizophrenia42. Some early
It was important that local trauma champions in each team facilitated intervention services for psychosis, in particular, are attempting to be more
supervision, management and implementation of the guidance. Staff trauma-informed. Toner and colleague43 showed that having a formulation-
could also call on external complex case consultation for trauma, which driven approach to understanding psychosis was more important in creating
was evaluated as being extremely helpful. staff that were empowered to address trauma than having the ability to
enquire about it. There is something very important about the model of mental
Follow-up training plans were then developed to respond to specific health that staff bring with them to the role.
areas of need as requested and so far this has been dominated by

7. What are the barriers to implementing TIAs in the UK? Sixth, there have been a number of initiatives aimed at improving mental
health services and relationships between service providers and users.
We have identified a number of potential explanations for the slow For example, in the UK, Star Wards aims to support excellence on inpatient
implementation of TIAs in the UK, although our list is not exhaustive. Many of psychiatric wards48, Safewards aims to reduce conflict and containment and
these implementation barriers are applicable to settings beyond the UK. First, increase safety on inpatient mental health wards49 and Compassion in Practice
despite compelling evidence, there remains strong resistance to the notion centralises the 6Cs of nursing and midwifery (care, compassion, competence,
that trauma and childhood abuse plays a causal role in psychosis and mental communication, courage and commitment). While such initiatives are
distress. Historically, such claims have been seen as “family blaming”, and compatible with TIA, they are nonetheless another way to conceptualise and
have been vehemently opposed, e.g. historic opposition to Freud and Laing. implement care for providers to grapple with.
Instead there is a focus on the biological basis of mental distress, with genes
and neurology seen as causal and trauma relegated to a trigger at best44. Thus, Seventh, many UK mental health staff have no access to regular structured
mental distress is understood as a scientific, medical and pharmacological supervision, and this is a serious barrier to the implementation of TIA. In our
problem, rather than a human, familial or social issue. case study (see the box below) we cite trauma-specific supervision groups as a
way of supporting therapists to respond to issues of complex trauma.
Second, Western societies have strongly resisted notions of historical and
cultural violence and their consequent trauma legacies. Jackson45, an African
American survivor and therapist, has produced a powerful research account
of scientific racism, slavery and colonialism and the impact this has had on Case study: key factors in successfully implementing TIA
survivors generationally and today. Focussing on the social and systemic
causes of trauma places practitioners in opposition to powerful groups and The experience gained by TEWV in implementing the Clinical Link
134 consequently is often avoided46. Pathway for Trauma has generated some insights. It has taken a lot of 135
planning, patience and determination to keep it on the agenda in spite
Third, Coles47 has described “horror” as a barrier to practitioners embracing of organisational changes, mergers and competing priorities. There
notions of trauma: “to stand as witness to the extent and horror of people’s are, however, a few key factors that have facilitated the ambitious
accounts of pain and suffering is to encounter and experience fear, despair, scope and success so far: first, it was important to sell the concept to
loss and rage”. senior leaders in the organisation using language that connected with
its change processes and aims. The TIA was then sponsored by the
Fourth, UK public services face continuous change and upheaval, making medical director. TEWV uses “Lean” methodology, which looks for ways
many wary and weary of new initiatives. Consequently, introducing new to reduce inefficiencies in its delivery of care. Unidentified trauma was
conceptualisations of care can be challenging, and this is particularly acute demonstrated using local statistics and service user stories as one way
with TIAs because the role and prevalence of trauma is disputed (e.g. the that a person’s journey could stall, be misguided or be less than optimal.
DH and NICE focus on diagnostic categories, rarely referring to trauma). The TIA needed to demonstrate how it fitted with the organisation’s
Compounding this, UK austerity means that resources are scarcer and morale key objectives both strategically and in practise with individual clients.
lower. This context makes it harder to engage with new initiatives. By engaging senior support, the approach has maintained high level
support in spite of competing demands.
Fifth, TIAs are a relatively complex and involved approach to service provision,
and are easily confused with trauma-specific services. Muskett (2014) Second, it helped to use the methodology for system change that
has described how mental health nurses in Australia struggle to translate the Trust already employed. TEWV uses ‘pathways’ to describe the
TIA principles into their everyday practice beyond reducing seclusion and structures, management systems and clinical decision making necessary
restraint. to support the needs of a specific client group. Pathways aim to deliver

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26 Bloom, S. (2006) Op. cit. 48 For more information see: www.starwards.org.uk

49 For more information see: www.safewards.net
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unfinished business. London: National Mental Health Development Unit.

Childhood Experiences: a public health concern
9. Adverse Childhood Experiences: and improving the nation’s health and in working through regional and local
a public health concern

centres to support local authorities in fulfilling their public health functions.
The chapter also highlights PHE’s role in providing information directly to
the public. The chapter starts by setting out the defining features of a public
Claire Robson and Corinne Harvey health approach – its aim and some of the key areas of public health practice.
(on behalf of Public Health England) It describes the wider determinants of health and the significance of this as
a conceptual basis for public health actions that seek to affect change at an
individual, community and wider societal level. It then focuses in more detail
on key aspects of public health practice to improve outcomes for children,
Summary young people and families, highlighting links to helping prevent and mitigate
the impact of ACEs.
A public health approach is essential if we are to prevent many of the
poor health, social and economic problems experienced by individuals
and communities. Using our understanding of risks and assets, enables
us to invest more effectively in prevention of poor health, maximise 2. Defining features of a public health approach
positive outcomes across every stage of the lifecourse and empower
individuals to realise their full potential. The skills that lie at the core of Public health aims to promote and protect health and wellbeing, prevent ill-
public health are powerful tools in our endeavours to work together to health and prolong life. The World Health Organisation describes health not
affect change and reduce inequalities. only as the absence of disease and infirmity, but a state of complete physical,
mental and social wellbeing4.
140 141
A public health approach aims to intervene early across the life stages and
domains of people’s lives, to reduce and avoid escalation of risks and to
1. A public health approach to addressing childhood adversity enhance protective factors for health, wellbeing and build resilience5. Public
health emphasises a collective responsibility for health and wellbeing and
The term Adverse Childhood Experiences (ACEs) is used to describe a wide engages with a wide range of partners to champion macro/whole systems level
range of stressful or traumatic experiences that children can be exposed to change focussing on both universal and targeted population interventions.
while growing up1. ACEs include direct experiences such as suffering physical, It draws on data, evidence and insights into the expressed needs of the
verbal or sexual abuse, and physical or emotional neglect and indirect experi- population as a means of identifying need, highlighting inequalities and
ences affected by the environment in which a child grows up. Examples include prioritising opportunities for action at both a policy and practice level. A
parental separation, domestic violence, mental illness, alcohol abuse, drug use public health approach also seeks to build skills among the health and wider
or incarceration. As the number of ACEs increases2, so does the risk of poor workforce as facilitators of change. It draws on local implementation expertise,
health outcomes3. As such, early childhood experiences are recognised within behavioural insights, social marketing and other technical expertise to
public health as a wider determinant of subsequent lifelong health and are influence action for health improvement.
an important area of focus given the potential to prevent and to mitigate the
adverse consequences. A public health approach recognises that there are a range of risk and
protective factors which operate across different domains of people’s lives
This chapter sets out the contribution that a public health approach can and that the determinants of health and wellbeing result from the interplay
make in helping prevent and mitigate the impact of adversity in the lives of of genetics, lifestyle, health care and wider physical, social, economic and
children, families and their wider community. It references the work of Public environmental factors, as depicted in Whitehead and Dahlgren’s model6.
Health England (PHE) in providing national systems leadership for protecting

Chapter 9 Childhood Experiences: a public health concern
Figure 1: The Determinants of Health – Dahlgren-Whitehead model exposures or health-enhancing opportunities are socially patterned and those
living in adverse childhood social circumstances are more likely to be of low
birth weight, and be exposed to poor diet, childhood infections and passive
omi c , c u l t u r a l a n d e nv i r o n m smoking.
con ent
i o-e Living and working al c Each stage of the lifecourse provides an opportunity to bring an integrated
soc co n d it io n s Une
o approach to an otherwise potentially fragmented focus on typical public
ndi
mp
l
rk ment
era
loy
community net health priorities spanning conventional risk factors such as smoking, drinking
tion
n n d
env Wo
Gen
al a w
me
ork alcohol, drug misuse, mental health, teenage pregnancy and obesity. It allows
iro
oci
s
nt s
a l lif e s ty le for bespoke actions to be taken according to the stage of the lifecourse and
Wateitatioin
u fact
ivid
an
s
S
the potential to deliver an integrated child and family-centric approach to
r and
ors
Education
Ind
health improvement. It also provides an opportunity for considering how best

to coordinate delivery of associated government policy priorities including
Health care
services
mental health, child sexual exploitation and abuse, and social justice. The
Age, sex and lifecourse approach thus provides a useful framework through which to
n
Agri d productio
re and
constitutional acknowledge the importance of ACEs, to customise appropriate approaches

factors
Housi
to prevention, identification and early intervention at each life stage and to
cultu
ng
foo
secure better outcomes for children, young people and their families.
At each stage of the lifecourse across the ages 0–24 years, PHE has examined
142 the evidence of the main risks and assets to good health and wellbeing. 143
Source: Dahlgren and Whitehead, 1991 Some health issues span all our lives, including good mental health and the
prevention of mental health problems9. Maternity provides an important
lifecourse stage for public health interventions to help to realise positive
outcomes for mother and baby. It has been estimated that the cost to the
3. Improving outcomes for children, young people and families public sector of perinatal mental health problems is 5times the cost of
improving the services. Nearly three-quarters (72%) of this cost relates
A lifecourse approach to public health recognises that there are key stages in to adverse impacts on the child rather than the mother10, associated with
people’s lives that have a particular relevance for their health and wellbeing. It long-term consequences of disordered early attachment. Examples of work
acknowledges that an individual’s, a population cohort’s or a generation’s life that PHE is leading to address this include working with local NHS and
experiences shape current and future patterns of health and disease. These local government to lead the prevention workstream within the Maternity
in turn are shaped by the wider social, economic and cultural determinants of Transformation Programme, developing a multi-disciplinary perinatal
health7. competency framework with Health Education England and using its social
marketing expertise to develop mental health content of the Start4Life
There are critical periods of growth during maternity, early years, childhood Information Service for Parents11.
and adolescence when environmental exposures do more damage to health
and long-term health potential than they would at other times8. There are also The Early Years (0–5) part of the lifecourse is particularly crucial for laying
sensitive developmental stages in childhood and adolescence when social and the foundations for healthy development and protecting against adverse
cognitive skills, habits, coping strategies, attitudes and values are more easily experiences12. Promoting early attachment and positive parenting at this
acquired than at later ages. These strongly influence lifecourse trajectories stage builds resilience and physical, mental and socio-economic outcomes
with implications for health in later life. Furthermore, health-damaging in childhood and later life. The economic case for investment during the

early years is also strong – for example the cumulative fiscal cost of acute However some young people face a disproportionately greater risk of adverse
services for a child with Speech, Language and Communications problems experiences that warrants a more targeted, focused approach to addressing
can be over £150,000 by the age of 16 once custodial costs are included, need. A report from the Children’s Commissioner22 has identified 32
compared to a cumulative cost of £42,000 to provide speech, language and categories of very diverse forms of vulnerability. These range from the direct
communication support throughout childhood13. As part of the public health experience of slavery or trafficking to risk factors like having a parent with a
grant, local authorities are required to deliver 5universal health reviews to mental health condition, being in a low income household, being taken into
all children under-5, as part of the Healthy Child Programme14. One of PHE’s care or being a member of a gang. For these groups of children the risks and
national priorities is to ensure every child is given the best start in life15 and difficulties they carry makes it much harder for them to succeed in life, to be
we are working closely with other sectors on a national programme, with happy and healthy and have a chance at a good future.
specific workstreams to promote speech and language and secure attachment,
improve oral health, and reduce unintentional injuries – all of which have a PHE’s specialist substance misuse services records seventeen vulnerability
strong social gradient, with children from the poorest areas doing less well items for young people accessing specialist substance misuse services,
than their peers from more affluent areas. including mental health problems, being ‘looked after’, NEET (Not in Education,
Employment, or Training), offending, self-harming, experiencing sexual
PHE is also focussing its efforts at this stage of the lifecourse to provide extra exploitation or domestic abuse, and being exposed to another’s substance
support for families most at risk, including supporting teenage parents and misuse. Eighty three per cent of young people who entered treatment in
addressing co-morbidities such as children with alcohol dependent parents or 2015–16 reported having two or more vulnerabilities and 38% reported
living in families where there is domestic abuse. having four or more. This highlights the need for specialist substance misuse
services as well as other children, young people and families workforce to be
Data indicates there may be around one in three children in an average school able to work with a range of presenting needs in a multi-agency way to ensure
144 class with a clinically diagnosed mental disorder at any one point during that all needs of a young person are met. 145
childhood and that 50% of mental health disorders arise by the age of 14 rising
to 75% by the age of 2516. The latest Health Behaviour in School Age Children
Survey for England reported more than one in five fifteen year olds to have self
harmed17 and surveys in Further Education and the University sector report 4. Assets based approaches
significant increases in the number of students with mental health difficulties18.
Evidence and data support a case for building resilience at an individual level,
Economic analyses have identified school based programmes to prevent within families and at an organisational level to help manage adversity. Figure
bullying and school based social and emotional learning programmes delivered 2 is taken from our recent report on the mental health of children and young
as part of PSHE to be cost effective prevention activities19. PHE is working people in England, and describes some of the important building blocks of
with local authorities to improve the effectiveness of school health services resilience23.
as part of the Healthy Child Programme, including a focus on developing
resilience and emotional wellbeing as a high impact area of focus for the PHE has published wider data and infographics which help define protective
school nursing service20. School nurses provide an important role through a factors that young people say contribute to positive health and wellbeing
universal, non-stigmatised, confidential service that is trusted by children and outcomes24. These protective factors include:
young people. It can help bridge the interface between schools, families and
specialist services, helping to navigate referral systems and pathways. PHE is Within the context of family life:
also actively supporting education settings from nurseries, to schools, Further
Education colleges and universities to be aware of, and to put into practice • “important issues being regularly spoken about in my family”
evidence based principles for whole school/system approaches to mental
health and wellbeing21. • “someone listens to me”

At a school level: Figure 2: Building resilience (the ability to cope with adversity and adapt to
change)
• personal and social skills being covered well in PSHE
• feelings of belonging
FAMILY
• perceptions of safety within school
Effective caregiving Int
hers & parenting ellig
e
• the quality of relationships with their teachers and peers e teac ols solv nce &
ing pr
iv o
ect nd sch ski o
ll
a
ble
Eff
s
m
At a community level:
ITY
romantic riends or
ers
Self skills
COMMUN
partn
regula
• “feeling safe in the area in which I live”
Positive f
tion
Resilience is important
• “having good places to spend your free time” for emotional wellbeing.
Correlates of resilience in
tive rng adults
Percceive
young people include:
elations
• “being able to trust people around here”
and con efficac

P cari
d
trol y
with
os i
PHE has published a framework for a public health approach to resilience25
I N
146 147
D
and through its Centre teams has led local events to promote resilience in li
h a s e f s th
I
en
Be
VI D
t
public health practice. PHE’s social marketing expertise has also helped to m e a t li fe i e ve m ti o n
UA
a nin h
A c o t i va L
develop Rise Above26 – a peer led digital platform for 11-16s which uses g Faith, hope, m
relevant content in creative ways, tapping into inspirational video from s p i r it u a li t y
vloggers and YouTubers to get young people talking about the things that
matter to them. The campaign helps young people to develop resilience skills
for dealing with diverse life challenges such as cyberbullying, exam stress,
body image and self-harm.
Source: PHE (2016)
5. An intelligence driven approach to understanding need The Child and Maternal Health tools28, the perinatal mental health profile29
and the Children and Young People’s Mental Health and Wellbeing Profile30
Understanding and quantifying the impact of ACEs is a key element in the are available through PHE’s Local Knowledge and Intelligence Service and will
public health approach to reduce and prevent harm at an individual and be particularly useful to those wanting to quantify the scale of ACEs within
population level27. Through its knowledge and intelligence service, PHE the local population. The Child and Maternal Health tools can be viewed by
collates and analyses a wide range of publicly available data on: prevalence, lifecourse stage or theme31.
protective factors, primary prevention (adversity and vulnerability) and
finance. It also provides commissioners, service providers, clinicians, service As well as supporting the application of data, a further valued and important
users and their families with the means to benchmark their area against similar public health function is to promote application of evidence and cost-
populations and gain intelligence about what works. effectiveness data in a timely way so as to helpfully inform policy and practice,

and to highlight where there are gaps in the evidence. PHE has published providers to ensure emerging evidence is part of workforce development and
evidence papers relevant to addressing the issue of ACEs. For example a training.
framework for local authorities for prevention and intervention of child sexual
exploitation (CSE), produced jointly by PHE, the Office of the Children’s
Commissioner and the Association of Directors of Public Health32. For more on routine enquiry see Paper 19.
6. Engagement with community and young people

Listening to, engaging, empowering and responding to the views of young
people is critical in increasing our understanding of need and what works. The
communities within which they live, social support and social networks are all
essential aspects of effective population based public health interventions.
You’re Welcome quality standards for young people-friendly health services
are a helpful tool designed to help commissioners and service providers to
improve the suitability, accessibility, quality and safety of health services
for young people33. NICE guidance on community engagement34 and PHE
and NHS England’s guide to community-centred approaches for health and
wellbeing can also be used to support local public health practice35.
148 149
7. Tackling wider determinants and taking a multi-sectoral

approach to addressing inequalities
Improving outcomes and addressing the causes of inequality requires multi-
sectoral collaboration. Public health advocacy and leadership, the sharing of
robust evidence and the facilitation of learning and exchange of best practice
can drive this effectively.
Across the country, PHE’s nine Centres report an increasing interest in

partnership working across health, social care and community safety systems
to promote ACEs awareness and respond in addressing needs. Public health
teams are leading collaborative work to inform stakeholders, including local
elected members and representatives across the health, social care and
criminal justice system, of the evidence of the impact of ACEs. This work
includes sharing information about how to embed Routine Enquiry into
Adverse Childhood Experiences (REACh)36 as part of an assessment process
to help then plan more focussed interventions. It also includes working with

References 19 Public Health England (2017) Prevention Concordat for Better Mental Health: https://www.
gov.uk/government/collections/prevention-concordat-for-better-mental-health
20 PHE (2016) School Aged Years 5-19: resilience and emotional wellbeing: https://www.gov.uk/
1 For more information see: www.blackburn.gov.uk/Pages/aces.aspx government/uploads/system/uploads/attachment_data/file/564089/School_aged_years_high_
2 Ford, K., Butler, N., Hughes, K., Quigg, Z., and Bellis, M. A. (2016) Adverse Childhood Expe- impact_area1_resilience_emotional_wellbeing.pdf
riences (ACEs) in Hertfordshire, Luton and Northamptonshire. Liverpool: Centre for Public 21 PHE (2015) Promoting Children and Young People’s Emotional Health and Wellbeing: a whole
Health (Liverpool John Moores University) school and college approach: https://www.gov.uk/government/uploads/system/uploads/at-
3 Bellis, M. A., Ashton, K., Hughes, K., Ford, K., Bishop, J. and Paranjoth, S. (2015) Adverse tachment_data/file/414908/Final_EHWB_draft_20_03_15.pdf
Childhood Experiences and their impact on health-harming behaviours in the Welsh adult 22 Children’s Commissioner (2017) On Measuring the Number of Vulnerable Children in Eng-
population. Cardiff: Public Health Wales: https://www.wao.gov.uk/sites/default/files/ACE%20 land: https://www.childrenscommissioner.gov.uk/wp-content/uploads/2017/07/CCO-On-vul-
%26%20Mental%20Well-being%20Report%20E.pdf nerability-Overveiw.pdf
4 For more information see: www.who.int/about/mission/en/ 23 PHE (2016) The Mental Health of Children and Young People in England: https://www.gov.uk/
5 Resilience is the capacity to bounce back from adversity. Protective factors increase resilience, government/uploads/system/uploads/attachment_data/file/575632/Mental_health_of_chil-
whereas risk factors increase vulnerability. Resilient individuals, families and communities are dren_in_England.pdf
more able to deal with difficulties and adversities than those with less resilience. See: PHE / Picture credits for Figure 2: From the Noun Project: Children by Gilad, Church by Creative
UCL Institute of Health Equity (2014) Local Action on Health Inequalities: building children Stall, Genetics by Edward Boatman, Individual Responsibility by CO. Department of Health
and young people’s resilience in schools: https://fingertips.phe.org.uk/documents/Resilience_ Care and Policy Financing, Puzzle by Becky Warren, and by Dr Marilena Korkodilos: Degree,
in_schools_health_inequalities.pdf Friend, Reflect, School.
6 Dahlgren, G. and Whitehead, M. (1991) Policies and Strategies to Promote Social Equity in 24 PHE (2017) Health Behaviour in School Age Children Survey: data analysis: www.gov.uk/
Health. Stockholm: Institute for Futures Studies. government/publications/health-behaviour-in-school-age-children-hbsc-data-analysis
7 World Health Organisation (2000) A Lifecourse Approach to Health: http://www.who.int/ 25 Association of Young People’s Health (2016) A Public Health Approach to Promoting Young
ageing/publications/lifecourse/alc_lifecourse_training_en.pdf People’s Resilience: http://www.youngpeopleshealth.org.uk/wp-content/uploads/2016/03/
8 ibid resilience-resource-15-march-version.pdf
9 PHE (2017) Annual Business Plan 2017-18: www.gov.uk/government/uploads/system/up- 26 For more information see: https://riseabove.org.uk
150 loads/attachment_data/file/610181/PHE_business_plan_2017_to_2018.pdf 27 For more information see: https://www.cdc.gov/violenceprevention/acestudy

151
10 Bauer, A., Parsonage, M., Knapp, M. et al (2014) Costs of Perinatal Mental Health Problems. 28 Data available from: https://fingertips.phe.org.uk/profile-group/child-health
London School of Economics and Political Science. 29 Data available from: https://fingertips.phe.org.uk/profile-group/mental-health/profile/perina-
11 For more information see: www.nhs.uk/start4life tal-mental-health
12 PHE (2016) Health Matters: giving every child the best start in life: www.gov.uk/government/ 30 Data available from: https://fingertips.phe.org.uk/profile-group/mental-health/profile/cypmh
publications/health-matters-giving-every-child-the-best-start-in-life/health-matters-giving- 31 Data available from: https://fingertips.phe.org.uk/profile-group/child-health
every-child-the-best-start-in-life
32 PHE (2017) Child Sexual Exploitation: how public health can support prevention and interven-
13 I CAN (2006) The Cost to the Nation of Children’s Poor Communication: http://www.ican.org. tion: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/629315/
uk/~/media/Ican2/Whats%20the%20Issue/Evidence/2%20The%20Cost%20to%20the%20 PHE_child_exploitation_report.pdf
Nation%20of%20Children%20s%20Poor%20Communication%20pdf.ashx
33 For more information see: www.youngpeopleshealth.org.uk/yourewelcome
14 DH (2009) Healthy Child Programme: pregnancy and the first 5 years of life: https://www.gov.
uk/government/publications/healthy-child-programme-pregnancy-and-the-first-5-years-of- 34 National Institute for Health and Care Excellence (2017) Community Engagement Pathway
life Overview:
15 PHE (2016) Op. Cit. https://pathways.nice.org.uk/pathways/community-engagement#content=view-info-catego-

ry%3Aview-about-menu
16 Figures cited in Measuring Mental Wellbeing in Children and Young People. Prevalence
estimates are based on ONS 2004 Survey of Mental Health of Children and Young People in 35 PHE / NHS England (2015) A Guide to Community-centred Approaches for Health and
Great Britain. Estimates applied to 2014 mid year population children aged 5 – 16 years. For Wellbeing: https://www.gov.uk/government/uploads/system/uploads/attachment_data/
more information see: www.gov.uk/government/uploads/system/uploads/attachment_data/ file/417515/A_guide_to_community-centred_approaches_for_health_and_wellbeing__full_re-
file/611494/Measuring_mental_wellbeing_in_children_and_young_people.pdf port_.pdf
17 WHO (2014) Health Behaviour in School Aged Children: www.hbsc.org 36 More information about the REACh model is available at: https://www.lancashirecare.nhs.uk/
REACh
18 Williams, M., Coare, P., Marvell, R., Pollard, E., Houghton, A-M. and Anderson, J. (2015) Un-
derstanding provision for students with mental health problems and intensive support needs:
http://www.hefce.ac.uk/media/HEFCE,2014/Content/Pubs/Independentresearch/2015/
Understanding,provision,for,students,with,mental,health,problems/HEFCE2015_mh_.pdf

What works in addressing childhood adversity
10. What works in addressing the country. Across England, each CCG and Local Authority is now party to a
childhood adversity
joint agency Children and Young People’s Mental Health Local Transformation
Plan (LTP)2, setting out not just core information and baselines but also the
components of a local offer to children, young people, parents and carers and
Kathryn Pugh MBE referrers, including how the needs of the most complex and vulnerable groups
(on behalf of NHS England) would be met.
The publication of Future in Mind coincided with an announcement of a further

£1.25 million available3 to improve access to evidence based interventions,
1. Introduction with the goal of seeing an extra 70,000 children and young people per year
by 2020. The Five Year Forward View for Mental Health4 reiterated the NHS
We know that adverse childhood experiences can have a deep and lasting commitment to Future in Mind, and Local Transformation Plans contribute to
impact on people’s lives. Its effects are complex and vary for each person the whole system Sustainability and Transformation Plans.
depending on a range of factors including genetics, family environment, the
child’s age and the type of maltreatment. However, some things are common NHS England, with other ‘arms-length bodies’ such as Public Health England,
across different types of maltreatment or adverse experience: maltreatment Health Education England and the Care Quality Commission, the Departments
is a source of stress, so can have a harmful effect on the developing brain, and of Health and Education, and the Youth Justice Board have developed work
some forms (sexual and physical abuse, exposure to violence between parents programmes to support commissioners and services to reshape the way
or carers) are traumatic. Neglect and emotional and physical abuse are often services for children and young people with mental health needs are delivered.
associated with disorganised attachment. Both nationally and locally we are looking to make some real changes right
152 across the whole system, thinking together about prevention and moving 153
Although we know many of the common effects of maltreatment and adverse investment opportunities upstream to build resilience in our children and
experiences, we cannot with any certainty predict when they will surface. young people, address adverse childhood experiences, promote good mental
Some children do not experience the negative consequences of maltreatment health and intervene early when problems first arise.
until later in their lives, and so the support networks surrounding children and
young people must be ready to support them at the right time. Those support An important force in realising this change, and one that has been rolled out
networks are different for each person, but we have an opportunity – in driving to services covering 90% of England, is the Children and Young People’s
better commissioning and service design across the country – to support Improving Access to Psychological Therapies transformation programme
children and young people who are struggling with the effects of adverse (CYP IAPT)5 – this is different to the adult IAPT programme, which delivers
childhood experiences in school, at home, when they start work, when they go standalone services for anxiety and depression. CYP IAPT has sought
to university and, of course, when they need help with their mental health. to re-orientate and modernise community services to make them more
responsive and accessible. The programme works through partnerships across
universities, CCGs, local authorities, and providers to embed evidence-based,
outcomes-focused interventions across the statutory and voluntary sectors,
2. What is NHS England doing to drive change? with full collaboration with children, young people and their parents and
carers.
Future in Mind1, the key strategic driver behind children and young people’s
mental health transformation in England, set out a clear and powerful Under CYP IAPT, CYPMH staff from the statutory and voluntary sectors and
consensus about how to make it easier for children and young people to non-clinical staff can access training in evidence-based interventions to post
access high quality mental health care when they need it. Not only did it set a graduate diploma level. Courses offered include CBT, Family Therapy and
national vision for change; it set in train improvements at a local level across Parent Training, counselling, interventions for ages 0-5, learning disability

Chapter 10 What works in addressing childhood adversity
and autistic spectrum disorder, the combination of pharmacological and areas were at varying stages in terms of developing models and approaches,
psychological interventions. It also includes whole team training for inpatient which included:
services and community eating disorder services, and specialist therapies
for eating disorder treatments. As well as directly developing the expertise • developing CSE/CSA care pathways to ensure there is age appropriate
of those on training, these courses create service management, supervision provision at all stages of the care journey
and outreach training to services for staff across the statutory and voluntary
sectors to support their colleagues with consultation and advice. • case management by a dedicated CSE coordinator
As well as supporting the CYPMH workforce to deliver evidence-based care, • increasing awareness among professionals and the public, as with
we need to help services understand and cater for the particular needs of Bury’s It’s Not Okay campaign
children and young people who have an extra vulnerability to developing a
mental health problem, and who face barriers in accessing the support they • whole school approaches, providing advice and support to schools or
need. This is especially important for children and young people who have holding forums where schools can discuss concerns and seek advice
experienced maltreatment or adverse childhood experiences, and who may
find it difficult to find the help they need at the right time. • a small number of areas highlighted the Think Family approach that
seeks to improve joint working between services from the police to
One group we know will be highly likely to have experienced trauma or ambulance services, to youth workers, voluntary organisations and
adverse childhood experiences is children and young people in care, adopted schools
children and care leavers. The Departments for Education and Health have
commissioned an expert working group to develop a care pathway to guide • sensitive enquiry into neglect, abuse and violence, with some areas
154 local services in what to do to support the mental health and wellbeing needs investing in CSE/CSA training for staff 155
of this group. We are also piloting integrated personal budgets for looked-after
children, adopted children and care leavers with joint partnerships of CCGs, • using outreach and non-conventional settings rather than clinics or
local authorities and voluntary sector organisations. The drive behind both of offices, such as CSE/CSA hubs or child houses
these initiatives is, above all, choice and control – and through this work we
are building replicable models so that more areas across the country are able • one-to-one relationships with an individual worker or single point of
to make this offer to looked-after children, adopted children and care leavers. access and
Choice and control supports this group of children and young people to
develop their own sense of agency. These initiatives are intended to bring their • robust, evidence-based specialist therapeutic interventions.
voice into every element of service design – from guidance for commissioners
through the MH and wellbeing care pathway, to a clear mechanism for joint
decision making through personal budgets. In addition to ensuring that early identification is in place, some areas were
using or developing indicators and risk-assessment tools to assist in the
identification of CSE/CSA. There are also regional responses, such as the
pan-London establishment of CSA hubs and child houses, which will act
3. Ways we are working together as integrated centres of support to deal with CSA, CSE and female genital
mutation (FGM).
Both providers and commissioners have a role in creating trauma-informed
services which cater for the needs of vulnerable groups. The platform to Commissioners and providers need to build on these initiatives and replicate
achieve the interagency working required to deliver services is the Local successful models to ensure that they can offer children and young people
Transformation Plan. Our thematic review6 of LTPs in July 2016 showed that across the country appropriate and trauma-informed services at the right time.

4. What can commissioners and providers do to support Building on this, there are some core principles for good practice in building
these children and young people? services to address mental health need arising from adversity:
• Involve children and young people, and where appropriate

In terms of systemic responsibilities, the NHS, public health, voluntary and their families and carers, at every level, from service design to
community, local authority children’s services, education and youth justice commissioning, recruitment and crucially decisions about their own
sectors need to work together to: care
• place the emphasis on building resilience, promoting good mental • Engage closely with local communities to create services that are
health and wellbeing, prevention and early intervention racially, ethnically and culturally sensitive
• deliver a step change in how care is provided – moving away from a • Build services that support those with extra vulnerabilities (either in
system defined in terms of the services organisations provide towards terms of developing a mental health problem, or who face barriers in
one built around the needs of children, young people and their families accessing services), such as those with a learning difficulty, children and
young people in gangs, or looked-after children.
• improve access so that children and young people have easy access to
the right support from the right service at the right time and as close • Aligning with the principles of CYP IAPT, ensure routine outcomes
to home as possible. This includes implementing clear evidence based measurement is embedded in services as standard practice
pathways for community based care to avoid unnecessary admissions
to inpatient care • Engage across service boundaries – schools, the police, children’s
156 services – so that children and young people are supported across the 157
• deliver a clear joined up approach: linking services so care pathways system with trauma-informed support
are easier to navigate for all children and young people, including those
who are most vulnerable • Work to reduce stigma and prejudice – this is a key part of ensuring
that children and young people seek the help they need, when they
• sustain a culture of continuous evidence-based service improvement need it.
delivered by a workforce with the right mix of skills, competencies and
experience
Commissioners can enact these principles with some practical steps, such as:
• improve transparency and accountability across the whole system
– being clear about how resources are being used in each area and • Embedding these principles into Local Transformation Plans. There
providing evidence to support collaborative decision making. needs to be a clear strategic vision locally for how services will work
in a trauma-informed way, and this needs to feed down to practitioner
• ensure that data is captured locally and nationally. For example, NHS level so that frontline staff feel empowered to implement that vision
commissioned services should ensure the Mental Health Services and children, young people, their families and carers are able to hold
Minimum Data Set reflects accurately the status and interventions their commissioners to account for implementing it.
with children and young people – for example ensuring the complexity
tool is completed so we have a record of factors which will impact on a • Ensuring there is strong communication across agencies working with
child or young person. children and young people who might be affected. There are myriad
ways this could be achieved locally, from co-location, to joint working
groups, to collaborative and pooled commissioning. Frontline staff

across universal and targeted services need to feel comfortable liaising References
across service boundaries to raise concerns and intervene at the
right time for the child or young person. Again, this needs to be built 1 DH / NHS England (2015) Future in Mind: Promoting, protecting and improving our children
into LTPs. Commissioners and providers might find the Schools Pilot and young people’s mental health and wellbeing: https://www.gov.uk/government/publica-
tions/improving-mental-health-services-for-young-people
evaluation a helpful touchstone for examples of cross-agency working.
2 For more information on Local Transformation Plans see: https://www.england.nhs.uk/men-
tal-health/cyp/transformation/
Supporting frontline staff in delivering trauma-informed care. This is about 3 This is over the five year period from 2015-16 to 2020-21.
the practical steps leaders and managers can take to ensure staff are properly 4 Independent Mental Health Taskforce (2016) The Five Year Forward View on Mental Health:
trained and confident having trauma-informed conversations. To ensure that https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-fi-
nal.pdf
they know what the next steps are, and the appropriate local pathways, and
5 For more information on Children and Young People’s Improving Access to Psychological Ther-
routes for safeguarding escalation, following disclosures.In addition that
apies transformation programme (CYP IAPT) see: https://www.england.nhs.uk/mental-health/
they know where to find support for themselves, if they are affected by these cyp/iapt/
disclosures. 6 NHS England (2016) Children and Young People’s Mental Health Local Transformation Plans:
a summary of key themes: https://www.england.nhs.uk/mentalhealth/wp-content/uploads/
sites/29/2016/08/cyp-mh-ltp.pdf
There is encouraging work taking place across the country to support children
and young people who have experienced trauma, and we shouldn’t lose sight of
the successes so far. But nor should we overlook the needs of these vulnerable
groups. We need to build on those successes and work jointly to embed lasting
networks of support across the system so that children and young people can
reach the help they need, when they need it.
158 159

Trauma-informed care for children with complex needs in the youth justice system
11. Trauma-informed care for children with This workstream aims to address some of the commonly identified gaps
complex needs in the youth justice system

in mental health provision for children and young people held within, and
transitioning into or out of, the Children and Young People’s Secure Estate
(CYPSE) either on youth justice or welfare grounds. It also targets improved
Caroline Twichett and Sue Sylvester service provision for children and young people coming into contact with other
(on behalf of NHS England) elements of the health and justice pathway, such as Liaison and Diversion,
Sexual Assault Referral Centres or crisis care related to police custody.
Additionally, it has a focus on those individuals receiving specialist mental
health services (specifically high risk young people with complex needs).
1. Unique and diverse needs A core objective of the workstream is to promote greater collaboration
between the various commissioners of services for those children and
Many of the children who are close to, or come into contact with, the Youth young people who come into the NHS England Health and Justice pathway.
Justice System have missed opportunities for early identification and This includes services for children with complex needs in the CYPSE as well
interventions of their health needs due to a variety of reasons. They are more as in the community. However, it also refers to those children and young
likely than their peers to have a mental health or neurodisability problem. They people within the NHS England Health and Justice pathway whose mental
may often have more than one mental health problem in combination with health needs may not meet traditional service thresholds, but for whom the
a range of additional vulnerabilities from adverse childhood experiences. A aggregated impact of multiple health and social issues presents not only an
common feature of this cohort is that they do not always fit into clear diagnostic immediate risk, but also one which may escalate to the point of crisis if left
categories, and as a result, some of their mental health needs are not being met. unaddressed.
160 It is important to also appreciate that the individuals in this cohort may 161
have multiple interactions with current services commissioned by different
organisations. This presents challenges around continuity of care, data sharing, 3. Health and Justice commissioning responsibilities
the creation of a holistic picture of the individual, consistency of approach
and management of transfers. It is therefore vital to ensure that each child The number of children who are now held in custody is much smaller than
entering the secure estate has a full health screen and assessment to use the in recent years (down from 3,500 to around 1000) but now consists of a
period of detention to understand the health needs of this group of children concentrated group of children with complex and challenging needs and a wide
and to improve their health and wellbeing outcomes. range of vulnerabilities. This cohort of children are over represented in terms
of their physical, mental, neurodisability and substance misuse needs, often
demonstrating co-morbidity.
2. Health and Justice current context and developments The commissioning of health services in these settings is carried out by local
Health and Justice commissioning teams, of which there are currently 10
A nationwide transformation programme is underway to improve mental across England. All NHS England Health and Justice Commissioners work
health outcomes for children and young people – the Children and Young closely with individual establishments within the Children and Young People’s
People’s Mental Health Services Transformation Programme. Within this Secure Estate. The CYPSE provides a national service, in which children may
programme is the Health and Justice and Specialised Commissioning Children be placed anywhere in the estate, and not necessarily within, or close to, their
and Young People’s Mental Health Services Transformation Workstream. originating locality.
They look at how to improve the commissioning of services which can meet
the specific needs of some children and young people who are considered The CYPSE is the collective term for three types of residential placements
especially at risk. where 10–17 year olds sentenced or remanded to custody can be placed by

Chapter 11 Trauma-informed care for children with complex needs in the youth justice system
the Youth Justice Board (YJB): and Young People’s Secure Estate. The tool has five parts: Part 1: Reception
Screen; Part 2: Health Screen; Part 3: Substance Misuse; Part 4: Mental
• Secure Children’s Homes (SCHs) Health; and Part 5: Neurodisability.
• Secure Training Centres (STCs) On completion of the CHAT a Care Plan is completed for all children, setting
out the needs and provision of health services while in the CYPSE. Where
• Young Offender Institutions (YOIs) needs relate to mental health or neuro disability, all sites have access to the
full range of Comprehensive Children and Young People’s Mental Health
provision, including, for example, Child and Forensic Child Psychiatrists,
The CYPSE currently consists of four YOIs holding under-18s, three STCs Clinical Child Psychologists, specialist nurses, Occupational Therapists and
(one of which, Oakhill, is not currently within NHS England Regulations) Speech and Language Therapists.
and 14 SCHs, six of which are ‘welfare only.’ SCHs may provide care and
accommodation for young people placed by local authorities under a Secure NHS England commissions health services to consistent standards set out in
Welfare Order for the protection of themselves and/or others (welfare Healthcare Standards for Children and Young People in Secure Settings by
placements), under Section 25 of the Children Act 1989. It is important to the Royal College of Paediatrics and Child Health and others in 2013, and to
remember that these children are not offenders. Some SCHs are ‘welfare only’ core specifications developed specifically for the CYPSE. The standards take
while others take a mixture of these children and those placed by the Youth a pathway approach, following the young person’s journey through a secure
Custody Service. setting to aid multi-professional working.
Health and Justice Commissioners also have commissioning responsibilities The standards and specifications cover mental health in detail.
162 for children and young people who: 163
Health and Justice commissioners work closely within individual
• Receive specialist child and adolescent mental health services establishments within the CYPSE, to commission and procure healthcare
(specifically high risk young people with complex needs). Not all of providers a range of high quality services which fully meet the needs of the
these children and young people are in the NHS England Health and cohort of children identified.
Justice pathway, since some may be in mainstream mental health
pathways All healthcare commissioners, governors/directors/managers and healthcare
providers continuously monitor and review performance and quality.
• Interact with Liaison and Diversion services Partnership working through established governance systems enable
appropriate and timely access to healthcare provision within the CYPSE,
• Present at Sexual Assault Referral Centres ensuring their safety and providing the best possible care.
• Are in crisis relating to police custody Commissioners are required to undertake regular Health and Wellbeing
Needs Assessments to ensure service planning and commissioning is
responsive to the needs of children in the secure setting. The views of children
and of their parents/carers, should be sought and taken into account in
4. Holistic health assessment and Healthcare Standards commissioning, delivering and improving health services in the secure setting.
Health and Justice and Specialised Commissioning Children and Young People
All children placed in the CYPSE are screened and have a holistic health Mental Health.
assessment using the Comprehensive Health Assessment Tool (CHAT), an
evidenced based tool designed specifically for children placed in the Children

5. Transformation Workstream projects a. Have needs which are multiple (i.e. not just in one domain, such as
mental health), persistent (i.e. long-term rather than transient), and
A core objective of the Health and Justice and Specialised Commissioning severe (i.e. not responding to standard interventions).
Children and Young People Mental Health Transformation workstream is
to promote greater collaboration between the various commissioners of b. Exhibit high-risk behaviours (to self, to others and from others) and
services for those children and young people who come into the NHS England present with complex management difficulties.
Health and Justice pathway. The workstream has three projects, each of
which focuses on a different area of care for this cohort. These workstream c. This needs to be filled in or deleted.
projects include specialist CAMHS for High Risk Young People with Complex
Needs, development of a framework for integrated care for the Children and d. Struggle to respond to or maintain progress with traditional regime
Young People’s Secure Estate (known as SECURE STAIRS) and Collaborative and interventions.
Commissioning Networks.
e. Have common histories of early onset anti-social and / or high-risk
• Workstream project 1: Specialist Child and Adolescent Mental Health behaviours, often supplemented with complex mental health needs and
Services for High Risk Young People with Complex Needs. experiences of trauma and attachment disruption.
• Workstream project 2: Development of a framework for integrated f. Be at increased risk of being diagnosed with personality disorder in
care for the CYPSE (SECURE STAIRS). adulthood.
• Workstream project 3: Collaborative Commissioning Networks. g. Be at risk of being diagnosed with personality disorder in the present,
164 frequently resulting in managed moves. 165
Each workstream project has a focus on a different part of the overall
commissioning landscape for this cohort of children and young people.
6. Implementation timescales and intended outcomes
Workstream project 1 focuses on high risk young people with complex needs,
who exist in a range of settings, both within the youth justice system and in the The aim of the workstream project is to roll out the SECURE STAIRS
community. It recognises that the skills which have been historically developed Framework of Integrated Care across all of the CYPSE, this will be phased
in Forensic CAMHS teams are applicable to these high risk young people, and in from April 2017. Ultimately, the SECURE STAIRS framework is intended
those with complex needs in situations where specialist expertise beyond to ensure that children and young people receive the same type of care
that available in local Children and Young People Mental Health Services and irrespective of location in England, built on an evidence-informed approach.
other provision for children and young people is required. While pockets of
such capability may exist across England currently, the opportunity now exists The SECURE STAIRS framework is based on two core elements, the ‘SECURE’
to extend this nationally and thereby ensure greater continuity of care (for element emphasises the importance of consistency in the day to day care
example between secure and community settings) for these young people of the young people by front line staff who understand the needs from an
between the many settings in which they find themselves and the multiple attachment/trauma perspective. The ‘STAIRS’ element emphasises the
professionals with whom they may come into contact. importance of a co-ordinated, multi-disciplinary, formulation approach to
intervention.
Workstream project 2 looks specifically at children and young people who
may:

Workstream project 3 is intended to bring together the various partners that

to have a staff team with the necessary skill set to meet the needs of the
young people effectively are involved in the commissioning of services for very vulnerable children and
young people, to deliver full clinical pathway consideration for all children and
young people who have received services delivered via NHS England Health
to have emotionally resilient staff who are able to respond in the child’s
best interest at all times (and reduce their own sickness and sick leave) and Justice directly commissioned provision. This is intended to address
some of the challenges that exist in this sphere currently, such as missed
opportunities for assessments, lack of continuity of care when individuals pass
to have staff that feel cared for to enable them to provide the most
from one organisation to another, and silo working that prevents a holistic
helpful therapeutic environment for these complex young people
approach to care delivery.
to have staff with the understanding of psychological theory and the
ability to apply this to practice (via training and supervision) to enable The three workstream projects will all contribute to the same workstream
young people to reach their full potential objective, by focusing on different parts of the overall cohort of children
and young people in question, at different points on their pathways. The
to have reflective systems which enable an improved unit environment approach recognises that these children and young people have some of the
– less risky behaviours in units, improved consistency and communication most complex needs and yet historically this complexity has been a barrier to
the successful provision of care. While any individual may only ever receive
services from a small part of the larger system, their potential pathway may
to ensure ‘every interaction matters’ and is positive
be hard to anticipate, meaning all these components must contribute to a
functioning whole.
166 to ensure sufficient scoping is done for each young person to ensure As these workstream projects focus on different parts of the system the 167
comprehensive assessment development of early intervention and prevention for children and young
people being diverted away from the youth justice system is important as
numbers in the CYPSE reduce. Further information about the development of
targets for stay are collaboratively developed for each young person Liaison and Diversion is detailed below.
activators for behaviours are identified as part of a comprehensive

psychological formulation
7. Liaison and Diversion – early intervention and prevention
informed by the formulation, ensure the interventions that are offered
are evidence-based and developed with the aim of delivering sustained In the year 2016/17, 9,027 children and young people engaged with liaison
change post discharge and diversion services, 77% of which were male and 21% female, 80% of the
9,027 were aged 15–18. All age liaison and diversion services are currently
progress towards targets/interventions efficacy is reviewed and revised accessible to 68% of the population in England, with plans in place to deliver
regularly
full coverage by 2021. This service provides early intervention, screening and
assessments for vulnerable young people as they come to the attention of the
sustainability of change post-discharge remains a key consideration
throughout stay in CYPSE, with the aim of long-term improvement of life youth justice system and provides a prompt response to concerns raised by
chances (specifically through reduced likelihood of reoffending, more the police, youth offending teams or courts staff. The service provides critical
stability of placements, better health education, housing and employment information to decision makers in the justice system, in real time, to inform
opportunities, more effective therapeutic pathways into adulthood and/ effective participation, diversion, charging and sentencing. It also involves
or community based provision)
referral and assertive follow up to ensure children and young people access,

and are supported to attend, treatment and rehabilitation appointments.

Without Liaison and Diversion services, children and young people’s needs For further information on the Health and Justice and Specialised
may go unidentified and untreated. Commissioning Children and Young People Mental Health
Transformation workstream and associated projects please contact:
[email protected]
Case study
The following text is taken from Relative Justice: the expressions and
views of family members a joint report by the Prison Reform Trust (PRT)
and Partners of Prisoners Family Support Groups, published by PRT in
September 2015. Those in contact with liaison and diversion services
spoke highly of the support they received. Whether it was help to make
sense of the situation or to understand what would happen next, the
offer of practical support or ensuring referrals to local agencies, the
relief at having, as one mother described it, “someone on my side” was
tangible.
One family member whose 15-year-old son was coping with his dad’s
death and had a drug addiction, said: “They [liaison and diversion] have
opened the door, things I couldn’t get before, I can now ... She [the
168 liaison and diversion worker] looked and found something for us; she 169
found out about the service, the name of the person we should talk to
and the telephone number. It was so helpful; we just didn’t know what to
do. My son is calmer – the house is calmer. We aren’t scared.”
What is common in this cohort of children and young people are their often
complex needs and complex relationships with care pathways, for a number
of personal, social and institutional reasons. Increased service provision is
not the only answer to meeting their needs. There is insufficient integration
between mental health, social care, youth justice services and other relevant
services for children and young people. This means that opportunities are
missed to share information about an individual and build up a holistic picture
of their needs. This is especially a problem where a number of relatively low
level needs could be aggregated to deliver a comprehensive picture that
could trigger an appropriate intervention. Staff skills need to be developed
accordingly to enable integrated joint working and to underpin a whole system
approach to addressing the complex needs of these children and young people.

Meeting the mental health needs of looked-after children and care leavers
12. Meeting the mental health needs of (61%)6. The majority of the rest of cases being family reasons such as a parent
looked-after children and care leavers

becoming ill or disabled. More broadly, the separation and upheaval implied by
being taken into care can in itself be understood as an experience of adversity.
Professor Peter Fonagy Perhaps of particular relevance to LAC is the fact that there appears to be a
dose-response relationship between trauma and psychopathology. This was
observed in the Adverse Childhood Experiences Survey, which found that
34.6% of participants who had experienced at least 2types of maltreatment
1. Introduction also experienced significantly greater mental health disorder7. More recently,
a study8 of over 3,000 15-year-olds found that each additional traumatic event
The number of looked-after children (LAC) in the UK has been steadily or loss in childhood significantly increased the likelihood of high-risk behaviour
increasing over the last eight years1; there were 70,440 looked-after children problems and/or functional impairment in adolescence by 6% to 22%. There
at 31 March 2016, an increase of 5% compared to 2012. The majority of is, in addition, a wide literature indicating the negative outcomes in terms of
these children (74%) are in foster care and 6% of LAC in March 2016 were physical health9 and socio-economic function associated with adversity10.
unaccompanied asylum-seeking children2. Of LAC, 56% are male, and 44% The issue of adversity and how best to treat and support children who have a
female. The age of LAC is slightly increasing: 62% were aged over 10 years in history of adversity is therefore particularly pertinent in the case of LAC.
2016, compared to 56% in 2012.
The experience of trauma and maltreatment in the context of the attachment,
Children who are looked-after are considerably more likely to suffer from a caregiving relationship lies, we argue, in the distorting impact it has on the
mental health disorder than the general population: almost half of children who individual’s capacity to access and benefit from their social environment.
170 are looked-after meet the criteria for a psychiatric disorder (rising to three This disruption is an adaptive response to experiencing a formative climate 171
quarters of children who are living in residential homes)3. This is in comparison of relationships that communicate to the child that mentalizing oneself
with a prevalence rate of 10% in the general population. The most commonly or others (i.e., that it is safe, relevant and pleasurable to think about the
diagnosed disorder among LAC is conduct disorder, which is thought to affect mental states of others in a reflective and open way) is not an appropriate
around 38% of LAC. About 12% of LAC are thought to suffer from internalising strategy in their social environment. Individuals who have benefited from
disorders such as anxiety or depression4. There are many factors implicated “good enough” parenting have experienced the mind of their caregiver as
in the high rates of mental ill health and psychological distress in this group interested and invested in their own mind, and have therefore learnt that
of young people. One particular factor at play is the experience of adversity, it might be in their interest to be invested in what others do – to mentalize
trauma and maltreatment before being taken into care. and to collaborate. A traumatic and highly adverse environment may lead
the child to close down this approach to the social world around them; there
are adaptive, protective reasons for adopting this stance, but it can leave the
individual unable to function in relation to the social environment in a way that
2. The role of adversity is ultimately beneficial. It can result in social dysfunction and instability, and
an apparent “rigidity” that makes it hard to enjoy the benefits and protection
The relationship between early adversity, maltreatment and trauma, and that arise from the ability to interact flexibly and collaboratively with one’s
mental health disorder is well established. The US national comorbidity survey social environment (whether that is school, close relationships or professional,
found that childhood adversities are associated with 44.6% of all childhood- helping networks)11.
onset psychiatric disorders and 25.9 – 32% of all adult-onset disorders5. Early
adversity in the form of abuse and neglect is the most common reason for “Resilience” is a much-vaunted notion in current debates about child mental
children entering into the care system – in England in 2015, the main reason health. It is an important concept, but we can only progress in the hope of
for social services first engaging with LAC was because of abuse and neglect promoting resilience in our young people if we properly understand what it

Chapter 12 Meeting the mental health needs of looked-after children and care leavers
is. It is not an intrinsic factor that an individual is born predisposed to. Rather, and assessment of mental health needs, and who is meaningfully connected
resilience is composed of an individual’s perception of their relationship to the to local CAMH services, could stand as a key component in ensuring that
social network that surrounds them, and how this affects the decisions they services are joined up13. This aspiration is in keeping with the NICE guideline
make in relation to their social environment. To put it in the language of our on attachment in children in or on the edge of care, which suggests that such
theoretical framework, we would describe this as the way in which the young children should be provided with a key worker (envisaged in this report as a
person mentalizes – how they understand the mental states of others, and designated teacher) who has specialist training and with whom the child can
themselves in relation to their actions. The reason why adversity is implicated maintain an ongoing and consistent relationship across their school life, as well
in vulnerability to poor mental health, as well as other long-term outcomes as ensuring that all staff who may have contact with the child concerned are
ranging from physical to socio-economic, we suggest lies in the fact that it properly trained in understanding their needs14.
has such a power shaping influence on the child’s perception of the social
environment they inhabit, and the most effective means of navigating it. Placement stability is another key component in the mental health of LAC. The
figures for all LAC children in England as of March 2016 found that 21% had two
placements and 10% had had three or more placements during the preceding
year15. Frequent moves in and out of care, and frequent placement changes
3. Broad approaches to help and support within the care system, damage children’s capacity to form attachments and
reinforce their experiences of transience, separation and loss. A meta-analysis
Given the evidence we now have indicating the benefits of programmes of and systematic review found that placement breakdown is predominantly
enhanced foster care, there seems to be a clear case that all children placed associated with child behaviour problems, but is also increased by older age
in foster care should be provided with such care, which will be described at placement, a history of residential care and more previous placements16. A
in more detail in the next sections. But there are broader areas in which longitudinal study17 of nearly 600 foster children found that there were five
172 looked-after children who have experienced adversity can be supported. groups of factors involved in the likelihood of placement success: 173
In particular, ongoing experiences of the care system are a critical factor.
Frequent moves between placements and a caregiving system that fails to
recognise and engage with the child’s mind – i.e. a non-mentalizing system –
are likely to further damage a child’s perhaps already vulnerable capacity to 5 groups of factors involved in the likelihood of placement success
form attachments, and reinforce the child’s experience of transience, loss and
separation. 1. In relation to the child, success is greater if the child wants
to be in placement, if the child has attractive characteristics,
As argued in a recent NSPCC report on the emotional wellbeing of LAC, a and fewer emotional and behavioural problems.
whole system approach to the mental health of the child is required12. This
involves the care system as a whole to regard the emotional wellbeing of LAC 2. In the carer: carers are more likely to be successful if rated
as a clear priority, backed up by regular assessments of the emotional state of highly as social workers for their parenting qualities; were
LAC, and underpinned by education and understanding of mental health needs seen to be ‘child-oriented’ on a questionnaire and had
within the workforce. experience few allegations of abusive practice and few
previous disruptions in previous placements. These factors
Traditionally the approach towards the mental health of LAC has been a remained important after taking into account the child’s
reactive rather than preventative one. Having a more preventative, less characteristics.
crisis-driven system depends upon a joined-up approach, in which what LAC
themselves report about their emotional wellbeing is heard, foster families 3. In the relationship: how well child and carer ‘clicked’, i.e.,
are more supported and schools are integrated. The presence of a school- how well they felt they fitted together.
based mental health worker who is properly trained in the identification

One such programme is the Attachment and Biobehavioural Catch-up (ABC)

4. In the school: placements more likely to succeed if child programme, which was designed to help carers work to support very young
happy at school and carer felt able to encourage them.. children (12-24 months) by supporting their capacity for affect regulation,
Contact with an educational psychologist was strongly helping carers to understand foster children’s apparently alienating behaviour,
associated with an absence of a breakdown (again, after and to override issues that may inhibit their capacity to provide nurturing
taking other factors into account). care. A Randomized Control Trial (RCT) showed that as well as enhancing child
attachment security, the intervention improved diurnal cortisol production,
5. In the birth family: where there was strong evidence of executive functioning and emotional regulation20.
prior abuse and no birth family member was forbidden
contact, breakdown was three times more likely than if it Where the focus of ABC is on attachment, there are other treatment
was forbidden. approaches for younger children which focus on behaviour. One of these is
Parent-Child Interaction Therapy (PCIT), which is for children aged two to
eight years. A short-term intervention based on the social learning thinking,
this seeks to help carers learn communication and behaviour management
Placement breakdown has a mutually reinforcing relationship with mental techniques to positively (through praise and attention) or negatively (through
health difficulties, particularly behavioural problems. The research findings on selective withdrawal of attention and techniques such as ‘time-out’) reinforce
what contributes to the likelihood of placement instability comprehensively behaviour. This intervention has shown promise in terms of behavioural
reinforce the key theme of best practice findings in this area: the vital outcomes in foster children who are manifesting externalising behaviours21.
importance of protective networks of help around the child and the carers.
Multidimensional Treatment Foster Care (MTFC), now known as Treatment
174 The point of transition out of care can be a time of particular vulnerability Foster Care Oregon (TFCO) is one of the most well established enhanced 175
for young people. Support can further fall away at the age of 18 as it’s the fostering programmes. Based on social learning theory, it provides specialist
age at which young people are no longer eligible for CAMHS. As the NSPCC foster carers with training and intensive continuing support. An adaptation
report suggests, this risks creating a “cliff edge” for vulnerable young people of MTFC for preschool aged foster children – the Early Intervention Foster
at the point of transition. The NSPCC report makes a convincing case for local Care Programme (EIFC) – has been found to lead to an increase in the rate
authorities and health services to retain a position of corporate parenting of subsequent permanency of placement (versus placement failure) for the
responsibilities – identifying mental health needs and providing support children in increasing secure attachment and decreasing avoidant attachment
for care leavers up to the age of 2518. The House of Commons Education organisation.
Committee19, in their 2016 report on the mental health of LAC, similarly
concluded that given the particular vulnerability of young care leavers, A large RCT of MTFC for the middle childhood age group found that it led
CAMHS should be available to all looked-after young people until the age of 25. to improved rates of positive placements for the children (return home,
placement with extended family, or adoption), increased the foster parents’
positive reinforcement of the children’s behaviour and reducing the children’s
behaviour problems22. However, a recent RCT of MTFC for adolescents
4. Focused interventions in England found no better outcomes over usual care, although with some
indication that the intervention may have been beneficial for adolescents with
There are several interventions that have been developed to support carers in antisocial behaviour23. However, it has been suggested that this latter finding
meeting the needs of LAC. The move to enhance foster care reflects the growing was statistically underpowered and that further research is needed to shed
awareness that the needs of children and young people who have experienced light on the effectiveness of this programme.24
maltreatment and adversity are not simply met by removing them from their
home. Further help is needed to alleviate the difficulties they may experience. Fostering Changes, which was developed by the Adoption and Fostering

National Team at the Maudsley Hospital, South London, in conjunction References

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Todd, published by Bantam Press. Reproduced by permission of The Random
17 Sinclair, I., Wilson, K., and Gibbs, I. (2004) Foster Placements: Why they succeed and why they
House Group Ltd. It includes a new conclusion written for this collection.
fail. London: Jessica Kinglsey.
18 Bazalgette et al. (2015) Op. cit.
19 House of Commons Education Committee (2016) Mental Health and Well-being of Looked-af-
ter Children: https://publications.parliament.uk/pa/cm201516/cmselect/cmeduc/481/481.pdf Summary
20 Dozier, M., Peloso, E., Lewis, E., Laurenceau, J.-P. and Levine, S. (2008) ‘Effects of an attach-
ment-based intervention on the cortisol production of infants and toddlers in foster care’ Although not widely studied or understood, there is growing awareness
Development and Psychopathology 20(3): 845-859.
that prejudice and lack of support and understanding of the specific
21 Luke, N. et al. (2014) Op. cit.
needs of LGBT+ children and young people causes emotional trauma
22 Chamberlain, P., Price, J., Reid, J. and Landsverk, J. (2008) ‘Cascading implementation of a
foster and kinship parent intervention’ Child Welfare 87(5): 27-48.
that, in turn, leads to higher levels of addiction, depression, anxiety
Price, J. M., Chamberlain, P., Landsverk, J., Reid, J. B., Leve, L. D. and Laurent, H. (2008) ‘Effects
and suicide/ideation which is now at crisis point in the gay/bi male
178 of a foster parent training intervention on placement changes of children in foster care’ Child community. General ignorance and lack of evidence, combined 179
Maltreatment 13(1): 64-75. with misplaced fear of sexualising young people and lack of sex and
23 Green, J. M., Biehal, N., Roberts, C., Dixon, J., Kay, C., Parry, E., et al (2014) ‘Multidimensional relationships education, means that young gay/bi men come out into
treatment foster care for adolescents in English care: randomised trial and observational
cohort evaluation’ British Journal of Psychiatry 204(3): 214-221.
a highly sexualised and substance heavy gay culture that results in
24 Harold, G. T. and DeGarmo, D. S. (2014) ‘Concerns regarding an evaluation of MTFC-A for
higher levels of suicide, drug use and HIV/hepatitis C rates, among
adolescents in English care’ British Journal of Psychiatry 205(6): 498. other things. A groundbreaking and thorough investigation into the
25 Briskman, J. A., Castle, J., Blackeby, K., Bengo, C., Slack, K., Stebbens, C., et al (2013) Ran- experience of LGBT+ people from cradle to grave is urgently needed
domised Controlled Trial of the Fostering Changes Programme: http://reescentre.education. to adequately address these serious health inequalities that have a
ox.ac.uk/wordpress/wp-content/uploads/2014/09/onlinePoorMentalHealthfullreport.pdf
negative impact on NHS resources and greater human impact.
1. What is the problem?

Despite more LGBT+ people than ever before, thank goodness, leading happy,
successful lives, it is becoming increasingly clear that a disproportionate
number are not thriving, as we should.
Something isn’t working. Disproportionately high levels of depression, self-harm

and suicide1; not uncommon problems with emotional intimacy; people keeling

Chapter 13 Straight Jacket: the mental health consequences of LGBT+ prejudice
over dead in saunas; the highest rates of HIV infection2 since the epidemic began population7. We do not know if more LGBT people actually die from suicide,
in the 1980s and now a small but significant subculture of men who are misusing, though a 2013 study by Martin Plöderl and colleagues, Suicide Risk and Sexual
some injecting, illicit drugs3, which, are killing too many people. Orientation, argues that this is the case8.
There is a problem, which has been hiding under plain sight, which needs to be A study (Part of the Picture, 2009–14) conducted on behalf of the LGBT
urgently addressed now. It is the subject of my book4 Straight Jacket: How to be Foundation in Manchester found that LGB people used drugs and alcohol at
gay and happy, published by Bantam Press in 2016. 7times the rate of the general population, and that LGB people were twice as
likely to binge-drink as the general population9. And in 2015 the UK’s leading
Many heterosexual people experience mental health problems, of course, and LGBT mental health charity PACE published the results of its five-year RaRE
indeed, most gay people are not taking drugs, not dependent on alcohol and (Risk and Resilience Explored) study, which showed, among other things,
are neither sex addicts nor bitchy, unhappy miserabilists propping up bars in higher levels of self-harm and suicide among LGBT than other people, and a
desperation over their lonely lives. The opposite is true. More and more of us greater incidence of body disorders in gay/bi men10.
are happy, thriving and leading fulfilled lives. But there are patterns that are
disproportionately common. For although over the last 30 years HIV and AIDS
have been considered the number-one problem, the true public health crisis of
LGBT+ people is that of poor mental health, low self-esteem and the damaging 2. Why is this the case?
ways in which we cope.
All over the world leading experts on emotional trauma, both gay and
At the core of this problem is a shame that has been inflicted upon us so straight, acknowledge that the psychological pressure on LGBT children
powerfully that those of us whom it affects often do not even realise it. It is a is overwhelming. Iconic author John Bradshaw, in Healing the Shame That
180 shame with which we were saddled as children, at school, to which we continue Binds You11, writes that “there is no group more shamed than LGBT kids”. Pia 181
to be culturally subjected, and which is magnified by the pinball-machine gay Mellody, at Arizona’s world-renowned treatment centre The Meadows and
scene and culture that sends some of us spinning from one extreme experience author of Facing Codependence12, says that gay people often feel “shamed by
to the next. As therapist and author Joe Kort has written, what’s wrong is society”, while in the seminal The Velvet Rage, Dr Alan Downs describes gay
not our sexuality itself but our experience of growing up in a society that still men being “overwhelmed by shame” and adds “[Childhood] is the start of the
does not fully accept that people can be anything other than heterosexual and journey for gay men and it is by far the most difficult and damaging [part]”13.
cisgendered (born into the physical gender you feel you are)5.
One of the most profound comments comes from Dr Joe Kort, who writes
There are more straight people than gay with these problems because there in his book 10 Smart Things Gay Men Can Do to Improve Their Lives that gay
are more straight people in the world. The difficulty for LGBT people is that, children are subject to “covert, cultural child abuse”14.
because of our childhood experience of growing up in shame, we are lucky if
we avoid this kind of childhood trauma. What effect does this have? I go into this in more detail in my book15, but in
effect, this constant shame leads to us perceiving ourselves as a threat to our
There is a dearth of research but some studies do exist. In June 2014 Public own existence meaning we are always on guard to possible threats that our
Health England issued the first of a series of reports, which concluded nervous system perceives as being caused by us. We see ourselves as a threat
that gay men were disproportionately affected by ill-health in three main and we begin to hate ourselves. This leads to problems with anxiety disorders.
areas – mental health; HIV and sexual health and the use of alcohol, drugs
and tobacco6. Various other studies in both Britain and the USA have come The natural state for all animals, including human beings, is one of relaxation,
to similar conclusions, pointing to higher risks of suicide, suicide ideation of being in ‘at-ease mode’. But when a threat appears – such as a man coming
(seriously considering killing yourself), self-harm, substance misuse, aggressively towards us wielding a knife – our entire being springs into ‘action
alcohol abuse and mental disorder among LGBT people than the rest of the mode’, sending us into a state of hyper-awareness so that we can make the

split-second subconscious decision either to attack or to run away: fight or “‘Look at the state of you, you camp fuck’. They said ‘How can a faggot have
flight. In other words, we are in a state of heightened anxiety. When the threat a baby?’”
passes, the fight or flight response shuts down and we return to our normal,
relaxed state. The abuse continued even when his body had been found. “On Ask.fm it was
‘Oh, your son was a little faggot, I’m glad he hung himself. One less gay in the
The problem is that the fight or flight response cannot differentiate between a country.’ They were saying to Jodie, ‘Haha, your brother’s a faggot’ and she
real physical threat and one that isn’t real but is just perceived in our heads. A was wailing.”
man coming towards us with a knife is a threat we can deal with – fight him or
get away from him – and the threat passes. But what I believe happens when Anthony is not alone. I believe most LGBT+ children who take their own lives
a child has been self-shamed (for whatever reason: bullied, abused, grown up remain invisible because they do not disclose the cause of their suicide. But
in poverty, etc.) is that subconsciously he has perceived himself as the threat, there are many names we do know about: Dominic Crouch (may or may not
so the threat is something from which he can never escape: he stays stuck in have been gay but was ‘accused’ of it, (15 years old, 2009), Ayden Olsen (14,
constant fight or flight mode. 2013), Elizabeth ‘Lizzie’ Lowe (14, 2013), Sophie Clarke (13, 2016) and many
more. Although more schools have anti homo/bi/transphobic bullying policies
LGBT+ kids have reason to be fearful. Many find themselves under attack and many don’t.
unsupported at school.
Paul Martin of Manchester’s LGBT Foundation estimates that over half
On 25 November 2012 Anthony Stubbs, a sixteen-year-old from Leyland the people accessing the LGBTF’s counselling services in the last year had
in Lancashire, father to a one-month-old baby girl, Lily, disappeared after a attempted to take their own lives and he believes there is often a common
row with his girlfriend. The police didn’t find his body for two months. He underlying cause. “If you scratch the surface with a lot of these guys and girls
182 had hung himself in a local woodland with his PlayStation cord. The media that come to our services,” he told me, “often it started at school, when people 183
speculated that he was stressed about being a young father, but in reality experienced their first form of rejection. That can quite often be followed up
Anthony had been struggling to come to terms with his sexuality and was by family and then the general world.”
being homophobically bullied because of it. He had taken an overdose the year
before and told a nurse he was “sick to death of being bullied” .His mother Despite all the advances that have been made, the Stonewall Teachers’ Report of
Denise Machin told me she had complained to the school when she first 2014 found16:
realised Anthony was being bullied, but she didn’t think anything was done
about it. Almost nine in 10 secondary-school teachers (86%) and almost half of primary-
school teachers (45%) surveyed said pupils in their schools experienced
“They used to slap him on the way home from school, rip his jumpers,” Denise homophobic bullying. The vast majority heard pupils use expressions like
told me. “He’d go up to his room crying. The teachers said they couldn’t do “That’s so gay” and “You’re so gay”. Two thirds of secondary-school teachers
anything because it was outside of school.” and one third of primary-school teachers heard pupils use terms like “poof”,
“faggot”, “dyke” or “queer”.
Denise found explicit texts on Anthony’s phone from men but, having gay
friends herself, she told him it was OK. Towards the end, he came out as More than half of secondary-school teachers (55%) and four in 10 primary
bisexual at school, saying he was “Proud of it!” But this, Denise said, just made school teachers (42%) said they didn’t challenge homophobic language every
the bullying worse. time they heard it.
After his death Denise found abuse on Anthony’s Facebook page. “It was going There is still no mandatory sex and relationships education in schools, which
‘Oh faggot’ and all this,” she said. “‘Gay boy, gay boy, shirt lifter’, all this to him.” leaves LGBT pupils, in particular, even more marginalised. In March 2015
the National AIDS Trust published their Boys Who Like Boys report17, which

surveyed more than a thousand fourteen- to nineteen-year-olds. It found that 2013/14, to have used illicit drugs at three times the rates straight men did20.
over a quarter (27%) did not know how HIV was passed on. Almost a third
didn’t know you can’t get HIV from kissing. Nearly three quarters did not know What is also problematic is that because of the mainstream’s homophobic lack
about PEP treatment (a course of medication you can take up to 72 hours after of interest in the wellbeing of LGBT+ lives and gay culture’s fear of looking at
exposure to HIV). such sensitive and painful issues, our disproportionate problems in this area
have not been widely discussed or investigated. Those suffering have been
A young man called James Hanson said in his response to the survey: “I was left to do so on their own or are turning to generic psychological services who
diagnosed with HIV at the age of 18, I knew very little about HIV at that age. I do not understand the problem or the connection with childhood trauma and
remember very clearly some awful sex ed lessons at school. I was never taught ‘gay shame’ or of the specific needs of LGBT+ populations. This can be even
of the love between 2men or 2women. I was having feelings I didn’t know what more isolating. Young people are left to deal with these problems on their own.
to do with and I felt so isolated because it was never spoken about. Looking Young men, in particular, often then find themselves self-medicating with sex
back now I feel let down.” via apps such as Grindr, sometimes before the age of 16.
There is a growing awareness that trauma at an early age leads to an increased There is a problem. It is bigger than we currently understand. Very little has
risk of addiction – and, crucially, also, that addiction is not simply a problem in been done to investigate it let alone to address it. For instance, I myself have
itself but rather a symptom of an underlying emotional condition; essentially heard of three friends of friends who have either died of a drug overdose or
that addiction is a dysfunctional way of soothing overwhelming distress. from suicide in the six weeks after Christmas 2016. I believe we need a full
enquiry looking at the experience of LGBT+ kids from children, through school,
The ACEs study18 carried out by the Centers for Disease Control and to education, health inequalities, high HIV and Hepatitis C infection rates,
Prevention in Atlanta and Kaiser Permanente (a care consortium based in suicide rates, the experience of the gay scene and racism and body fascism,
184 Oakland, California), claims to have found “staggering proof of the health, how the gay and social media is impacting the situation and more. 185
social, and economic risks that result from childhood trauma”. Seventeen
thousand patients were studied and a strong relationship was found between This problem produces a burden on the NHS but takes an even bigger human
severe childhood trauma and “all kinds of addictions including overeating”. The toll. This is not ‘a gay issue’. LGBT+ people are, on the whole, the children
research found that a child with four or more negative childhood experiences of straight people. This is an issue which society must address now in the
(including incest; emotional, physical or sexual abuse; having an addicted or interests of all of us. It is time for the experience of young LGBT+ people and
mentally ill parent) was over 1.5 times more likely to become obese, five times children to come out of the closet. They are there. They have been ignored.
more likely to become an alcoholic and 46 times more likely to become an They need urgent help.
intravenous drug user than a child with no negative experiences.
In Time magazine, one of the ACE study’s founders, Dr Vincent Felitti,

discussing what type of childhood trauma did the most damage, said, “I would 4. Conclusion: what can be done?
have assumed before we looked at it that probably the most destructive
problem would be incest … but the one with the slight edge, was chronic There is a compelling case for local services to better understand the lives
recurrent humiliation, what we termed as emotional abuse”. of LGBT+ youth, and the mental health needs that arise from the prejudice,
adversity and trauma that they have experienced. Building on the suggestions
Chronic recurrent humiliation is how, I would argue, the majority of LGBT+ in the final section of my book (‘Recovery’), and the ideas in this paper, we
people experience childhood. suggest that commissioners and providers must prioritise:
I discuss how addiction works in my book19 but this, I am certain, is why gay
men, for instance, were found, in the Crime Survey for England and Wales in

a. adopting an LGBT+ affirmative commissioning and service models Binaries of male and female, gay and straight are being challenged by a shift
in young people’s expressions and experiences of gender and sexuality. For
The SAMHSA (Substance Abuse and Mental Health Services Administration) example, over two in five young people aged 18 to 24 years self-identify as
in the US, describes different degrees of LGBT+ sensitivity that mental being neither exclusively homosexual or heterosexual25, which is a contrast to
health and children’s services adopt (see Annex A for a more detailed the last 25 years. This includes the higher number of young men who have sex
overview)21. They advocate for services to be commissioned on the basis with men (MSM) and young women who have sex with women (WSW) who
of ‘LGBT+ affirmation’, which would ensure that services actively promote identify as neither gay, lesbian, nor bisexual.
self-acceptance of an LGBT+ identity and exploration as a key part of their
treatment and care model. Within this training and professional development, there must be a greater
focus on language, which LBGT+ young people might find re-traumatising,
Misattunement to the prejudice LGBT+ youth have experienced by shame-inducing, or might re-trigger memories or experiences of (for example)
professionals has been shown to have a significant impact on the potential being coerced to gender conform. This would include awareness of the ways
for positive outcomes in therapeutic and social services22. As such, LGBT+ in which a young person wants to be described (i.e. using the pronouns he, she,
affirmative models also aim to significantly reduce the risk of staff re-triggering they, ze, zir or describing themselves as non-binary, intersex, queer, cis, trans,
and re-traumatising their clients23. This is achieved by ensuring professionals etc26) and the increasing fluidity in the use of these terms during explorations
are better attuned to the prejudice-related adversity and trauma that the of gender and sexuality, and identity formation.
young people have experienced (including experiences of homophobia,
biphobia, transphobia, hate crimes or micro-aggressions). This also involves Beyond language use, staff should understand and recognise the traumatic
trauma-informed supervision that supports the staff to both explore vicarious impact of prejudice among LGBT+ communities27. This should incorporate trauma
trauma arising from the young people’s experiences and the staff member’s relating to the increased risk, and experience, of violence, micro-aggression,
186 own prejudicial assumptions and behaviours. hostility, intimidation, bullying and shame resulting from growing up in a 187
heterosexist and cis-gendered society. For example the latest Stonewall School
Finally, all commissioners and providers should ensure that counsellors and Report found that around half of all LGBT+ pupils still face bullying at school for
therapists (working in the NHS and/or under the registration of professional being LGBT+ (rises to two in three trans students), with one in 10 receiving death
bodies covering counselling, psychotherapy, psychology, General Practice threats because of their sexuality or gender expression or identity28. Similarly, four
and psychiatry) are adhering to both the Memorandum of Understanding on in five LGBT+ people of all ages have experienced a hate crime, with one in four
Conversion Therapy in the UK24, which regards “efforts to try to change or having experienced a violent hate crime; one in three an online hate crime, and
alter sexual orientation through psychological therapies [to be] unethical and one in 10 exposed to sexual violence as part of a hate crime29.
potentially harmful”, and the updated statements of ethical practice from the
relevant professional bodies. The professional training must also include how to respond in an affirmative
way to disclosures of gender identity or sexuality, which is especially important
if they have encountered hostility or rejection from family members, a
b. investing in LGBT+ trauma-informed education, training and continuing community, peers or other professionals – i.e. A&E staff following self harming
professional development within local services. behaviour or teachers following a mental health crisis at school. Within this
staff need to understand the psychological trauma and shame resulting from
This means ensuring that staff have an adequate level of understanding about covering, having to gender conform, coming-out, internalised prejudice, and
identity exploration and formation during childhood and adolescence, and (for example) the heightened distress some trans young people feel during
the various ways in which young people identify and express their genders or puberty, resulting from people incorrectly assuming or asserting their gender
sexualities. This would include a recognition that identity exploration is a core identity because of physiological changes in their body (especially if the
part of adolescent development, and that any LBGT+ prejudice can have a manifestation of their secondary sex characteristics have not been delayed or
lasting impact on the psychological wellbeing of the young people. suppressed through hormonal interventions).

c. investing in trauma-informed responses to health-harming behaviours While inclusive posters, signage, inclusive options on forms, and resources
go some way to demonstrating that the environment is safe for the young
Young people can engage in health-harming behaviours (including the misuse person, the service must also signal that exploration and discussion around
of substances, risky sexual behaviours, and self harm) in order to make sense issues of gender and sexuality can be met with compassion, understanding and
of, or respond to, the adversity or trauma they have experienced. As a result, openness34. This also means continually asserting that the service is LGBT+
psycho-education within services need to be LGBT-informed, introducing safe through the actions and attitudes of staff. For example, professionals
self-care, self-soothing techniques, self-harm mitigation30 and suicide safety actively challenging incidents of peer-based homophobic, biphobic or
measures as new mechanisms for coping with the emotional dysregulation transphobic bullying through a restorative approach (embedded in a service
that comes with the memories and experience of trauma31. This involves process or protocol) that builds greater understanding of the impact of this
avoiding any judgement of existing coping mechanisms (such as exposure to on young people’s mental health, empathy for the difficult experiences that
sexual risk, being a victim or perpetrator of domestic violence), which could the LGBT+ young person has faced, as well as normalising the development,
intensify or re-trigger feelings of shame, worthlessness, low self-esteem or experimentation and exploration of gender and sexuality during childhood,
body confidence. adolescence and young adulthood35. This should also be the case for
addressing in-group prejudices, where young people’s different characteristics
Professionals must always seek to contextualise these behaviours and or identities intersect. For example, in dealing with the prejudice that many
attitudes within the lived experiences and mechanisms for survival that Black, Asian, Arab and Minority Ethnic (BAME) youth face within the LGBT+
a LGBT+ young person will have acquired in the face of adversity and community, which can deprive them of the only “remaining source of social
prejudice32. This does not mean a young person cannot in time be supported to support” in terms “inducing negative social and psychological outcomes for
take responsibility for their behaviour, but rather this needs first to be located identity processes”36.
in the function that is might have played for them in the context of possible
188 rejection, hostility and prejudice. 189
We continue exploring the intersections between childhood
adversity, different forms of prejudice and trauma in the next
d. establishing safety in services and communities of support section of this collection. Readers should refer to Responding to the
traumatic impact of racial prejudice by Lord Adebowale CBE with
My book explores a number of different models focused on supporting the Dr Marc Bush and Sanjana Verghese (page 199), and Investing in
LGBT+ community to recover from health-harming behaviours. Across all of gender and trauma-informed services by Katharine Sacks-Jones
these models there are two features that commissioners should ensure are (page 219).
embedded into local service offers as part of an LGBT+ affirmative approach: ).
establishing safety, and b). reconnecting with others33.
The first is establishing safety for LGBT+ youth within the service Furthermore, service staff should be aware of the need to maintain
environment. LGBT+ young people are more likely to be hypervigilant when confidentiality when presented with young people’s disclosures of sexual
interacting with services because of the micro-aggressions, hostilities and orientation, gender identity or expression, unless otherwise requested by
prejudice they have experienced in their relationships with others. This can the client. The young person may be disclosing this for the first time, and
lead to low levels of trust in professionals and in some cases an active rejection may not want this to be shared with their peers in the service, their parents
of offers of support because of the perceived threat of further exposure to or their wider community – especially in situations where this may expose
shame, aggression or mistreatment. Therefore, in order to establish safety, them to further hostility or prejudice. Staff have an obligation to respect the
LGBT+ inclusive imagery, messages, attitudes and behaviours need to be seen young person’s disclosure and right to confidentiality, and therefore should
and felt by young people to be weaved into the very fabric of the service. not unwittingly ‘out’ the young person when communicating with other
professionals, parents or carers in their life37.

Once safety has been established LGBT+ young people may feel more able to rejecting and prejudicial behaviours, attitudes and beliefs that caregivers,
talk about the prejudice they have experienced, and the impact it has had on siblings and the wider family may have about the young person and their sexual
their mental health and identity formulation. Sharing experiences, and being orientation, gender identity or expression. The Family Acceptance Project
empathetically witnessed by others, can be a powerful way of reconnecting suggests that this involves sensitivity to the wider social and cultural factors
with peers and (re)establishing friendships based on a commonality of that influence familial rejection. Readers can read more about the interaction
experience or through respecting and accepting diversity and difference. between LGBT+ and racial prejudice in Lord Victor Adebowale’s paper in this
collection.
Some services use peer-support models to achieve this, where a young person
acts as a mentor, supporter, educator, friend, or empathetic listener for a Finally, some young people may find meaning and healing through using their
peer, enabling them to share their experiences and concerns, and is able to experiences to actively change services or communities that continue to
provide low level support, encouragement, LGBT+ affirmation and (where perpetuate LGBT+ prejudice and discrimination. This has been shown to be a
appropriate) signposting onto other services38. It is vital that the peer-mentor powerful tool for re-establishing a sense of belonging within a community, as
(or equivalent) is provided with training and supervision to ensure that they do well as provide young people with positive skills that enhance post-traumatic
not trigger their mentee, and so that they also have the opportunity to process growth and resilience44. To enable this, local services should have relationships
any social or emotional distress (or difficult memories) that are triggered with local social action, or LGBT+ community action programmes (which could
through supporting a peer. include art-based organisations), that a young person could be made aware of
and/or signposted onto, if requested or deemed appropriate.
Other services use parenting groups or networks, family mediation and/
or caregiver support to establish safety within the home environment and
to address the non-acceptance of LGBT+ identity and expression by young
190 people. Familial or caregiver acceptance ensures greater self-esteem, a social 191
support network and protects against mental ill health and health-harming
behaviours in LGBT+ youth39. Pioneering research by San Francisco State
University found that parental or caregiver rejection of LGBT+ youth resulted
in a very high risk of health-harming behaviours and mental ill health by the
time they reach 25 years40. Their research suggests that highly rejected
LGBT+ youth are eight times more likely to have exhibited suicidal behaviours,
six times more likely to report high levels of depression, three times more likely
to use illegal drugs, or be high risk for HIV and sexually transmitted diseases
than accepted LGBT+ peers. Research by the Albert Kennedy Trust in the UK
has shown how familial and parental rejection is also a significant factor in the
risk of LGBT+ homelessness41. Young people have suggested that rejection of
their LGBT+ experience, expression and/or identity can be traumatic, and is
experienced as if they are being rejected for who they are, leading to shame,
humiliation and isolation from their immediate family or caregivers42.
The Family Acceptance Project43 is a community research, education and

intervention model that has developed evidence-based programmes that build
an LGBT+ affirming environment in familial and caregiving relationships. The
approach builds a new understanding between family members, and LGBT+
affirming ways of relating to one another, which constructively challenges

Annex A: LGBT+ Sensitivity Model – adapted and expanded from SAMHSA

(2012)
Model/ Model/
feature LGBT-damaging LGBT-unaware LGBT-naive LGBT-tolerant LGBT-sensitive LGBT-affirming feature
No LGBT+ sensitivity Moderate level of No LGBT+ sensitivity Minimal LGBT+ Moderate level of Highest level of LGBT+
Sensitivity
Sensitivity
LGBT sensitivity sensitivity LGBT sensitivity sensitivity
Antagonistic toward Provider and staff Realisation and Realisation and Several clients and/ Service and staff
LGBT+ youth and do not realise or acknowledgement acknowledgement or staff are open with understand the
their experiences acknowledge that they that they have LGBT+ that they have LGBT+ their LGBT+ identity, experience of LBGT+
Awareness
Awareness
of prejudice and have LGBT+ youth youth using their youth using their and this is welcomed youth, the impact of
adverswity using their services, services services and supported by the prejudice and trauma,
and do not recognise service and respond to
their of prejudice, Awareness is usually disclose and identity
adversity and trauma due to a passionate exploration / formation
LGBT+ staff member with an open, positive
and attuned attitude
Services focus Service assumes Services primarily Services contains no Service accepts Service is fully LGBT+
192 exclusively on
heterosexual
heterosexual
presentations of need
assumes heterosexual
presentations of need
(or tokenistic) specific
LGBT+ treatment
a young person’s
sexual orientation or
and trauma-informed
193
presentations of or concern or concern components or gender orientation, Self-acceptance and
need or concern, pathways and how they want affirmation of an
and excludes LGBT+ Services contains Services contains their identity and LGBT+ identity or
clients no specific LGBT+ no specific LGBT+ Accepting a young expression to be experience is a key
treatment components treatment components person’s sexual described (including part of the support
Services contains or pathways or pathways orientation or gender use of pronouns) model
no specific LGBT+ orientation most likely
treatment components will not be directly Service incorporates Signposts and partners
with local social action
Provision
Provision
or pathways addressed LGBT experiences of

homophobia, biphobia programmes
Dealing with and transphobia
experiences of (associated trauma) Adheres to the
homophobia, biphobia into core service ‘Memorandum of
and transphobia model Understanding on
(associated trauma) Conversion Therapy in
most likely will not be Services contains the UK’
directly addressed some specific LGBT+
treatment components
or pathways
Signposts onto
local social action
programmes
Continued...

Annex A: LGBT+ Sensitivity Model – adapted and expanded from SAMHSA

(2012)
Model/ Model/
feature LGBT-damaging LGBT-unaware LGBT-naive LGBT-tolerant LGBT-sensitive LGBT-affirming feature
Staff training and Staff training and Staff training and Staff training and Staff training and Staff training and
development does not development does not development does development includes development includes development includes
include components include, or includes not include, or tokenistic or limited some components core components on
on LGBT+ identity and tokenistic components includes tokenistic core components on on LGBT+ prejudice, LGBT+ prejudice,
experience on LGBT+ identity and components on LGBT+ LGBT+ prejudice, identity, experience identity, experience
experience prejudice, identity and identity, experience and related-trauma and related-trauma
Staff supervision experience and related-trauma – this includes and
questions (or seeks to Supervision is offered Staff are offered understanding of
invalidate) the identity to staff, but is not Supervision is offered Staff are offered regular supervision, in-group prejudice
and experiences of LGBT+ sensitive, and to staff, but is not regular supervision, that supports them
Training
experienced (for
LGBT+ youth – or is possibly questions (or LGBT+ sensitive that supports them to address vicarious example) by BAME
based on prejudicial seeks to invalidate) and unwittingly to address vicarious trauma and any LGBT+ youth
or discriminatory the identity and questions (or seeks to trauma, but only issues that have been
assumptions / experiences of invalidate) the identity offer limited support triggered by the young Staff are offered
language use is offered LGBT+ youth – or is and experiences of on addressing staff people’s experiences regular supervision,
to staff, but is not based on prejudicial LGBT+ youth – or is prejudice (beliefs, that supports them
LGBT+ sensitive or discriminatory based on prejudicial attitudes and/or to address vicarious
assumptions / or discriminatory behaviours) trauma and any
Training
194 language use assumptions /

language use
issues that have been
triggered by the young
195
people’s experiences
Staff infrequently ask Staff tokenistically Staff tokenistically Staff infrequently Service was designed Experiences and
young people to input or infrequently ask ask LGBT+ youth to asks LGBT+ youth to or improved with the ideas of LGBT+
Involvement
into the design or young people to input input into the design input into the design active involvement of youth are used to
Involvement
improvement of the into the design or or improvement of the or improvement of the LGBT+ youth shape the direction
service, but make no improvement of the service service of commissioning and
effort engage LGBT+ service, but make little service improvement
young people or no effort engage
LGBT+ young people
Re-traumatises LGBT+ Likely to re- Likely to re- Potentially re- Less likely to re- Unlikely to to re-
young people, with traumatises LGBT+ traumatises LGBT+ traumatises LGBT+ traumatises LGBT+ traumatises LGBT+
staff using triggering young people, with young people, with young people, with young people as young people as
Trauma impact
and discriminatory staff unreflectively staff unreflectively staff unreflectively staff and service staff and service
language or using triggering using triggering using triggering are more sensitive are more sensitive
behaviours, and and discriminatory and discriminatory and discriminatory about triggering about triggering
Trauma impact
showing prejudicial language or language or language or and discriminatory and discriminatory

attitudes and beliefs behaviours, and behaviours, and behaviours, and language or language or
showing prejudicial showing prejudicial showing prejudicial behaviours, and the behaviours, and the
attitudes and beliefs attitudes and beliefs attitudes and beliefs impact of prejudicial impact of prejudicial
attitudes and beliefs attitudes and beliefs

References 17 National AIDS Trust (2015) Boys Who Like Boys: a study of where young MSM learn about
sex, relationships and HIV: http://www.nat.org.uk/sites/default/files/publications/Boys_Who_
Like_Boys.pdf
1 c.f. Chakraborty, A., McManus, S., Brugha, T., Bebbington, P. and King, M. (2011) ‘Mental health 18 Felitti, V. J. et al (1998) ‘Relationship of childhood abuse and household dysfunction to many
of the non-heterosexual population of England’ Journal of Psychiatry 198: 143–148. of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study’
Zietsch, B.P., Verweij, K.J.H., Heath, A.C., Madden, P.A.F., Martin, N.G., Nelson, E.C. and Lynskey, American Journal of Preventative Medicine 14(4): 245-258.
M.T. (2012) ‘Do shared etiological factors contribute to the relationship between sexual orien- 19 Todd, M (2016) Op. cit.
tation and depression?’ Psychological Medicine 42(3): 521–532. 20 Home Office (2014) Drug Misuse: Findings from the 2013/14 Crime Survey for England
Liu, R. and Mustanski, B. (2012) ‘Suicidal ideation and self-harm in Lesbian, Gay, Bisexual, and and Wales: https://www.gov.uk/government/uploads/system/uploads/attachment_data/
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Marshal, M.P., Friedman, M.S., Stall, R. and Thompson, A.L. (2009) ‘Individual trajectories 21 SAMHSA (2012) A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay,
of substance use in lesbian, gay and bisexual youth and heterosexual youth’ Addiction 104: Bisexual, and Transgender Individuals: https://store.samhsa.gov/shin/content/SMA12-4104/
974–981. SMA12-4104.pdf
2 Public Health England (2016) HIV in the UK: 2016 report: https://www.gov.uk/government/ 22 c.f Fish, L. S. and Harvey, R. G. (2005) Nurturing Queer Youth. New York: W. W. Norton.
uploads/system/uploads/attachment_data/file/602942/HIV_in_the_UK_report.pdf Ritter, K. Y. and Terndrup, A. I.(2002) Handbook of Affirmative Psychotherapy with Lesbians
3 Bourne, A., Reid, D., Hickson, F., Rueda, S. T. and Weatherburn, P. (2014) The Chemsex Study: and Gay men. New York: The Guilford Press.
drug use in sexual settings among: gay and bisexual men in Lambeth, Southwark and Lewisham: 23 Massachusetts Executive Office of Health and Human Services (2013) A Companion Guide
http://researchonline.lshtm.ac.uk/2197245/1/report2014a.pdf to The Safe and Successful Youth Initiative Best Practice and Strategy Review: http://www.air.
Bourne, A., Reid, D., Hickson, F., Rueda, S. T. and Weatherburn, P. (2015) ‘Illicit drug use in org/sites/default/files/downloads/report/Trauma-Informed%20and%20GLBTQ%20Cultural-
sexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in South ly%20Competent%20Care.pdf
London: findings from a qualitative study’ Sexually Transmitted Infections 91: 564-568. 24 NHS England, NHS Scotland, Scottish Gov, ACC, BABCP, BACP, BPC, BPS, COSRT, GLADD,
4 Todd, M (2016) Straight Jacket: How to be gay and happy. London: Bantam Press. NCS, Pace, Pink Therapy, RCPG, RCPSych, Relate, UKCP (2015) Memorandum of Under-
5 c.f. Kort, J. (2008) Gay Affirmative Therapy for the Straight Clinician: the essential guide. New standing on Conversion Therapy in the UK: https://www.psychotherapy.org.uk/wp-content/
York: W. W. Norton. uploads/2016/09/Memorandum-of-understanding-on-conversion-therapy.pdf
196 6 Public Health England (2014) Promoting the health and wellbeing of gay, bisexual and other 25 YouGov (2015) Omnibus Survey Results: https://d25d2506sfb94s.cloudfront.net/cumu-
lus_uploads/document/7zv13z8mfn/YG-Archive-150813-%20Sexuality.pdf
197
men who have sex with men (summary document): https://www.gov.uk/government/uploads/
system/uploads/attachment_data/file/324802/MSM_document.pdf 26 For more information on language and terminology see the glossary produced by the Proud
7 King, K., Semlyen, J., Tai, S., Killaspy, H., Osborn, D., Popelyuk, D. and Nazareth, I. (2008) ‘A Trust, a charity supporting and advocating for LGBT+ youth: https://www.theproudtrust.org/
systematic review of mental health disorder, suicide, and deliberate self-harm in lesbian, gay resources/glossary
and bisexual people’ BMC Psychiatry 8: 70. 27 Institute of Medicine (2011) The Health of Lesbian, Gay, Bisexual, and Transgender People:
8 Plöderl, M., Wagenmakers, E. J., Tremblay, P., Ramsay, R., Kralovec, K., Fartacek, C. and building a foundation for better understanding. Washington, DC: National Academies Press.
Fartacek, R. (2013) ‘Suicide Risk and Sexual Orientation: a critical review’ Archives of Sexual 28 CFR / Stonewall (2017) School Report: the experiences of lesbian, gay, bi and trans young peo-
Behavior 42: 715-727. ple in Britain’s schools in 2017: http://www.stonewall.org.uk/sites/default/files/the_school_re-
9 For more information see: http://lgbt.foundation/policy-research/part-of-the-picture port_2017.pdf
10 Nodin, N., Peel, E., Tyler, A. and Rivers, I. (2015) The RaRE Research Report: LGBandT 29 Galop (2016) The Hate Crime Report 2016: homophobia, biphobia and transphobia in the UK:
mental health – risk and resilience explored: http://www.queerfutures.co.uk/wp-content/up- http://www.galop.org.uk/wp-content/uploads/2016/10/The-Hate-Crime-Report-2016.pdf
loads/2015/04/RARE_Research_Report_PACE_2015.pdf 30 Public Health England / Royal College of Nursing (2015) Preventing Suicide Among Trans
11 Bradshaw, J. (2006) Healing the Shame That Binds You. Florida: Health Communication Inc. Young People: a toolkit for nurses: https://www.gov.uk/government/uploads/system/uploads/
attachment_data/file/417707/Trans_suicide_Prevention_Toolkit_Final_26032015.pdf
12 Mellody, P., with Wells Miller, A. and Miller, K. (2002) Facing Codependence: what it is, where it
comes from, how it sabotages our lives. New York: HarperCollins. 31 Chakraborty, A., McManus, S., Brugha, T., Bebbington, P. and King, M. (2011) ‘Mental health of
the non-heterosexual population of England’ The British Journal of Psychiatry 198(2): 143-
13 Downs, A. (21012) The Velvet Rage: Overcoming the pain of growing up gay in a straight man’s 148.
world (second edition). MA. Da Capo Press.
32 Nodin, N., Peel, E., Tyler, A. and Rivers, I. (2015) The RaRE Research Report: LGBandT mental
14 Kort, J. (2013) 10 Smart Things Gay Men Can Do to Improve Their Lives. New York: Magnus health – risk and resilience explored. London: PACE.
Books.
33 Following the trauma recovery model advocated by: Herman, J. (2015 [1992]) Trauma and
15 Todd, M (2016) Op. cit. Recovery: the aftermath of violence – from domestic abuse to political terror. New York: Basic
16 Stonewall (2014) The Teachers’ Report 2014: homophobic bullying in Britain’s schools: https:// Books.
www.stonewall.org.uk/sites/default/files/teachers_report_2014.pdf

Chapter 13
See also Bloom, S. L. and Farragher, B. (2013) Restoring Sanctuary: A new operating system for
trauma-informed systems of care. New York: Oxford University Press, and Bloom, S. L (2013) 14. Responding to the traumatic impact of
racial prejudice
Creating Sanctuary: Toward the evolution of sane societies. Oxon: Routledge.
34 c.f. National LGBTI Health Alliance (2013) LGBTI People Mental Health and Suicide: briefing
paper (second edition): https://www.beyondblue.org.au/docs/default-source/default-docu-
ment-library/bw0258-lgbti-mental-health-and-suicide-2013-2nd-edition.pdf?sfvrsn=2
35 c.f. Stonewall (2015) Getting Started: a toolkit for preventing and tackling homophobic, bipho-
Lord Adebowale CBE and Dr Marc Bush,
bic and transphobic bullying in secondary schools: https://www.stonewall.org.uk/sites/default/ with Sanjana Verghese
files/getting_started_-_a_toolkit_for_secondary_schools.pdf
36 c.f. Jaspal, R. (2017) ‘Coping with perceived ethnic prejudice on the gay scene’ Journal of LGBT
Youth 14(2): 172-190.
37 NCTSN (2014) LGBTQ Youth and Sexual Abuse: information for mental health professionals:
http://www.nctsn.org/sites/default/files/assets/pdfs/lgbtq_tipsheet_for_professionals.pdf
1. Childhood adversity and racial prejudice
38 Mind (2016) Making Sense of Peer Support: https://www.mind.org.uk/media/4782929/
mind_making_sense_of_peer_support_2016.pdf Racial stereotypes pervade media and public discourse surrounding people
Girlguiding / YoungMinds (2016) Think Resilient: take it forward (activities for Leaders): experiencing mental health problems, and even determine whether they will
https://www.girlguiding.org.uk/globalassets/docs-and-resources/programme-and-activities/ get access to support, and the quality of care they will receive.
think-resilient-take-it-forward-2016.pdf
39 Ryan, C., Russell, S. T., Huebner, D., Diaz, R. M. and Sanchez, J. (2010) ‘Family acceptance in
Young people frequently find themselves labelled by officials and professionals
adolescence and the health of LGBT young adults’ Journal of Child and Adolescent Psychiatric
Nursing 23(4): 205-13. as being ‘hard to reach’, ‘marginalised’ or ‘radicalised’. They are told by those in
40 Ryan, C., Huebner, D., Diaz, R. M. and Sanchez, J. (2009) ‘Family Rejection as a Predictor of authority that their attitudes and behaviours are highly ‘sexualised’, ‘criminal’
Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual Young Adults’ and/or ‘pathological’1. This culminates in Black, Asian, Arab, and other minority
Pediatrics 123(1): 346-52
ethnic (BAME) children and young people growing up in a climate where they
198 41 The Albert Kennedy Trust (2015) LGBT Youth Homelessness: a UK national scoping of cause,
prevalence, response, and outcome: http://www.akt.org.uk/webtop/modules/_repository/doc-
regularly experience fear, prejudice and discrimination. Consequently, they are 199
uments/AlbertKennedy_researchreport_FINALinteractive.pdf confronted with harsher responses from public services, and those whose role
42 SAMHSA (2014) Practitioner’s Resource Guide: helping families to support their LGBT chil- it is to keep them safe or support them during a time of crisis.
dren: https://familyproject.sfsu.edu/sites/default/files/FamilySupportForLGBTChildrenGuid-
ance.pdf
These labels about the perceived ‘morality’ of BAME youth are compounded
43 For more information about the project see: https://familyproject.sfsu.edu
by commonly held misperceptions amongst the public about the size of the
44 c.f. Herman, J. (2015 [1992]) Op. cit.
BAME population, and the prevalence of minority faiths, in Britain today. For
example, a recent survey of the British public found a misperception that 31%
of the population is BAME (in fact it is 11%), and similarly that the number of
people identifying as Muslim was 24% (compared to the reality of just 5% of
the British population)2.
Misrepresentations of BAME communities in the mainstream media can

quickly lead to moral panics about the lives, morality, behaviours and attitudes
of BAME young people3. We need only look at fears exposed about the
welfare dependency of vulnerable children who are seeking refuge in Britain
because of the conflict in Syria, or the skewed coverage of the radicalisation
among British Muslim youths, without due regard to their experiences of
Islamophobia, or the reported spike in hate crimes following the referendum
on our membership of the European Union.

Chapter 14 Responding to the traumatic impact of racial prejudice
The real problem with this misrepresentation is that it stigmatises BAME are from a BAME family14. Your parent(s) or carer(s) is significantly more likely
young people, and deflects attention away from the true extent of the to be unemployed (12.9% compared to 6.3%), or if they are in work they will be
inequalities and prejudice that they face in our society4. Moreover, racial earning less than their white colleagues. This economic disadvantage results
prejudice within society, and discrimination within services, results in the in children from Pakistani, Bangladeshi (30.9%) and Black (26.8%) households
overrepresentation of BAME young people in situations where they are more being more likely to live in substandard and overcrowded accommodation than
likely to be exposed to different forms of adversity during their childhood. White families (8.3%).
For example, recent data from the Department for Education5 found that Together the social and economic disadvantage that arises from
students from a mixed White and Black Caribbean heritage were over two discrimination, and acts of prejudice, produces an environment that is
times more likely to be permanently excluded than the school population as a “extremely harmful” to the mental health and emotional wellbeing of young
whole. Pupils from a Black Caribbean heritage were two times more likely to BAME children and young people15.
be excluded for a fixed period, and three times more likely to be permanently
excluded as compared to students from all other ethnic groups. Needless to say, racial prejudice is not a White on Black phenomena. There is a
wealth of literature exploring the tensions and prejudices between and within
While there has been a welcome reduction in the number of under 18 year BAME communities in the UK. Sometimes the complexity of racial prejudice
olds being held in youth custody, children from BAME groups are similarly is under-theorised because we lose sight of the fact that the categories ‘Black
overrepresented in secure children’s homes, training centres and young British’, ‘White British’, ‘Asian British’, etc actually represent an ethnically
offender institutions6. Within these settings they are also more likely to diverse group of people, incorporating a wide variation of ethnic heritages and
be restrained that their White peers7. In youth justice proceedings, Black traditions.
defendants, and those with a mixed heritage, are more likely to be remanded
200 in custody than White defendants, despite having a higher chance of being 201
acquitted at court8.
2. Multiple adversity of asylum-seeking and refugee
There is, however, variation within BAME groups. For example, pupils of Asian
ethnic groups have the lowest rates of permanent and fixed period exclusion,
children
and are underrepresented in contacts with Youth Offending teams9. These
differences can be partly explained by prejudicial attitudes and behaviours, Children who migrate to the UK, take refuge here, or seek asylum may face
with police being more likely in practice to give a reprimand or final warning racial prejudice for the first time, or it may trigger memories of the prejudice
to Asian young offenders, and less likely to Black and mixed heritage young they have faced in their country of origin. The rise in the number of BAME
offenders, compared to their White counterparts10. looked-after children has been attributed to the increase in unaccompanied
asylum-seeking children in care, with 3,440 unaccompanied asylum-seeking
Studies in England had found no significant relationships between ethnicity children entering care, and 1,980 leaving care in 201616.
and prevalence of adverse child experience11 or poor adult mental wellbeing12.
However, a wealth of literature has shown that the cumulative experience of An analysis of mental health need at Immigration Removal Centres, by
racial prejudice (and continued exposure to discriminatory practices) in itself the Centre for Mental Health, demonstrates that most will have already
creates significant adversity, and has a lasting impact on the mental health and experienced multiple adversities in the country of origin, on the journey to
wellbeing outcomes of BAME young people13. the UK, and admission to, or detention in, the UK. As a result they will have
experienced traumatic stress, and many will have acquired a mental health
This is compounded by the economic hardship and higher levels of deprivation problem, or an existing condition will have escalated or reached a point of
faced by many BAME families. Recent analysis by the Equality and Human crisis17.
Rights Commission found that you are still more likely to live in poverty if you

Experts working in the area of mental health and asylum-seekers or refugees, The acute and chronic stress resulting from experiences of prejudice can result
list the following as common pre-migration and post-migration adversities in common childhood mental health conditions, for example anxiety disorders
(the 7D’s) that can have an impact on the mental health of children and young or depression. It can also produce harder to identify symptoms of traumatic
people18. stress, which are the emotional responses to forms of prejudice. The exposure
to trauma (resulting from racial prejudice) can take many forms. From a
discrete or repeated experience that has a lasting impact on the emotional
Table 1: Common pre- and post-migration adversities and psychological state of the young person, to more subtle and insidious
micro-aggressions that are not immediately seen by the perpetrator to be
prejudice21. This might include discriminatory treatment within schools or by
Common pre-migration Common post-migration
adversities adversities social services.
• War • Discrimination A recent analysis by the Centre on Dynamics of Ethnicity at the University
• Imprisonment • Detention of Manchester, demonstrates that racial discrimination has a cumulative,
and corrosive, effect on the mental health outcomes of ethnic minorities22.
• Genocide • Dispersal
Importantly, the researchers note that the fear associated with experiencing
• Physical and sexual violence • Destitution another incident of racial prejudice had the biggest cumulative impact. This
• Witnessing violence to others • Denial of the right to work shows that the trauma of the initial incident(s) entrenches hypervigilance and
• Traumatic bereavement • Denial of healthcare produces traumatic stress responses.
• Starvation • Delayed decisions on asylum
For example, in 2016 those from BAME groups were three times more likely
applications
202 • Homelessness
to be stopped and searched as those who were White23. Shockingly, this 203
• Lack of healthcare rises to six times more likely to be stopped if you are of Black or Black British
heritage24. The likelihood of being stopped is so much higher for Black young
people, because searches of people from BAME groups fell by just 13%
Around three in four UK asylum applicants are from countries in conflict, between 2015 and 2016, compared to 38% among people identified as White.
and the pre-migration adversities that a child might face (i.e. witnessing or From what we know about traumatic stress, some Black young people will be
experiencing violence), are further entrenched through the experience of experiencing higher levels of hypervigilance resulting from both the actual
prejudice within British society (because of both their BAME, refugee, asylum experience of being stopped and searched, and the perceived threat of being
or migrant status), and through either additional post-migration adversities subjected to this again in the future.
(i.e. being taken into care) or the treatment of services (i.e. in Immigration
Removal Centres or by children’s social care). Children and young people experiencing racial prejudice may develop
symptoms of traumatic stress, including:
• intrusive memories or flashbacks to experience(s) of racial prejudice.

3. Traumatic impact on young people’s mental health
• symbolic and nonverbal enactment of traumatic racial prejudice
International systematic reviews and meta-analyses, have demonstrated that through the use of play or in relationships with significant others.
experience of racial prejudice and discrimination is a determinant of poor
mental and psychical health outcomes19; even when controlling for other • distressing dreams and reoccurring night terrors where features of the
factors like age, gender and level of education20. dream relate to their experiences of prejudice.

• avoiding situations, or people in authority, who trigger memories of 4. Recognising intersectional trauma and in-group prejudice
these traumatic experiences.
The cumulative trauma of racial prejudice is further complicated by
• intense feelings of detachment, disassociation or estrangement from intersectionality, and prejudice within BAME communities. For example, we
others. know that many Lesbian, Gay, Bisexual or Transgender (LGBT) young people
of BAME heritage face both the intersectional trauma of homophobia and/
• perceiving threats from those in authority and an exaggerated or transphobia within their BAME community (on the basis of their sexuality
suspicion about the motives or intentions of those in authority who or gender identity or expression) and racism within the LGBT community (for
offer support. their BAME embodiment or identity)32. This complexity is reflected in the
higher risk, for example, of suicide among gay Black men33.
• becoming quickly irritable or angry towards people or objects with
little provocation, and engaging in reckless or self-destructive Similarly, coercive cultural traditions have continued to be an issue for many
behaviours. girls and young women of Asian heritage. In five cases handled by the Forced
Marriage Unit related to the possible forced marriage of girls or young
women34, and a quarter of all cases were children and young people under the
Studies have demonstrated that racial prejudice acts as a catalyst for both age of 18 years. By far the majority of cases related to families from Pakistan
trauma-related systems25, and perhaps also explains the higher prevalence (43%) and Bangladesh (8%). Within small pockets of these communities in
of Post Traumatic Stress Disorder (PTSD) amongst BAME adults, and in Britain girls face the dual adversity of experiencing racial prejudice from
particular those of Black or Black British heritage (8.3% compared to 4.2% others outside of the community due to their ethnic heritage, and within the
White adults)26. community discriminatory attitudes and highly coercive behaviours because of
204 their gender. 205
There have been lively debates over differential diagnoses of these symptoms
of traumatic stress among BAME patients. Researchers from the US have, Finally, over the last decade there has been an increase in the number of
for example, created a classification of Race-Based Traumatic Stress Injury children growing up in inter-ethnic families35. Historically, we know that
(RBTSI), which is differentiated from PTSD by a core stressor of emotional inter-ethnic couples and their mixed heritage children have faced significant
pain resulting from prejudice, rather than a threat to life27. Others have prejudice and discrimination within the communities of origin. Despite
proposed a Developmental Trauma Disorder (DTD) to describe experience of increased visibility in society and the media, the prejudice continues today,
chronic developmentally adverse traumatic events occurring in childhood and with many inter-ethnic families reporting hostility, confusion or non-
frequently within the child’s caregiving system and/or immediate community acceptance of children in BAME communities. Today around one in 10 couples
life28. are inter-ethnic, and (perhaps reflecting a commonality of experience) young
people from mixed or multiple ethnic groups are most likely to be in an inter-
In reality children are rarely diagnosed with PTSD, and as it stands neither ethnic relationship in adulthood (85%).
DTD nor RBTSI have been included in the official classification systems
compiled by the American Psychiatric Association29 nor the World Health An important report by the National Children’s Bureau (NCB) tracks the
Organisation30. It is estimated that around one in six children and adolescents mental health impact of racism, discrimination and identity confusion
develop PTSD after being exposed to a traumatic event31, however many more experienced by children and young people of a mixed heritage background36.
develop mental health problems that result from experiences of traumatic This can include the emotional distress that arises from confusion over ethnic
stress. identity, experiencing racism and making sense of their own enactments of
racial prejudice as a mixed ethnic child.

Those facing intersectional prejudice frequently report hostility and responding to this behaviour – keeping in mind that feelings of uncontrollable
non-acceptance from their communities. This compounded isolation can anger can be a response to trauma.
expose young people to (often contradictory) forms of direct prejudice and
discrimination that reduce the availability of places of safety within the
community, and increases the adversity they will face (frequently experiences
of threat, violence or coercion). These experiences all heighten the symptoms 6. Discrimination within mental health services
of traumatic stress.
The prejudice that BAME young people face in wider society is mirrored
in both children’s and adult mental health services. BAME children are
underrepresented in Child and Adolescent Mental Health Services (CAMHS)
5. The cyclical impact of traumatic stress and overrepresented in adult mental health services40. Similarly, there is an
overrepresentation of Black mental health patients compulsorily detained in
The trauma of racial prejudice is cyclical, in that the normative responses forensic and secure services41. This is partly explained by the more complex
to emotional distress are misinterpreted by those in authority as signs of pathways into psychiatric care that BAME patients face42. This additional
noncompliance, aggression or non-engagement37. complexity of pathways includes more frequent involvement of the police
or criminal justice system43, higher rates of compulsory detention, and
There is a wide body of literature38 showing how chronic hypervigilance Black patients being more likely to be secluded44 and restrained45 as part of
effects the functioning of the prefrontal cortex. This means young people’s their detention in psychiatric services. For example, recent analysis by the
ability to focus on the cognitive tasks and decision making demanded by the University of Sheffield46 found that Black patients were three times more likely
school curriculum or the youth justice system will be significantly reduced. to be compulsorily admitted under the Mental Health Act in 2010-11.
206 Furthermore, the hyperarousal associated with traumatic stress makes it 207
more difficult for a young person to deescalate in a confrontation. When we Research from the UK has shown that patients from BAME communities were
add this to the general higher levels of impulsiveness during adolescence 30% to 83% more likely to access mental health services through the criminal
it is understandable that some of these young people will respond to their justice system than their White peers47. The Sainsbury Centre for Mental
emotional distress with bursts of aggression, hostility or withdrawal39. Health found that patients from African Caribbean backgrounds are more
likely to be “misdiagnosed and diagnosed with psychotic conditions”48, and as
We also know that if a child is met with an uncompassionate or further a consequence treated using medication at a higher dosage than their White
discriminatory attitudes by those in authority, it can heighten suspicion counterparts49.
over the motives of professionals, or rekindle the feelings of helplessness
or powerlessness they experienced in the original traumatic situation. With Similarly, a recent study of four Early Intervention Services (EIS) for psychosis
this in mind, we can only break the cycle of traumatic stress by correctly found that Black patients were three times more likely to be detained and
identifying these young people’s behaviours and emotions, as expected and hospitalised compared to their White counterparts. This increased likelihood
understandable responses to the trauma of a childhood adversity, and/or the was related specifically to more complex pathways into care, and differences in
cumulative experience of racial prejudice. help-seeking behaviours among BAME communities50.
So rather than simply marking DNA (did not attend) next to the name of Worryingly, young Black Caribbean men are three times more likely to have
a young person who does not turn up for a therapy session, we should be been in contact with mental health services in the year before suicide, and
inquiring as to whether the environment and form of therapy is appropriate Black African psychiatric inpatients are twice as likely to commit suicide as
for the young person. Instead of labelling a young person as being ‘aggressive’ their White peers51.
or having ‘challenging behaviour’ we should ask what in their experience is
being triggered in their interaction with us, and how we are describing and

7. Variations in health-seeking behaviours self-soothing by talking aloud57. The Sainsbury Centre for Mental Health in
their Breaking the Circles of Fear report describe how this leads to a relationship
Many BAME families and communities have a different cultural understanding of mutual distrust and hostility between African-Caribbean patients and
of mental ill health, and the fear of being labelled (for example) ‘mad’ or mental health staff58.
‘possessed’, or being ostracised by the community can act as a significant barrier
to seeking support from GPs or specialist mental health services. Likewise, Echoing this, the Lambeth Black Health and Wellbeing Commission found that
some childhood adversities are underreported as BAME communities fear that experience of discrimination in the community led to local Black youth being
mental health and public services do not understand the cultural significance fearful of formal CAMHS support. They highlighted the benefits of investing
of what we might see as complex and traumatic experiences, including Female in more informal drop-in services that reduce the stigma of accessing support
Genital Mutilation (FGM), so-called ‘honour-based’ violence, scarification and in the community, provide a more equal ground for engagement, and help to
forced marriage. The fear, stigma and shame associated with mental ill health prevent the escalation of needs59.
and childhood adversity in some BAME communities leads parents to actively
avoid interactions with mental health services to circumvent a diagnosis and
possible exclusion from community life52.
8. Becoming culturally sensitive and trauma-informed
Furthermore, some families turn to faith-based organisations for support
during a mental health crisis. A survey by the African Health Policy Network In order to better identify and support the mental health needs of children and
found that 60% of respondents would ‘most likely’ turn to a community group, young people who face racial prejudice, mental health and public services in
and 50% a faith group53. This might be because they feel more comfortable England must become both culturally sensitive and trauma-informed.
speaking to people from their community, or because they see the symptoms
208 as part of their supernatural or faith beliefs54. In some areas there remains As a starting point we recommend that all commissioners adopt the 209
animosity between mental health services and faith leaders, and this only Guidance60 issued by the Joint Commissioning Panel for Mental Health, which
frustrates early intervention for children. That said, the Government’s is chaired by Royal College of General Practitioners (RCGP) and the Royal
initiatives (for example) to tackle FGM alongside community leaders is proving College of Psychiatrists (RCPsych). Included in this guidance is a welcome
to ensure quicker access to specialist support55. suggestion that commissioners invest in public mental health interventions
that focus on “reducing or moderating the adverse impact of social and
Given this, concerns remain that many interpreters and translators do not material adversities (including racism) on these communities”.
have experience of working in mental health. As such, they may unwittingly
use language that a family or young person would find culturally stigmatising Supplementing these, we draw on what we have learnt from the experiences
or shaming. Likewise, families report a reluctance in relying on bilingual family of BAME young people and families, to propose below additional principles
or friends as this could disclose to the wider community an illness that could that commissioners and providers alike should adopt to help to tackle racial
lead to the isolation or discrimination of the family. Furthermore, parents prejudice and address its traumatic impact.
report that the nuances of (for example) decisions about voluntary and
involuntary admission to specialist mental health wards, and the implications
on parental rights, or the distance of specialist placements are frequently lost a. Raising awareness of the traumatic impact of racial prejudice
in translation.
Commissioners and providers should be aware of their existing responsibilities
Finally, because of the trauma of perceived and actual prejudice many BAME under the Equality Act61 and Human Rights Act62 in respects to non-
young people experience fear about receiving a negative response from the discrimination, and that it is enshrined as a right of patients and responsibility
GPs and other health practitioners56. They may also fear the misreading of of NHS staff in the NHS Constitution for England63.
social behaviours by frontline mental health staff, for instance the practice of

All public service professional working directly with children and young interventions, and ensure that service design is culturally sensitive – including
people should have a baseline knowledge of both racial prejudice and the the use of non-traditional modes of delivery. For example, the Time To
adverse and traumatic impact it can have on the mental health of young people Change 300 Voices project65 co-developed with young men of African and
and their families. initial professional training and Continued Professional Caribbean heritage is an engagement model for mental health professionals
Development (CPD) must include a more detailed understanding of the impact and the police. This model aims to reduce the stigma of seeking mental
of trauma on young people’s thoughts, emotions, behaviours and embodiment. health support within the African and Caribbean communities in the UK, and
Furthermore, it should require an interrogation of professionals’ own uses appreciative inquiry, restorative justice, storytelling and community
experiences of, or attitudes towards racial difference and prejudice. engagement to challenge the prejudicial attitudes and behaviours of
professionals.
Dr Janet Helms64 and colleagues identified the interaction styles used by
mental health professionals when assessing people who had faced trauma
and adversity (see annex A). They describe how young people might respond c. Collaborating with local communities
to these different behaviours of mental health professionals. The researchers
suggest that we need to be aware of our own prejudice in order to successfully Experience and research clearly demonstrates that mental health
navigate the identification and treatment of prejudice-related trauma, and to interventions in BAME communities are most successful when they
bring these encounters to a non-confrontational and supportive (progressive) meaningfully engage the community in the design and delivery of services and
approach. In this way, awareness of one’s own prejudice is important as it support66. Similarly, service design should understand the collective adversity
can mitigate the potential for re-traumatising young people and further and trauma that communities have faced, and use this to inform the delivery
entrenching mental ill health they may experience. mechanism and the partnerships they create to build trust and confidence in
the community. For example, South West London and St. George’s NHS Mental
210 Within this, prejudicial and professional assumptions need to be challenged Health Trust co-designed with the local Tamil community a culturally-informed 211
about understandings of behaviours that are frequently labelled as hyper- model of the Improving Access to Psychological Therapies (IAPT) initiative in
sexualised, criminal, pathological. For example, professionals need to be Wandsworth and Merton67.
sensitive to the paradoxical ways in which membership of a gang can create for
young people a sense of safety and belonging that traumatically bonds them to The service, named Manashanthy (mind-peace) recruited Tamil speaking
their peers. Peer violence and aggression towards authority here may be more cognitive behavioural therapists who provided workshops at the Wimbledon
about retaining or strengthening a traumatic bond, and making sense of the Shree Ganapathy temple (and other local community and faith centres) to
prejudice they have experienced, rather than the morality of the young person the Tamil community. A community development worker and services leads
or the BAME community that they are identified with. ensured that the project established good working relationships with wider
health services (including GPs), specialised services (including Freedom from
Torture and the Tamil Welfare Organisation) and community leaders. The
b. Navigating cultural stigma and shame workshops provided information on how the community could access IAPT
services, as well as giving a culturally-sensitive introduction to mindfulness
Services and professionals need to better understand the stigma that techniques and importantly psycho-education about traumatic stress and
surrounds mental ill health in some BAME communities, and how disclosure PTSD. Subsequently, the community were able to access both community and
or treatment risks isolation, estrangement and victimisation within the specialist led trauma support.
community. Similarly, for some the adversity that is or has been faced will be
a cause of significant cultural shame both within their community and wider Similarly, the Up My Street projects evaluated by Centre for Mental Health
society (i.e. child sexual exploitation or inter-ethnic violence). demonstrate the importance of providing culturally and psychologically-
informed safe spaces encouraging aspiration, openness and positive
On this basis interventions need to be wary of overly medicalising relationships between young black men who had overcome adversity68.

Finally, the involvement of community groups becomes especially important Annex A

for those young people who are facing intersectional prejudice or adversity.
This might include BAME LGBT+ youth, or girls facing coercion or violence Table 2: interaction styles between Mental Health Professionals and BAME
within families. young people (adapted from Helms et al, 2012)
d. Ensuring early access to specialist trauma-informed care Description Mental Health Professional
(MHP) behaviours
Young person reactions
MHP and young MHP meets the young Young person will
Type of interaction
Parallel
Where a young person or community has faced a specific adversity or trauma person understand person on common ground, experience the assessment
it is vital that they get access to specialist trauma-informed care. Those who the factors related to but must be careful not environment as supportive,
the racial or cultural to collude in avoiding but may not be forthcoming
experienced complex and enduring forms of trauma (including witnessing or trauma similarly. the details of the trauma with vital information if the
being a victim of torture in their country of origin) need swift and continued experience. evaluator colludes with her
access to trauma support and therapeutic services. For example, Freedom or him in denying the racial
or cultural aspects of the
from Torture, which is a charity operating from London, Glasgow, Manchester, situation.
Newcastle and Birmingham provide a programme of structured and creative MHP, as the person MHP attempts to impose Young person experiences
Regressive
therapeutic support to children and young people, in many cases alongside in power, ignores his or her understanding of the assessment environment
the racial or cultural racial or cultural events on as unsupportive and
existing interactions with statutory services.
aspects of the the trauma victim, possibly withdraws.Typically, such
situation and tries to because the evaluator’s assessment environments
convince the victim life experiences have been are re-traumatising and
that such factors different and the victim’s the victim may engage in
are irrelevant to the understanding of her or some of the reactions that
212 situation. his own experiences are occurred with the original 213
threatening in some way. trauma.
MHP and young MHP assessment and/or Surviving trauma victims
Crossed
person are exact treatment of the young may withdraw from the
opposites in person may be punitive, interaction, which may
their reactions or perhaps not purposefully. be manifested as not
understanding of Because he or she is talking, avoiding contact
the traumatic event opinionated with respect to with service providers, or
and, consequently, the racial or cultural aspects increased manifestation of
react to one another of situations and cannot set psychological symptoms,
from a combative or aside those opinions, the such as depression.
suspicious position. evaluator is unable to assess
the situation from the young
person’s perspective.
Supportive MHP attends to person’s Young person experiences
Progressive
assessment racial/ cultural issues and these environments as
environments attempts to create an supportive, but may engage
characterised by environment conducive in tests to determine
efforts by the MHP to discussing race and whether the MHP is
to understand the culture. The MHP is able to authentic. Tests might
young person’s ask questions about racial include saying negative
racial and cultural or cultural conditions of things about people from the
experiences of trauma the situation, even if the MHP’s ethnic group to see
even when they might perceived antagonists in how they will react.
not be evident to the such situations are people
person manifesting who are racially or culturally
such symptoms or similar to the MHP.
reactions.

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FINDINGS%20Dangerous%20Associations%20Joint%20Enterprise%2C%20gangs%20 18 McColl, H., McKenzie, K. and Bhui, K. (2008) ‘Mental healthcare of asylum-seekers and
and%20racism.pdf refugees’ Advances in Psychiatric Treatment 14: 452-459: http://apt.rcpsych.org/content/
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4 Equality and Human Rights Commission (2016) Race rights in the UK (Submission to the UN British Journal of Psychiatry 180: 475 – 477.
Committee on the Elimination of Racial Discrimination in advance of the public examination of
the UK’s implementation of ICERD): https://www.equalityhumanrights.com/sites/default/files/ Bhui, K. (2016) ‘Discrimination, poor mental health, and mental illness’ Journal International
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5 Department for Education (2016) Permanent and fixed-period exclusions in England: 2014 20 c.f. Paradies, Y., Jehonathan, B., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta,, A., Kelaher,
to 2015 (National tables: SFR26/2016): https://www.gov.uk/government/uploads/system/ M. and Gee, G. (2015) ‘Racism as a Determinant of Health: a systematic review and meta-anal-
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6 Ministry of Justice / Youth Justice Board (2017) Youth Custody Report: https://www.gov. 21 Scurfield, R. M., and Mackey, D. W. (2001) ‘Racism, trauma and positive aspects of exposure
uk/government/uploads/system/uploads/attachment_data/file/597266/youth-custody-re- to race-related experiences: Assessment and treatment implications’ Journal of Ethnic and
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7 House of Commons Justice Committee (2013) Youth Justice (inquiry report): https://www. 22 Wallce, S., Nazroo, J. and Bécares, L. (2016) ‘Cumulative effect of racial discrimination on the
214 publications.parliament.uk/pa/cm201213/cmselect/cmjust/339/339.pdf mental health of ethnic minorities in the United Kingdom’ American Journal of Public Health
106(7): 1294-1300.
215
Mind (2013) Mental Health Crisis Care: physical restraint in crisis: https://www.mind.org.uk/
media/197120/physical_restraint_final_web_version.pdf 23 For further detail on concerns over the use of Section 60 of the Criminal Justice and Public
Order Act, see: http://www.runnymedetrust.org/section-60-stop-and-search-powers.html
8 May, T,. Gyateng, T. and Hough, M. (2010) Differential Treatment in the Youth Justice System
(EHRC research report 50): https://www.equalityhumanrights.com/sites/default/files/re- 24 Home Office / ONS (2016) Police Powers and Procedures, England and Wales: https://www.
search_report_50_differential_treatment_in_the_youth_justice_system.pdf gov.uk/government/uploads/system/uploads/attachment_data/file/562977/police-pow-
ers-procedures-hosb1516.pdf
9 MoJ / YJB (2017) Op. cit.
25 Helms, J. H., Nicolas, G. and Green, C. E. (2012) ‘Racism and Ethnoviolence as Trauma: Enhanc-
10 Feilzer, M. and Hood, R. (2004) Differences or Discrimination?: minority ethnic young people ing professional and research training’ Traumatology 18(1): 65-74.
in the youth justice system. London: Youth Justice Board.
26 Fear, N. T., Bridges, S., Hatch, S., Hawkins, V. and Wessely, S. (2016) Posttraumatic Stress Disor-
11 Bellis MA, Hughes K, Leckenby N, Perkins C and Lowey H. (2014) ‘National household survey der (Adult Psychiatric Morbidity Survey 2014 results): http://content.digital.nhs.uk/catalogue/
of adverse childhood experiences and their relationship with resilience to health-harming PUB21748/apms-2014-ptsd.pdf
behaviours in England’ BMC Medicine 2: 72.
27 Carter, R. T. (2007) ‘Racism and Psychological and Emotional Injury: Recognizing and assessing
12 Hughes, K., Lowey, H., Quigg, Z. and Bellis, M. A. (2016) ‘Relationships between adverse race-based traumatic stress’ The Counseling Psychologist 35: 13-105.
childhood experiences and adult mental well-being: results from an English national household
survey’ BMC Public Health 16: 222. 28 van der Kolk, B. et al (2009) ‘Proposal to include a Developmental Trauma Disorder diagnosis
for children and adolescents in DSM-V’: http://www.traumacenter.org/announcements/
13 Priest, N., Paradies, Y., Truong, M., Karlsen, S. and Kelly, Y (2012) ‘A systematic review of stud- DTD_papers_Oct_09.pdf
ies examining the relationship between reported racism and health and wellbeing for children
and young people’ Social Science and Medicine 95: 115-27. 29 American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disor-
ders (fifth edition – DSM-5) Washington DC: American Psychiatric Publishing.
14 EHRC (2016) Healing a Divided Britain: the need for a comprehensive race equality strategy:
https://www.equalityhumanrights.com/sites/default/files/healing_a_divided_britain_-_the_ 30 World Health Organisation (2016 version) The International Classification of Diseases (ICD-
need_for_a_comprehensive_race_equality_strategy_final.pdf 10): http://apps.who.int/classifications/icd10/browse/2016/en
15 Elliott, I. (2016) Poverty and Mental Health: A review to inform the Joseph Rowntree Founda- 31 Alisic, E., Zalta, A. K, van Wesel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K. and Smid, G. E.
tion’s Anti-Poverty Strategy: https://www.mentalhealth.org.uk/sites/default/files/Poverty%20 (2014) ‘Rates of post-traumatic stress disorder in trauma-exposed children and adolescents:
and%20Mental%20Health.pdf meta-analysis’ The British Journal of Psychiatry 204(5): 335-340.

32 Those interested in the mental health impact of LGBT prejudice should refer to the paper by 47 Care Quality Commissioning (2011) Count me in 2010: Results of the 2010 national
Matthew Todd in this collection. census of inpatients and patients on supervised community treatment in mental health and
33 c.f. Hickson, F., Davey, C., Reid, D., Weatherburn, P. and Bourne, A. (2016) ‘Mental health learning disability services in England and Wales: http://webarchive.nationalarchives.gov.
inequalities among gay and bisexual men in England, Scotland and Wales: a large communi- uk/20110504130559/http://www.cqc.org.uk/_db/_documents/Count_me_in_2010_FINAL_
ty-based cross-sectional survey’ Journal of Public Health 1-8. (tagged).pdf
34 Home Office / Foreign and Commonwealth Office (2017) Forced Marriage Unit Statis- 48 see also: Pinto, R., Ashworth, M. and Jones, R. (2008) ‘Schizophrenia in black Caribbeans living
tics 2016: https://www.gov.uk/government/uploads/system/uploads/attachment_data/ in the UK: an exploration of underlying causes of the high incidence rate’ The British Journal of
file/597869/Forced_Marriage_Unit_statistics-_2016.pdf General Practice 58(551): 429-434.
35 ONS (2014) What Does the 2011 Census Tell Us About Inter-ethnic Relationships?: http:// 49 Sainsbury Centre for Mental Health (2002) Breaking the Circles of Fear: a review of the
webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/ relationship between mental health services and African and Caribbean communities: https://
dcp171776_369571.pdf www.researchgate.net/profile/Andrew_Mcculloch5/publication/287808524_Breaking_the_
36 Morley, D. and Street, K. (2014) Mixed Experiences: Growing up mixed race – mental health circles_of_fear/links/56796d2708ae7fea2e98809f/Breaking-the-circles-of-fear.pdf
and well-being. London: National Children’s Bureau. 50 Mann, F., Fisher, H.L., Major, B., Lawrence, J., Tapfumaneyi, A., Joyce, J., Hinton, M.F. and John-
37 Carter, R. T., Forsyth, J., Mazzula, S. and Williams, B. (2005) ‘Racial discrimination and race- son S. (2014) ‘Ethnic variations in compulsory detention and hospital admission for psychosis
based traumatic stress’ in R. T. Carter (ed.) Handbook of Racial–cultural Psychology and across four UK Early Intervention Services’ BMC Psychiatry 14(1): 256.
Counselling: training and practice. New York: Wiley. 51 Confluence Partnership (2014) Ethnic Inequalities in Mental Health: promoting lasting
38 c.f. Van Der Kolk, B. (2015) The Body Keeps the Score: brain, mind, and body in the healing of positive change: https://lankellychase.org.uk/wp-content/uploads/2015/07/Ethnic-Inequali-
trauma, London: Penguin. ty-in-Mental-Health-Confluence-Full-Report-March2014.pdf https://www.ncbi.nlm.nih.gov/
books/NBK373873/pdf/Bookshelf_NBK373873.pdf
39 Briere, J. N. and Lanktree, C. B. (2012) Complex Trauma in Adolescents and Young Adults,
London: Sage. 52 c.f. Numerous reports of the BME Health Forum: http://www.bmehf.org.uk/index.php/publica-
tions
40 Mental Health Providers Forum / Race Equal Foundation (2015) Better practice in mental
health for black and minority ethnic communities: http://www.raceequalityfoundation.org. 53 African Policy Network (2013) The Mental and Emotional Wellbeing of Africans in the UK:
uk/sites/default/files/publications/downloads/Better%20practice%20in%20mental%20 www.ahpn.org.uk/files/147_The_Mental_and_Emotional_Wellbeing_of_Africans_in_the_UK__
health%20(2)%20(1).pdf AHPN_2013_139.pdf
54 Singh, S.P., et al (2013) Op. cit.
216 41 Dein, K., Williams, P. S. and Dein, S. (2007) ‘Ethnic bias in the application of the Mental Health
Act 1983’ Advances in Psychiatric Treatment 13: 350-357. 55 For more information see: https://www.gov.uk/government/publications/female-genital-muti-
217
42 National Institute for Mental Health in England (2003) Inside Outside: Improving Mental lation-resource-pack/female-genital-mutilation-resource-pack#legislation
Health Services for Black and Minority Ethnic Communities in England: http://webarchive. 56 We Need to Talk Coalition (2013) We Still Need to Talk: a report on access to talking therapies:
nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/ http://www.mind.org.uk/media/494424/we-still-need-to-talk_report.pdf
dh_digitalassets/@dh/@en/documents/digitalasset/dh_4019452.pdf 57 c.f. Race Equality Foundation (2015) Mental Health Crisis Review: experiences of black and
43 NACRO (2007) Black Communities, Mental Health and the Criminal Justice System: http:// minority ethnic communities: http://raceequalityfoundation.org.uk/sites/default/files/publi-
www.ohrn.nhs.uk/resource/policy/Nacroblackcommunities.pdf cations/downloads/Mental%20health%20crisis%20review%20-%20experiences%20of%20
44 Commander, M. J., Cochrane, R., Sashidharan, S.P., Akilu, F. and Wildsmith E. (1999) ‘Mental black%20and%20minority%20ethnic%20communities%20Final%20Version_0.pdf
health care for Asian, black and white patients with non-affective psychoses: pathways to the 58 Sainsbury Centre for Mental Health (2002) Op. cit
psychiatric hospital, in-patient and after-care’ Social Psychiatry and Psychiatric Epidemiology 59 Lambeth Council, SLAM NHS Foundation Trust, and Lambeth CCG (2014) From Surviving to
34(9): 484-91. Thriving (report of the Lambeth Black Health and Wellbeing Commission): http://lambethcol-
Singh, S.P., Islam, Z., Brown, L. J., Gajwani, R., Jasani, R., Rabiee, F. and Parsons, H. (2013) laborative.org.uk/wp-content/uploads/2014/08/ENC-4.4-BHWB-Commission-Final-Report2-
‘Ethnicity, detention and early intervention: reducing inequalities and improving outcomes PDF-June-2014.pdf
for black and minority ethnic patients: the ENRICH programme, a mixed-methods study’ Pro- 60 Joint Commissioning Panel for Mental Health (2014) Guidance for Commissioners of Mental
gramme Grants for Applied Research 1(3): https://www.ncbi.nlm.nih.gov/books/NBK373873/ Health Services for People from Black and Minority Ethnic Communities: http://www.jcpmh.
pdf/Bookshelf_NBK373873.pdf info/wp-content/uploads/jcpmh-bme-guide.pdf
45 Rethink et al (2004) Behind Closed Doors: the current state and future vision of acute mental 61 Equality Act [2010]: http://www.legislation.gov.uk/ukpga/2010/15/contents
health care in the UK: https://www2.rcn.org.uk/downloads/professional_development/men-
tal_health_virtual_ward/treatments_and_therapies/behind-closed-doors-reportpdf.pdf 62 Human Rights Act [1998]: http://www.legislation.gov.uk/ukpga/1998/42/contents
46 Weich, S., McBride, O., Twigg, L., Duncan, C., Keown, P., Crepaz-Keay, D., Cyhlarova, E., Parsons, 63 NHS England (2011) The NHS Constitution for England: https://www.gov.uk/government/
H., Scott, J. and Bhui, K. (2017) ‘Variation in compulsory psychiatric inpatient admission in publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england
England: a cross-classified, multilevel analysis’ The Lancet http://dx.doi.org/10.1016/S2215- 64 Helms, J. H., Nicolas, G. and Green, C. E. (2012) ‘Racism and Ethnoviolence as Trauma: Enhanc-
0366(17)30207-9 ing professional and research training’ Traumatology 18(1): 65-74: http://education.miami.
edu/crecer/pdf/publications/publication-ref2.pdf

Chapter 14
65 Time to Change (2016) 300 Voices Toolkit: better must come: towards hope: https://www.
time-to-change.org.uk/sites/default/files/Time%20to%20change%20-%20300%20Voices%20 15. Investing in gender and trauma-
informed services
Toolkit%20comp.pdf
66 c.f. National Survivor User Network / Lankelly Chase (2014) Ethnic Inequalities in Mental
Health: Promoting Lasting Positive Change (A Consultation with Black and Minority Ethnic
Mental Health Service Users): http://www.nsun.org.uk/assets/downloadableFiles/EthnicIn-
equalitiesinMentalHealthReportFebruary20142.pdf Katharine Sacks-Jones
Centre for Health and Social Care Research (2015) Increasing the Uptake of Primary and
Community Long-term Conditions Services in Black and Minority Ethnic (BME) Communities
in Nottingham: an exploratory research study: http://www4.shu.ac.uk/research/cresr/sites/
67
shu.ac.uk/files/increasing-uptake-services-bme-communities-nottingham-interim.pdf
NHS London Strategic Clinical Networks (2014) London Mental Health Crisis Commissioning:
1. Young women, mental health and adversity: prevalence
case studies: http://www.slcsn.nhs.uk/scn/mental-health/mh-urgent-commiss-cs-102014.pdf
68 Centre for Mental Health (2017) Against The Odds: Evaluation of the Mind Birmingham Mental ill health among women and especially young women is on the rise.
Up My Street programme: https://www.centreformentalhealth.org.uk/Handlers/Download. About one in five women now have a mental health problem, compared to one
ashx?IDMF=14f86686-7882-43cb-b64e-1540f12ab01a
in eight men1. Young women (16–24) are at greatest risk of poor mental health
– with one in five self-harming and one in seven (13%) experiencing post-
traumatic stress disorder2. This trend is particularly concerning as we know
mental health problems, which can continue right across someone’s life, are
first experienced young, with 50% established by age 14 and 75% by age 243.
The gender disparity in rates of mental ill health between young women and
men has arisen, in part, because while rates of mental ill health have remained
218 largely stable in men, they have steadily increased in women. And while men 219
remain more likely to die by suicide, there has been a worrying increase among
women, with female suicide rates in England and UK at their highest in a
decade4.
If we don’t act now to halt these worrying trends, we risk storing up substantial
problems for the future.
The reasons behind mental health issues are of course complicated and
individual. But there are particular risks and pressures associated with
being a young woman: greater worries over body image; early sexualisation;
interpersonal violence, harassment and abuse and sometimes the pressures of
caring or domestic responsibilities within families.
Physical and sexual violence is however, perhaps the single most significant
risk factor for girls and young women. Domestic and sexual abuse remains at
extraordinarily high levels and we are only now beginning to realise the scale
and extent of child sexual abuse and exploitation.
It is a sobering fact that of all women who have a common mental health
disorder over half have experienced violence and abuse. For one in four that

Chapter 15 Investing in gender and trauma-informed services
abuse started in childhood5. For those with the most severe mental health Although girls may be less visible in the statistics, they are no less at risk, with
problems, the links are even more pronounced. girls more likely to experience violence and abuse, sexual exploitation and
teenage pregnancy15. Girls who spend time in care for example are more likely
Evidence suggests that childhood abuse is a more common experience for to become teenage mothers, and have their own children taken into care16.
girls: severe maltreatment by a parent during childhood happens to 17.5%
of girls and 11.6% of boys, and sexual abuse is experienced by 17.8% of girls All of this underlines an urgent need to understand mental health in a
and 5.1% of boys.6 The sexual abuse of girls is more likely to be perpetrated gendered context and to develop mental health services and support in a way
by family members, to begin at an earlier age and to occur repeatedly than the which meets the needs of both young men and young women.
sexual abuse of boys. The sexual abuse of boys is more likely to be perpetrated
by non-family members, to occur later in childhood and to be a single incident.7
Children who experience multiple forms of victimisation are at greatest risk 3. Mental health service provision and gender
of developing mental health problems8 and those who are subject to multiple
adverse experiences in childhood are at particular risk of developing severe At the moment however, there is very little specific provision for young
behavioural problems. There is evidence that this is particularly the case for women. In response to a Freedom of Information request by Agenda17, only
girls.9 one of the responding mental health trusts had a women’s mental health
strategy. In every other trust, there was no strategy explicitly recognising
women’s mental health as an issue and no consideration of women’s needs
when planning which services to provide.
2. How mental ill health manifests
220 What’s more, just over half of trusts had no policy on routinely asking female 221
There are also clear gender differences in how girls and boys behave in patients about experience of abuse, despite the fact that NICE guidelines say
response to adverse experiences and trauma. Broadly, boys are more likely they should be doing so. Currently it appears that most mental health services
to externalise problems (for example to ‘act out’ and engage in anti-social take a gender blind approach – meaning they don’t recognise young men and
behaviour) by contrast girls are more likely to internalise their responses (for women’s different experiences and needs. And this matters.
example to experience depression or engage in self-harming behaviours).
To take an example, recent research for Agenda18 found the use of physical
This can mean girls’ distress is less visible than boys’. For example, it is notable restraint against women and girls in mental health settings was widespread.
that while Attention Deficit Disorder (ADHD) affects a similar proportion of Girls were more likely to be physically restrained than boys (17% compared to
men and women (approximately one in 10 of the population), men are over five 13%). This is despite the links between young women’s mental health problems
times as likely as women to have been diagnosed with ADHD.10 and abuse. Because of these links, restraint can not only be a frightening and
humiliating experience but it also risks re-traumatising young women and
Boys are more likely to be looked-after – 56% of looked-after children are exacerbating their mental health problems in the long term, with potential
male, 44% female and these proportions have varied little over recent years11. additional harm as much of the restraining is done by male nurses. Young
Boys are over three times more likely to receive a permanent exclusion and women have also told us of how, when they were at their most vulnerable in
almost three times more likely to receive a fixed period exclusion than girls12. mental health hospitals on ‘suicide watch’, being watched over by male staff
Boys are also at increased risk of entering the criminal justice system, making made them feel unsafe and contributed to their mental distress.
up over 80% of young people arrested13.
We think a new approach is needed which takes young women’s particular
It appears therefore that many girls are going ‘under the radar’ with an needs into account in mental health support and services.
increased likelihood of further abuse and long-term mental health difficulties.14

We recognise the tremendous pressures facing the health service but at a time services to better meet the needs of women and girls which could for example
of tightened resources it is more important than ever that support is effective be something as small as offering a choice of a female practitioner or providing
and targeted; and that it gets to the root of problems rather than acting as a an environment in which young women feel comfortable. Even small steps
sticking plaster as young women bounce from mental health crisis to mental could make a real difference to the care young women receive.
health crisis, at huge cost both to them and the public purse.
Commissioners should also recognise the particular experiences and needs of
There are some excellent first class services out there in both the voluntary different groups of young women including those from BAME communities.
sector and within the NHS but they are incredibly few and far between.
These provide female only spaces, place an emphasis on building trusting
relationships and recognise and respond to the particular pressures and b. Ensure mental health services take a trauma-informed approach and
challenges young women face. frontline NHS workers are trained to understand that young women’s mental
health, trauma and abuse are closely linked.
Health services should take a trauma and gender informed approach,

4. Responding to trauma, adversity and gender understanding young women and girls in the context of the abuse and
disadvantage they have suffered.
We believe commissioners need to be thinking in a gendered way about what
they commission and that Clinical Commissioning Groups should prioritise the In the US a few gender sensitive, trauma-informed interventions have been
following: implemented and substantially evaluated in a number of settings (including
mental health, substance abuse and criminal justice). These include Stephanie
222 a. Listen to and recognise women and girls’ experiences and needs: Covington’s trauma-informed approach19. The work of Maxine Harris and her 223
colleagues has been a major influence on trauma-informed interventions20
Women and girls’ needs should be explicitly recognised in policies, strategies with many adopting the core values she identifies for trauma sensitive
and services. One way of achieving this would be to develop a women’s services: ensuring physical and emotional safety, maximising trust through
mental health strategy which reaches across children and adult services and consistency, being honest and providing clear boundaries, maximising client
to appoint a clinical lead for women’s mental health to ensure the needs of choice and control, collaborating and sharing power, and empowering
women and girls are not overlooked. survivors21.
This process should include identifying and developing an understanding

of gender differences in relation to mental health conditions, pathways c. Introduce ‘routine enquiry’, within urgent and emergency care and specialist
and treatment. Consulting with young women with experience of mental ill services.
health on what services they need and want should be a key part of informing
commissioning decisions. This involves training professionals to sensitively ask about experiences of
violence and abuse and other childhood adversity. It needs to be accompanied
Commissioners should consider commissioning dedicated specialist services by proper support and pathways into therapeutic care.
to meet the particular needs of young women and girls who have experienced
abuse and trauma. Invest in early interventions that are shown to have longer-
term benefits for women and ensure there is consideration of and robust d. End the restrictive practice of face-down restraint and ensure other forms of
evaluation of gender effects within interventions. physical restraint are only used as a last resort.
It might also include thinking about the changes that could be made across The use of restraint is concerning because of the potential it has to re-

traumatise the many women and girls in mental health settings who have is insufficient support to mothers to cope with these situations27.
experienced abuse and violence. Restraint is often carried out by male nurses, It is important therefore that support targeted at families takes a gendered
which compounds the fear and trauma of those women and girls who have approach and recognises these dynamics. In particular, targeted support
histories of abuse and violence at the hands of men. Female patients’ dignity to help mothers be good parents can help provide the foundation children
is also at stake. Being physically held down and clothes pulled out of place, need to support their life chances in the early years. Similarly whole school
often in front of others, can be an extremely humiliating, as well as frightening, approaches to mental health must consider the role of gender and how to
experience. As such, the use of restraint is unlikely to improve mental ensure the needs of both boys and girls are being met.
wellbeing in the short or long-term – and is likely to do the opposite. This is
not to mention the well-documented physical dangers of face-down restraint,
which can be life-threatening. Some trusts appear to have almost eliminated
physical restraint and to have stopped using face-down restraint altogether
which shows that change is possible, and alternative de-escalation techniques
can and do work.
e. In whole school, parental and whole family support approaches it is vital

that trauma and gender are considered.
It is important targeted support to parents and care givers where children are
experiencing or have experienced trauma and adversity considers the role
224 gender plays within families. 225
For example, many families living in poverty which contain children facing
adversity are headed by women alone. Single parent families are the group
most likely to be in persistent poverty22, and 92% of single parents with
dependent children are mothers23. In many cases, the fathers of their children
are absent, unwilling or unable to get involved in raising children, meaning that
realistically many of these mothers will always be the sole engaged parent.
Where families are headed by a couple, mothers still provide the majority
of childcare24. Evidence has shown that a mother’s life experiences have a
strong predictive impact on her children, for example a mother’s level of
education has more impact on a child’s cognitive ability and the nature of their
home learning environment, than a father’s level of education or even than
household income25. Their role is therefore critical in a child’s formative years
and putting them in a position to parent well is the best way to make sure their
children have good life chances.
Sadly we know that in many of the most excluded families, women and children
experience violence and coercion at the hands of fathers and step-fathers26.
Abuse has serious negative impacts on children’s life chances, but often there

References 21 Fallot, R. D., McHugo, G. J., Harris, M. and Xie, H. (2011) ‘The Trauma Recovery and Empower-
ment Model (TREM): a quasi-experimental effectiveness study’ Journal of Dual Diagnosis 7(1):
74-89. and Harris, M. and Fallot, R. D. (2001) Using Trauma Theory to Design Service Systems:
1 McManus, S., Bebbington, P., Jenkins, R. and Brugha, T. (2016) Mental Health and Wellbeing in new directions for mental health services. San Francisco: Jossey Bass.
England: Adult Psychiatric Morbidity survey 2014. Leeds: NHS Digital. 22 Office for National Statistics (2015) Persistent Poverty in the UK and EU 2008-2013: https://
2 McManus, S., et al (2016) Op. cit. www.ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/incomean-
dwealth/articles/persistentpovertyintheukandeu/2015-05-20
3 Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R. & Walters, E. E. (2005) ‘Lifetime
prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity 23 Office for National Statistics (2015) Families and Households 2014 (statistical bulletin):
Survey replication’ Archives of General Psychiatry 62(6): 593-602. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/families/
bulletins/familiesandhouseholds/2015-01-28
4 Samaritans (2017) Suicide Statistics Report 2017: https://www.samaritans.org/sites/default/
files/kcfinder/files/Suicide_statistics_report_2017_Final.pdf 24 OECD (2011) Help Wanted?: providing and paying for long-term care: http://www.oecd.org/
els/health-systems/help-wanted-9789264097759-en.htm
5 McManus, S. and Scott, S. (2016) Hidden Hurt: violence, abuse and disadvantage in the lives of
women: Data Tables appendix, London: Agenda. 25 Equality and Human Rights Commission (2008) Early Years, Life Chances and Equality: a liter-
ature review: https://www.equalityhumanrights.com/sites/default/files/research-report-7-ear-
6 Radford, L., Corral, S., Bradley, C., Fisher, H., Bassett, C., Howat, N. and Collishaw, S. (2011) ly-years-life-chances-and-equality-literature-review.pdf
Child Abuse and Neglect in the UK Today. London: NSPCC.
26 Stark, E. and Flitcraft, A. (1996) ‘Women and children at risk: a feminist perspective on child
7 Finkelhor, D. (1986) A Sourcebook on Child Sexual Abuse. California: Sage. and Kelly, L., Regan, abuse’ in Women at Risk: domestic violence and women’s health. London: Sage. p. 73-98.
L. and Burton, S. (1991) An Exploratory Study of the Prevalence of Sexual Abuse in a Sample of
16 – 21 year olds. London: Child Abuse Studies Unit. 27 Women’s Aid (2014) SOS: save refuges, save lives: https://www.womensaid.org.uk/sos-da-
ta-report/
8 Finkelhor D (2008) Childhood Victimization: violence, crime and abuse in the lives of young
people. New York: Oxford University Press
9 Murray, J. and Farrington, D. P. (2010) ‘Risk factors for conduct disorder and delinquency: key
findings from longitudinal studies’ Canadian Journal of Psychiatry 55: 633-64. and Murray,
J., Irving, B., Farrington, D. P., Colman, I. and Bloxson, A. J. (2010) ‘Very early predictors of
conduct problems and crime: results from a national cohort study’ Journal of Child Psychology
226 and Psychiatry 51: 1198-207.
227
10 McManus, S. et al (2016) Op. cit.
11 Department for Education (2016) Children Looked After in England (including adoption) year
ending 31 March 2016: https://www.gov.uk/government/statistics/children-looked-after-in-
england-including-adoption-2015-to-2016
12 Department for Education (2016) Permanent and Fixed Period Exclusions in England: 2014 to
2015: https://www.gov.uk/government/statistics/permanent-and-fixed-period-exclusions-in-
england-2014-to-2015
13 Youth Justice Board / Ministry of Justice (2016) Youth Justice Statistics 2015/16 England and
Wales: https://www.gov.uk/government/statistics/youth-justice-statistics-2015-to-2016
14 Scott, S. and McNeish, D. (2014) Women and Girls at Risk: evidence across the life course.
London: Barrow Cadbury Trust / LankellyChase Foundation / Pilgrim Trust.
15 ibid.
16 BBC (2015) ‘Almost a quarter of girls in care become Teenage mothers’: www.bbc.co.uk/news/
education-30882105
17 Agenda (2016) Women’s Needs in Mental Health Services: a response to an FOI request.
London: Agenda.
18 Agenda (2017) The Use of Restraint Against Women and Girls: https://weareagenda.org/
wp-content/uploads/2017/03/Restraint-FOI-research-briefing-FINAL1.pdf
19 Covington, S. S., Burke, C., Keaton, S. and Norcott, C. (2008) ‘Evaluation of a trauma-informed
and gender-responsive intervention for women in drug treatment’ Journal of Psychoactive
Drugs 5: 387-98.
20 Scott, S. et al (2014) Op. cit.

Tackling child abuse in local transformation planning
16. Tackling child abuse in local 2. Lack of access to support

transformation planning Our analysis of child and adolescent mental health services (CAMHS) shows
that services are struggling to cope with demand from across England. In
Lisa McCrindle, Almudena Lara and Rosie Powell Davies 2015, an NSPCC Freedom of Information request discovered that one in five
children referred to CAMHS are denied a service, and the average waiting
time between referral and assessment ranges from just a week in some areas
to more than 26 weeks (6 months) in others – with an average waiting time of
1. Childhood abuse and mental health nearly two months7. This can be a significant proportion of a child’s life to be
waiting for support at a critical time and may result in significant escalation of
The NSPCC estimates that every year over half a million children in the UK their needs. Without early intervention, the demand for services continues to
are abused in the home1. Every child should be supported to recover from increase and thresholds for treating mental illnesses in children are pushed up
abuse. The support children receive can make the difference between them and waiting lists increase.
overcoming their trauma or living a life shaped by the abuse experienced.
Accessing CAMHS support is especially difficult for children who have been
We know that childhood experience of abuse can have a major impact on abused or neglected. In a NSPCC survey of child mental health professionals,
young people’s mental health and wellbeing. Children who have been abused 98% reported there was not enough therapeutic support for children who
are more likely to experience depression, anxiety and symptoms of post- have been abused. 8 Children who have been abused will not meet the high
traumatic stress disorder, as well as self-harm and suicide2. In addition, it can clinical thresholds for access to CAMHS unless they are in crisis.9 Even then
have a devastating effect on children and young people’s development, with many CAMHS workers do not support children who have been abused and
228 lasting consequences for their mental, physical and emotional health – as well neglected as their needs are considered to be specialist, resulting in many 229
as for their relationships with others and education3. children being turned away once they reach crisis point10.
A third of Childline counselling sessions related to mental and emotional Calls to the NSPCC’s Childline also show the difficulties that children face
health and wellbeing issues, including self-harm and suicidal thoughts or in accessing mental health support. In 2016, there were 3,250 counselling
feelings4. There is evidence that experience of maltreatment in childhood sessions in which children and young people talked about struggling to
doubles the risk of depression, and this depression is more resistant to access appropriate professional support locally, particularly for mental health
treatment than depression which occurs without experience of childhood problems. This represents an 87% increase on the previous year, which in turn
maltreatment5. Experiencing abuse in childhood can enhance vulnerability to followed a 124% increase on the year before11.
further adversity as a child or young adult, which can include further exposure
to abuse, health-harming behaviours (such as substance misuse or self-harm), The problem begins with identification. Many children who have been
and in some cases adoption of abusive and/or sexually harmful behaviour abused and neglected are simply not known to services, and even those who
themselves. are referred to services cannot be sure of getting the support they need
to recover, with one in five children in England who are referred to mental
In addition to the impact on individuals, child abuse presents wider health support services being denied help. Many children who are abused and
consequences for the economy and society. A study commissioned by the neglected receive no automatic entitlement to assessment or support as they
NSPCC estimated that child sexual abuse alone costed the UK £3.2 billion do not yet reach clinical thresholds. In all too many cases children are reaching
in 2012, arising from mental and physical health problems, drug and alcohol crisis point before they become eligible for support.
misuse, unemployment and criminal justice costs6.
These problems are particularly acute for looked-after children. Over 60%
of looked-after children in England and Wales are in care owing to abuse or

Chapter 16 Tackling child abuse in local transformation planning
neglect12. Looked-after children are four times more likely to have a mental Local Transformation Plans are a crucial opportunity to address the current
health issue than their peers, yet not all of these children are having their gaps in therapeutic support for children who have been abused. Two of
emotional wellbeing appropriately assessed. Even where looked-after children the main themes that underpin Future in Mind include “care for the most
are being assessed, these assessments are rarely undertaken by a trained vulnerable” and “promoting resilience, prevention and early intervention”. This
mental health professional, and there are no clear pathways in place to ensure focus particularly chimes with the needs of children who have been abused –
appropriate support where needs are identified. this is a vulnerable group of children, at high risk of psychological distress, who
will often benefit from early intervention to prevent mental health issues from
Looked-after children can face even greater challenges when seeking support escalating. CCGs have been instructed to refresh these plans and publish the
for mental health needs. Since 2015, local authorities have been required to updated versions on an annual basis.
conduct a mental health assessment for every child in care and report this
data to central government. However, the most recent figures suggest that The NSPCC carried out an analysis of the original plans to assess whether the
almost 30% of children who are taken into care do not receive this statutory needs of children who have been abused had been considered by the CCGs. In
mental health assessment. The children in care who are in greatest need of September 2017 we revisited this analysis using the updated plans14.
clinical mental health treatment are often also those with the most fragile
placements. CAMHS will often not accept referrals of children who are likely The analysis shows a picture of the extent to which local transformation plans
to move location frequently, and this can directly block those who most need recognise the mental health needs of children that have experienced abuse
the service. and neglect, and the services which are targeted to meet their needs across
the country. Our analysis shows that an estimated 1.2 million children who
The NSPCC is seeking to urgently address these issues to make sure the lives have suffered abuse live in areas with inadequate mental health plans. This is
of children who have experienced abuse and neglect are not derailed, and are despite NHS England guidance requiring plans to address the full spectrum
230 helped to put their life back together. We are calling for every child and young of needs. 231
person who has been abused to receive the support they need. We have urged
the Government to recognise the needs of children who have experienced According to the guidance and the ambition set out in Future in Mind the
abuse and neglect and to increase investment in targeted therapeutic services. Local Transformation Plans should set out how areas will transform children’s
This alone will not solve the problem. We also need to see a clear vision for the mental health services and ultimately address the growing mental health
planning, commissioning and delivery of services for children who have been needs of children. Given the scale and impact of child abuse and neglect the
abused and neglected. omission of their needs in planning and commissioning of support services is
a significant oversight. As a society we all strive to prevent abuse and neglect,
when we fail to do so we should ensure that we are able to respond to their
needs to ensure that they are supported and equipped to go on to lead healthy,
3. Delivering on the ambitions of Future in Mind happy lives.
In 2015, the Government’s Children and Young People’s Mental Health Task Our analysis identified a small number of very promising plans which are
Force published Future in Mind13, a landmark report setting out a new vision seeking to close the gap in therapeutic support for abused children. Examples
for children and young people’s mental health in England. The Government of good practice include:
subsequently committed to spend £1.4 billion over five years to improve
children and young people’s mental health services (up to 2021). CCGs were • recognition that abuse is a major risk factor for poor mental health.
asked to produce Local Transformation Plans setting out how they would
improve mental health services for children and young people in their area. • needs assessments which were much broader than a narrow focus on
The deadline for completion of the first round of plans was October 2015, with clinical disorders.
all plans due to be published locally by 31 December 2015.

• a commitment to addressing non-diagnosable mental health concerns 4. NSPCC services for abused and neglected children
following traumatic life events such as abuse.
The NSPCC has developed a number of targeted therapeutic services to
• clear and transparent information about current and planned services. improve the mental health and emotional wellbeing of children who have
experienced abuse and neglect. Some of these are delivered from our regional
service centres and others have been developed into scalable services that
can be used by local authorities. These provide examples of the type of
Box 1: Examples from Local Transformation Plans (LTPs) interventions that can be effective in helping children and young people who
Source: NSPCC 2017 analysis of LTPs have experienced abuse get back on track.
Somerset Local Transformation Plan – this plan is an excellent

example of how to make an assessment of needs in the local area and
how to consider the risk factors that impact on children and young Letting the Future In
people’s mental health. In order to inform its needs analysis, this plan
used Somerset’s Joint Strategic Needs Assessment for 2014/15, the Letting the Future In (LTFI) is a service designed by the NSPCC for
Somerset Children and Young People’s and Learners Needs Analysis children aged four to 17 years who have been sexually abused. The
(2013) and a large survey (n=9774) of young people in school years 4, approach helps children come to understand and move on from their
6,8,10 and 12. past experiences through activities such as play, drawing and painting
and storytelling. Parents and carers are also offered support to move on
Bury Local Transformation Plan – this plan is an excellent example from the impact of finding out about the sexual abuse and to help their
232 of how to make an assessment of needs in the local area and consider children feel safe. 233
the risk factors that impact on children’s mental health. The plan not
only considers its own needs and service provisions, but also takes into LTFI is grounded in an understanding of trauma, attachment and
consideration the Greater Manchester area. It acknowledges the fact resilience. It is largely psychodynamic in nature and emphasises the
that there are (good and bad) crossovers geographically and utilises therapeutic connection of the practitioner to the child’s emotional
integration with the neighbouring Manchester CCG in order to improve responses to abuse, which typically include betrayal, powerlessness,
its service design. The plan recognises that children and young people’s shame and traumatic sexualisation. The therapeutic relationship
needs must always be contextualised to the local area, but also exploits between child and practitioner is core to the programme and employs
the benefits of working across geographies. creative therapies with work on the awareness and management of
feelings. It also draws on other methods including counselling and socio-
Heywood, Middleton and Rochdale Local Transformation Plan – this educative approaches.
plan provides a good example of how to conduct a needs analysis. The
plan is strongly focused on the Joint Strategic Needs Assessment. It An NSPCC evaluation of LTFI found that at the beginning of the process
incorporates a life course approach and bases its analysis on the risk almost three-quarters (73%) of children aged eight and over had severe
factors for mental health. The plan makes good use of health outcomes emotional difficulties and after six months of treatment this dropped to
to inform its strategy, including mortality, the prevalence of mental less than half (46%). Children and parents who took part in the service
health problems and observed incidence. reported many positive results, including improved mood, a reduction in
depression and anxiety, and a reduction in guilt and shame15.

References
Face to Face
1 Radford, L. et al. (2011) Child abuse and neglect in the UK today. London: NSPCC.
The NSPCC’s Face to Face service supports children and young people 2 Faulconbridge, J., Law, D. and Laffan, A. (2015) ‘What good looks like in psychological services
in care or on the edge of care who are aged between five and 18 years. for children, young people and their families’ The Child and Family Clinical Psychology Review
(3)
The service was designed to respond to research that showed that
3 Glaser, D. (2000) ‘Child abuse and neglect and the brain – a review’ Journal of Child Psycholo-
looked-after children would most like to access confidential face-to-face gy and Psychiatry 41(1): 97-116.
support from someone who would “listen and not judge”. They wanted 4 NSPCC (2017) Childline Annual Review 2016/17: not alone anymore: https://www.nspcc.org.
a service that would result in tangible changes but would not feel “too uk/services-and-resources/research-and-resources/2017/not-alone-anymore-childline-annu-
al-review-2016-2017
heavy”. The Face to Face service offers children and young people
5 Nanni, V., Uher, R. and Danese, A. (2012) ‘Childhood maltreatment predicts unfavourable
up to eight sessions of support using a solution-focused approach.
course of illness and treatment outome in depression: a meta-analysis’ American Journal of
Young people are able to choose the location of the work and also how Psychiatry 169: 141-151.
frequently they wish their sessions to take place. 6 Saied-Tessier (2014) Estimating the Costs of Child Sexual Abuse in the UK: https://www.nspcc.
org.uk/globalassets/documents/research-reports/estimating-costs-child-sexual-abuse-uk.pdf
The service offers therapeutic support to children who are experiencing 7 NSPCC (2015) FOI into CAMHS Provision.
difficulties with their mental health but who have not necessarily 8 Survey of 1,308 children’s health, social care and education professionals assessing current
provision of therapeutic services for children who have experienced abuse and neglect, No-
reached the threshold of a mental health clinical diagnosis. This type of
vember/December 2015. NSPCC.
early intervention is vital. 9 NSPCC (2016) Transforming Mental Health Services for Children who have Experienced
Abuse: a review of Local Transformation Plans: https://www.nspcc.org.uk/globalassets/docu-
The NSPCC’s evaluation of Face to Face found that 58% of children and ments/research-reports/transforming-mental-health-services-children-experienced-abuse.
234 young people had a clinical level of distress when they first accessed
pdf
235
10 NSPCC (2016) It’s Time: campaign report: https://www.nspcc.org.uk/globalassets/documents/
the service16. At their last session only 15% of the same children were research-reports/its-time-campaign-report.pdf
still experiencing clinical levels of distress. Over two thirds of children 11 NSPCC (2016) Childline Annual Review 2015/16: https://www.nspcc.org.uk/globalassets/
and young people reported that Face to Face had helped them a lot in documents/annual-reports/childline-annual-review-2015-16.pdf
addressing the immediate concern that had been impacting on their 12 Bentley, H., O’Hagan, O, Raff, A. and Bhatti, I. (2016) How Safe Are Our Children?: The most
emotional wellbeing. comprehensive overview of child protection in the UK 2016. London: NSPCC.
Rate calculations for Northern Ireland and Scotland are not included as they are not compara-
ble with England and Wales.
13 Department of Health / NHS England (2015) Future in Mind: promoting, protecting and
improving our young people’s mental health and wellbeing: https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf
14 NSPCC (2017) Transforming the Mental Health Services for Children who have been Abused:
A review of Local Transformation Plans for Children and Young People’s Mental Health and
Wellbeing: https://www.nspcc.org.uk/globalassets/documents/research-reports/transforming-
mental-health-services-children-who-have-been-abused_report.pdf
15 Carpenter, J. et al. (2016) Letting the Future In: a therapeutic intervention for children affect-
ed by sexual abuse and their carers. An evaluation of impact and implementation: https://www.
nspcc.org.uk/globalassets/documents/research-reports/letting-the-future-in-evaluation.pdf
16 Fernandes, P. (2015) Evaluation of the Face to Face service: using a solution-focused approach
with children and young people in care or on the edge of care: https://www.nspcc.org.uk/
globalassets/documents/evaluation-of-services/face-to-face-final-evaluation-report.pdf

Up-skilling the housing and homelessness sector
17. Up-skilling the housing and These findings have two important implications for a society which wants
homelessness sector
to end homelessness. Firstly, that it is vital to provide trauma-informed
services to children and adults affected by adversity and trauma who are
at risk of experiencing homelessness in the future, and secondly, that it is
Jo Prestidge equally important to provide trauma-informed services to an adult homeless
population who have, and continue to experience, trauma to varying degrees
and who may struggle to access services as a result of this.
Acknowledgements: our thanks go to staff from St Basils, Porchlight and
Basingstoke and Deane Borough Council for providing the case studies.
2. The homelessness sector’s response

The editor recommends reading a complementary paper on the
author’s experience of learning about trauma-informed care in the Despite the levels of trauma faced by most people experiencing homelessness,
US in the journal Housing, Care and Support under the title of ‘Using the majority of services provided to homeless people in England have a
Trauma-Informed Care to provide therapeutic support to homeless workforce that is unlikely to have any professional training or qualifications in
people with complex needs: a transatlantic search for an approach to working with traumatised people. In addition, many ‘single’ homeless people
engage the “non-engaging”’. (i.e. those not owed a statutory housing duty) accessing services experience
multiple and complex needs, often as a result of long histories of adversity,
which presents a challenge to the services that are there to support them.
236 Homeless Link is working to address systems failure and improve service 237
1. The explicit link between trauma and homelessness provision to those experiencing the highest levels of multiple disadvantage
through the Making Every Adult Matter coalition and Housing First England.
There has been much research into the correlation between homelessness At an operational level, organisations have long been moving towards the
and trauma. It is understood that a person’s chance of becoming homeless provision of personalised, flexible and therapeutic support to respond to the
is exacerbated as a result of experiencing one, or many, traumas and that needs of those using services.
homelessness itself can lead to further experiences of adversity. In their paper,
Goodman and colleagues1 detail that there are three potential factors linking In the last few years, there has been a growing movement to up-skill staff
trauma and homelessness: (1) the experience of losing your home, (2) your and, in 2012, government guidance4 was published on the development and
experiences once homeless, especially in relation to systems that are there to delivery of Psychologically Informed Environments (PIE): a framework which
offer support and (3) past experiences of trauma which increase the likelihood can be adopted by services to improve the psychological wellbeing of those
of you becoming homeless. accessing and working in them based on the knowledge that there is a high
prevalence of trauma in the homeless population.
Histories of trauma have been further evidenced to be prevalent within
the homeless population. In a literature review conducted at Southampton Feedback from those adopting the approach suggest improved outcomes
University2, researchers found a clear link between complex trauma (beginning for those using services, in addition to reduced incidents and decreased staff
in early childhood) and homelessness. This has been further supported by turnover as a result of burnout. Many organisations have been adopting PIE
the Hard Edges3 large scale analysis of data relating to adults who have including those working with young people experiencing homelessness.
contact with homelessness, criminal justice and substance misuse systems.
Researchers found that of those individuals in contact with all three systems,
85% reported experiencing adversity as children.

Chapter 17 Up-skilling the housing and homelessness sector
From the author’s own experience, and from feedback we have received
Case Study: St Basils’ psychologically informed environment from those attending our courses, training on trauma enables staff to
better understand the needs, presentation and engagement of people who
Each year, St Basils provides supported accommodation and a range of are homeless. Following the training, workers are able to understand how
services to over 4.5 thousand homeless young people across the West relationships, support approaches and services can be delivered to create
Midlands. More than a third of these individuals present with multiple safety and empowerment and reduce re-traumatisation. Training on trauma
needs, and many have experienced adverse life experiences, including enables staff to feel more resilient, better equipped to understand and work
trauma and abuse. positively with behaviours which challenge services, and to understand the risk
that they will experience vicarious trauma as a result of their work.
St Basils aspires to create services that empower young people to
flourish and thrive. To achieve this, they implemented and developed a
Psychologically Informed Environment , utilising scientific learning, to
transform their cultural framework and inform procedures, behaviours Case study: Porchlight’s implementation of psychologically and
and policies across all areas of the organisation. Leaders, managers trauma-informed practice
and staff appreciate that maintaining a PIE is a dynamic and ongoing
process: therefore, for nearly six years, they have committed to a When implementing the Psychologically Informed Environment
programme of formal training, reflective practice and access to an in- approach, staff at Porchlight concluded that including an understanding
house psychologist. of trauma and its affect allowed for a better understanding of a person’s
psychological make-up. They knew that statistically there is a high
Integral to a PIE approach, systematic evaluation involving ongoing proportion of trauma survivors among people using homelessness
238 reflection and outcomes measurement is conducted at different levels services and so deemed it vital to give staff the tools and knowledge 239
with assistance from researchers from the University of Birmingham. around working with clients who have experienced trauma.
Arguably, the most important lesson learned is that the quality of
staff-client interactions matters, and it takes time to break through a At Porchlight, staff are trained to be trauma-informed. This has allowed
past history of adversity and abandonment to develop genuine trusting the organisation to create an environment where staff learn about the
relationships and the conditions for positive change. impact of trauma, the residue effects of trauma and the behaviours
associated with trauma. Staff are able to review and reflect on how they
communicate; enabling choice for trauma survivors who may not have
experienced choice before. Staff monitor their environments to ensure
clients feel safe. Being trauma-informed has also enabled staff to work
3. Trauma-informing the homelessness sector with the individual and their unique experiences.
Alongside an increasing number of organisations adopting PIE, it became The support and safety planning in Porchlight’s Youth and Family
apparent that the homelessness sector would benefit from specific awareness Services are based on the principles of trauma-informed care; taking
of trauma and trauma-informed approaches to delivering services. Since into account each person’s individual past and present experiences in
2015, Homeless Link has been raising the profile of trauma-informed practice order to plan for their future. Services are subsequently tailored around
and has seen a high level of demand from organisations who wish to educate the individual’s needs with innovative approaches to support and
and up-skill their staff about trauma and its impact. We have developed two improved interagency communication and joint working. This ultimately
courses and trained over 1000 frontline workers and managers. provides environments where each person’s past trauma can be dealt
with effectively using a person-centred approach.

Many local authority commissioners of supported housing services for

homeless people are starting to include psychologically and trauma-informed Case study: Basingstoke and Deane Borough Council
practice into their commissioning contracts.
Basingstoke and Deane Borough Council commissioned Homeless
Link to deliver Trauma Informed Care training to a multi-agency social
inclusion partnership of operational managers and front line workers.
4. The wider housing sector This included staff from local alcohol pathway health services, the
Community Safety team, the police, supported housing provision,
Where the homelessness and supported housing sectors have for decades outreach and day centre services, local authority housing officers, the
provided support to address the health and wellbeing needs of people floating support team and creative arts services.
accessing services, the wider system working to provide housing to adults,
young people and families it is less likely to be equipped to recognise and They took this approach to ‘trauma-inform’ the housing pathway from
respond to those affected by trauma. The work of local authorities and each access point with the aim of ensuring that all agencies had a shared
general needs housing associations is often focused on accommodation as understanding of the issues that people may be experiencing, how this
an end in itself without consideration of wider support needs, and staff may can affect their response to the environment and their ability to access,
not be aware of how to work effectively with children and adults who have engage with and trust services. This has improved coordinated planning
experienced adversity. and activity between a range of agencies with an aim of preventing re-
traumatisation.
This is a concern because individuals or families who have experienced trauma,
or who are more vulnerable, are those most likely to have contact with the Within the council’s housing team, staff have trauma and psychologically
240 wider housing sector. A lack of trauma-informed support provision has two informed practices embedded into their job descriptions. The council 241
consequences: have made changes to procedures so that individuals and families
who present to the service are offered person-centred support. This
1. Staff are unable to identify the potential risk of trauma faced by includes offering people the chance to have their assessment at a
individuals and families and may miss opportunities to act in ways to convenient time and place, often away from the council offices. After
prevent, safeguard or respond appropriately. the training, staff were quickly able to change some aspects of service
provision, including ensuring that the initial contact someone has with
2. Services and systems which do not recognise trauma or respond the service is welcoming and creates a sense of safety, planning some
appropriately can exacerbate the feelings of fear and disempowerment changes to the physical environment, as well as considering how and
faced by those affected by trauma, and can be wholly ineffective and where assessments can be undertaken.
harmful.
There are some examples of good practice which illustrate that a simple
awareness of trauma and the principles of trauma-informed practice can
change the way services are delivered.
5. Growing trauma-informed practice in the homelessness
and housing sector
Homelessness is both a consequence and cause of trauma. Access to a stable
and safe home is vital to ensuring that trauma is both prevented in the first
place, and that those who have already experienced adversity are enabled to
begin recovery.

Consequently, systems and services there to prevent homelessness, or References

intervene once an individual (child or adult) or family is already experiencing
homelessness, will deliver more effective provision if the staff of those 1 Goodman, L., Saxe, L. and Harvey, M. (1991) ‘Homelessness as Psychological Trauma: broaden-
services, including decision and policy makers, have an awareness of trauma ing perspective’ American Psychologist 46(11): 1219-25.
and its impact. This knowledge allows organisations and workers to create and 2 Maguire, N. J., Johnson, R., Vostanis, P., Keats, H. and Remington, R. E. (2009) Homelessness
and Complex Trauma: a review of the literature. Southampton: University of Southampton.
deliver policies and procedures which address the needs of trauma survivors
3 Bramley, G. and Fitzpatrick, S. (2015) Hard Edges: mapping severe and multiple disadvantage.
and, most importantly, do not re-traumatise. London: Lankelly Chase Foundation.
4 Keats, H., Maguire, N. J., Johnson, R. and Cockersell, P. (2012) Psychologically Informed
Building on emerging good practice, we would recommend that commissioners Services for Homeless People: good practice guide. LondonL Department of Communities and
Local Government
ensure:
• Decisions made at a local and national level, which determine the

response to homelessness, are underpinned by the principles of
trauma-informed care to prevent further traumatisation of an already
traumatised population.
• Decision makers commissioning health services should consider

increasing provision of trauma-focussed support to people
experiencing multiple disadvantage who are often unable to access
mainstream services due to their multiple and complex needs.
242 243
• Training about trauma and the principles of trauma-informed care is
available, and where necessary mandatory, for staff at any organisation
involved in preventing or tackling homelessness of children, families
and adults; including local authorities, general and supported housing
providers, and voluntary sector organisations for homeless young
people and adults.

Section 3
Emerging
good practice
(a local view)
244 245

Enquiring about childhood adversity and trauma
18. Enquiring about childhood adversity routinely ask service-users about childhood adversity and trauma. The Future
and trauma
in Mind report4 outlined the impact of experiencing or witnessing adversity
and trauma and set out a specific recommendation for the development of
routine enquiry procedures as a means of responding to these concerns.
Dr Warren Larkin and Dr Graham Simpson-Adkins Furthermore, the Tackling Child Sexual Exploitation report5, which set out how
the Government is dealing with child sexual exploitation in the UK, signalled a
commitment from government to introduce routine enquiry. The introduction
1. The Impact of Experiencing Adversity and Trauma in of such procedures would enable services to offer, and the public to access,
more targeted support and would aim to prevent the continuation of abuse
Childhood and adversity in future generations.
There is now a vast and compelling body of research demonstrating the link
between experiences of childhood adversity and trauma and the development
of detrimental health and social outcomes later in life. Research on Adverse 2. Why are services not already asking?
Childhood Experiences (ACEs) over the last two decades has accelerated and
has led to important developments in our understanding of these links1. ACEs Research and practice have both demonstrated a number of barriers to
refer to some of the most commonly occurring, toxically stressful experiences hearing disclosures of childhood adversity and trauma. For instance, survivors
that take place during the first 18 years of life. These experiences include of such experiences can often be reluctant to disclose voluntarily6, due in part
multiple forms of abuse and neglect, as well as various household adversities, to feelings of shame, guilt and anxiety about their experiences and the act or
such as witnessing violence between parents or caregivers. consequences of disclosure7. However, survivors have suggested that these
246 issues can either be exacerbated or alleviated by the responses of the person 247
There have been a number of large scale population based studies that listening to their disclosure8.
collectively provide powerful evidence confirming that ACEs are causally
and proportionately linked to poor physical, emotional and mental health Furthermore, health and social care practitioners have described an
outcomes. Put simply, the more ACEs an individual experiences, the worse unwillingness or discomfort with the idea of having to ask people about
their outcomes. Recent UK regional and national ACEs studies2 revealed that childhood adversity and trauma9. Young and colleagues10 identified
around 50% of the UK population experience at least 1ACE, with around professional anxiety as a major cause of such reluctance, particularly due
12% experiencing 4or more. Greater numbers of ACEs are associated with to a perceived risk of upsetting the service-user, fears of the process being
dramatically increased risk of poor educational and employment outcomes, upsetting for them as professionals and concerns related to the development
low mental wellbeing and life satisfaction, alongside the development of some of false memories. Consequently, both service-users and professionals have
of the leading causes of disease and death. described a need for professionals to be trained to ask routinely; helping
professionals to feel more confident to ask, in order to support service-users
Furthermore, abuse, trauma and other adverse experiences have been found to feel more comfortable to talk about their experiences.
to often co-occur. For instance, if a person experiences one type of abuse or
adversity, they are 87% more likely to experience other types of abuse and
adversity; the more types of abuse and adversity a person experiences, the
higher the risk of harmful health and social outcomes later in life3. 3. What do we know about impact of disclosures?
These findings indicate a public health imperative to prevent and respond Research has regularly shown that, although people rarely disclose voluntarily,
more appropriately to experiences of adversity in our society. Health and people often expect to be asked about these experiences by health and social
social care services have an opportunity at the point of initial contact to care practitioners. Furthermore, disclosure can have the opposite effect to

Chapter 18 Enquiring about childhood adversity and trauma
what professionals often think: it can actually reduce distress. Disclosures a. Development of REACh
can positively impact recovery, promote resilience and improve a person’s
perceptions of themselves11. However, delaying a disclosure or never having In 2013, Dr Warren Larkin and a small team from Lancashire developed
the opportunity to make a disclosure is associated with more negative the REACh model; a training programme designed to develop the skills and
outcomes. confidence of professionals to routinely ask about childhood adversity and
trauma. This programme was developed to offer a clear practical framework
Evidence suggests that, if people are not asked directly, it can take between for change and to support professionals to feel confident enough to routinely
nine to 16 years for an adult to disclose a history of abuse or adversity12. We ask service-users about early adverse life experiences.
have received practice examples where a service-user has accessed a service
intermittently for many years, but when a professional invited that person The REACh approach began when the lead author used the ACE literature
to discuss whether they had experienced childhood adversity or trauma, the as a compelling case for the introduction of routine enquiry about abuse and
service-user disclosed a number of adverse experiences, which had not been traumatic experience within a first episode psychosis (FEP) service. As a result
previously known to the service. When professionals asked people why they of positive engagement and support at team development sessions it was
had never disclosed this information before, the reply was often, “you never agreed that routine enquiry should be introduced within the service, given the
asked”. excess of abuse and trauma reported by people with psychosis13. Almost 100
practitioners in the FEP service were trained and this experience provided
Asking enables people to move on from their current situation. This valuable insight into the essential ingredients required to implement and
conversation can support people to understand the impact of their embed routine enquiry.
experiences in the context of their current circumstances, helping them to
find new solutions. People begin to create meaning through telling their story, Funding was secured from a range of sources between 2013 and 2015, and
248 which can help them to make sense of the experiences with that professional. partnerships with local authority, public health, charitable and voluntary sector 249
This empowering experience can be a catalyst for meaningful change. Making organisations were formed. REACh was successfully implemented across a
links between their past adversity and present difficulties can facilitate range of services, including health visiting, substance misuse, domestic abuse,
a greater potential for self-compassion and helps people re-frame their young people’s services, early help and family intervention and prevention.
current situation as an understandable reaction to extremely challenging These organisations are still routinely enquiring three years post training.
circumstances. Partners report that this approach has enabled organisational and cultural
change as well as improved engagement and outcomes for service-users.
Services are better able to provide targeted support for people, resulting in
improved outcomes for services and service-users.
4. Recognising a need to change
As outlined, experiencing adversity and trauma early in life increases one’s b. The REACh model
risk of developing negative health and social outcomes, including poor
mental health and wellbeing. Consequently, the Government, in response REACh aims to raise awareness among professionals and the public about
to a recognition of such high prevalence, have called for services to do more long-term outcomes of childhood adversity and trauma. This is achieved by
to routinely identify and provide support for those who experience early life establishing and supporting organisational practice and culture change by
adversity, so that health and social care service providers can offer appropriate embedding REACh within every appropriate assessment.
interventions to support positive recovery.
REACh involves, as part of the model of delivery, one or 2-day training on
To support this need, the Routine Enquiry about Adversity in Childhood why, when and how to enquire safely and sensitively, alongside organisational
(REACh) model was developed. support, helping teams to navigate potential risks and challenges and to ensure

appropriate staff support is in place. The model has five key elements. c. The Evidence
• Stage 1 is a co-produced audit and evaluation of an organisation’s In 2014, evaluation of the experiences and insights of staff trained in REACh
readiness to engage in routine enquiry. This helps to identify any revealed a number of positive impacts on professional practice and client
potential systemic barriers and supports organisational buy-in. outcomes14. For instance, REACh training inspired practitioners to develop
a trauma-informed understanding of clients’ experiences, resulting in clinical
• Stage 2 involves consideration of change management processes and practice changes, which, in turn, facilitated more lasting change for clients.
a review or design of an organisation’s specific systems and processes It was found that enquiries encouraged clients to make links between their
required to support effective and safe enquiry. past and their present situation, enabling them to accurately identify the right
support for them, at the right time. The research findings also suggested that
• Stage 3 is the delivery of REACh training, which is tailored to the not all clients required, or wanted, referrals for psychological or other practical
organisations specific needs, in terms of content and delivery methods. support in relation to their disclosure. In the majority of cases, therapeutic
conversations with practitioners seemed to be sufficient to encourage
• Stage 4– the REACh team offer time-limited follow-up support to meaningful change.
the organisation, including consultation and supervision for staff and
leadership teams, to ensure effective implementation. In 2015, an independent evaluation of the REACh programme15 found that
REACh training equips practitioners with the knowledge and tools to conduct
• Stage 5– the team support the organisation to evaluate the routine enquiry effectively with the people they support. All practitioners who
implementation of REACh, to assess practice change and the impact on attended the training reported that it was useful, enjoyable and increased
their service and service-users. their knowledge and awareness of childhood adversity and trauma, including
250 its widespread impacts. REACh was found to initiate earlier intervention, as 251
a result of speedier disclosures. Importantly, practitioners reported no issues
Figure 1: The REACh Model with implementing REACh in their practice and reported no increase in service
need following the enquiries made. Participants and managers felt that they
were able to create with the individual a more appropriate intervention plan if
they have enquired about previous experiences, dealing with the root cause of
Readiness checklist and organisational ‘buy in’ presenting issues rather than the ‘symptom’.
The most recent evaluation in 2016 qualitatively explored the impact of

Change management – systems and processes to support enquiry REACh on parents accessing an early help family support team16. Results
demonstrated that all parents agreed to engage in enquiries. Although the
process of disclosure was emotive, parents’ post-disclosure reflections
Training Staff – hearts and mind and how to ask and respond appropriately resulted in a process in which they re-evaluated their parental goals, roles and
priorities. This re-evaluation appeared to initiate a drive to parent differently,
propelled by their desire to give their child a better start in life. These results
Follow-up support and supervision for staff and leadership team demonstrated that, without any post REACh intervention, parents appeared
to engage in a self-determined process of post-disclosure behaviour change,
alongside a number of positive impacts, such as increased mentalizing
Evaluation and research capacity17 and experiences comparable to post-traumatic growth18. These
impacts resulted in reports of improved relationships between parents and
their children.

d. Current projects 5. Next steps

The Tackling Child Sexual Exploitation report19, reported failings across the Firstly, we hope to continue to improve community awareness about the
wider care system to respond to or protect children and young people from impact of childhood adversity and trauma and to support the development
child sexual abuse (CSA) and Childhood Sexual Exploitation (CSE). As a of approaches to address this widespread public health issue. We hope that
response the Government made a commitment to introducing routine enquiry on-going research and evaluation of REACh will help to provide a better
about such abuses in some targeted NHS commissioned services. Services understanding of methods for harm reduction and broader prevention
such as Mental Health and Substance Misuse teams will be supported to strategies in relation to experiences of childhood adversity and trauma. From
routinely ask those over 14 years old who present to their services about their the work we are currently doing, we also hope to identify and quantify the
experiences of adversity. In 2016, as a result of the success of the REACh impact of practice change produced by REACh in terms of improved outcomes
model, the Department of Health commissioned the REACh team to develop for services and service-users, alongside highlighting any resulting cost
a method of improving the skills and confidence of services to routinely ask avoidance and service utilisation as result of implementing routine enquiry
about CSA, nationally. The objective of this training package is to provide in standard practice. More broadly, the information collected from enquiries
the materials, tools and evidence to enable the Department of Health, NHS in the Department of Health pathfinder project and subsequent roll out will
England and Public Health England to progress wider roll-out of routine hopefully enable earlier identification of abuse and adversity at local and
enquiry; a key deliverable in the Tackling Child Sexual Exploitation strategy. national level. Providing prevalence data for local commissioners and services
should enable more appropriate service provision, earlier offers of meaningful,
The REACh team have utilised learning from their work to devise procedures tailored support and support widespread cultural and practice change.
and training for enquiring specifically about various forms of CSA, in the
context of other childhood adversities, using the broader framework of ACEs.
252 This has also involved adapting an approach initially designed to work with 253
adults, to support sensitive enquiries with children and young people. This
has provided evidence that the REACh model can be extended to enquiries
about various forms of adversity and can support enquiry with children and
young people. The Department of Health pilot will initially be trialled with
professionals in targeted services, including children’s mental health, sexual
health and substance misuse services.
The team have also commenced work on a number of other pathfinder projects
to further develop the REACh approach in various settings. For instance,
REACh is currently being adapted and evaluated for use in GP practices. In
collaboration with Blackburn with Darwen local authority Children in Our
Care Virtual Head-Teacher, the team have also begun work on developing a
trauma-sensitive school model and have also commenced work with a local
safeguarding children board to devise trauma-informed procedures to support
the missing from home pathway. The team have recently developed an online
training module to improve awareness of childhood adversity and trauma-
informed approaches. This online module has been developed by and is
currently being utilised within Lancashire Care NHS Foundation Trust and will
also form part of the resource package designed for the Department of Health
project described above.

References 15 Real Life Research (2015) An Evaluation of REACh: Routine enquiry into adversity in child-
hood. Blackburn with Darwen: Independent evaluation of work commissioned by Blackburn
local authority Public Health team.
1 For more information: https://www.cdc.gov/violenceprevention/acestudy and Filetti, V.J., 16 Simpson-Adkins, G. J., and Daiches, A. (in press) Exploring the Impact of Enquiring About the
Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M. and Marks, J. Adverse Childhood Experiences of Parents. Manuscript submitted for publication.
(1998) ‘Relationship of childhood abuse and household dysfunction to many of the leading 17 Allen, J.G. and Fonagy, P. (2006) The Handbook of Mentalization-based Treatment. New
causes of death in adults’ American Journal of Preventive Medicine 14(4): 245-258. Jersey: John Wiley and Sons.
2 Bellis, M.A., Lowey, H., Leckenby, N., Hughes, K. and Harrison, D. (2013) ‘Adverse Childhood 18 Tedeschi, R.G. and Calhoun, L.G. (2004) ‘Posttraumatic Growth: Conceptual foundations and
Experiences: retrospective study to determine their impact on adult health behaviours and empirical evidence’ Psychological inquiry 15(1): 1-18.
health outcomes in a UK population’ Journal of Public Health 36(1): 81-91.
19 HM Government (2015) Op. cit.
Bellis, M.A., Hughes, K., Leckenby, N., Perkins, C. and Lowey, H. (2014) ‘National household
survey of adverse childhood experiences and their relationship with resilience to health-harm-
ing behaviors in England’ BMC medicine 12(1): 72.
3 Filetti, V. J., et al (1998) Op. cit.
5 HM Government (2015) Tackling Child Sexual Exploitation: https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/408604/2903652_RotherhamResponse_acc2.
pdf
6 Read, J., McGregor, K., Coggan, C. and Thomas, D. R. (2006) ‘Mental health services and sexual
abuse: the need for staff training’ Journal of Trauma and Dissociation 7(1): 33-50.
7 Alaggia, R. (2004) ‘Many Ways of Telling: expanding conceptualizations of child sexual abuse
disclosure’ Child Abuse and Neglect 28(11): 1213-1227.
254 Dorahy, M.J. and Clearwater, K. (2012) ‘Shame and guilt in men exposed to childhood sexual
abuse: A qualitative investigation’ Journal of Child Sexual Abuse 21(2): 155-175.
255
Tener, D. and Murphy, S. B. (2015) ‘Adult disclosure of child sexual abuse: a literature review’
Trauma, Violence and Abuse 16(4): 391-400.
8 Glover, D. A., Loeb, T. B., Carmona, J. V., Sciolla, A., Zhang, M., Myers, H. F. and Wyatt, G. E.
(2010) ‘Childhood sexual abuse severity and disclosure predict posttraumatic stress symp-
toms and biomarkers in ethnic minority women’ Journal of Trauma and Dissociation 11(2):
152-173.
9 Read, J., Hammersley, P. and Rudegeair, T. (2007) ‘Why, when and how to ask about childhood
abuse’ Advances in Psychiatric Treatment 13(2): 101-110.
10 Young, M., Read, J., Barker-Collo, S. and Harrison, R. (2001) ‘Evaluating and overcoming barri-
ers to taking abuse histories’ Professional Psychology: Research and Practice 32(4): 407.
11 Frattaroli, J. (2006) ‘Experimental disclosure and its moderators: a meta-analysis’ Psychologi-
cal Bulletin 132(6): 823.
Marriott, B. R., Lewis, C. C. and Gobin, R. L. (2016) ‘Disclosing traumatic experiences:
correlates, context, and consequences’ Psychological Trauma: theory, research, practice, and
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12 Read, J. et al. (2006) Op. cit.
13 Larkin, W. and Read, J. (2009) ‘Childhood trauma and psychosis: evidence, pathways and
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14 Pearce, J., Murray, C., Larkin, W., and Simpson-Adkins, G. (forthcoming) Asking about Child-
hood Adversity and Trauma: Experiences of professionals trained to routinely enquire about
child adversity.

Rethinking specialist and liaison services for young people who have experienced adversity or trauma
19. Rethinking specialist and liaison a. What is a ‘specialist’ service?

services for young people who have Frequently, when services designed to meet a specific area of need are
experienced adversity or trauma

being considered for development there follows a sometimes heated debate
about the pros and cons based on commissioners’ and professionals’ existing
experience of ‘specialist provision’ (see Table 1). This can lead to inertia
Dr Nick Hindley and Dr Carmen Chan because of strongly held views on either side of the debate, all of which may
be, in some respects, valid. A specialist service could be defined simply as
one “which offers skills or expertise which are not available in more routine
provision”. The key to developing such provision would be to maximise the
1. Introduction benefits and minimise the potential disadvantages (as outlined in Table 1) of
such an enterprise. This will be the principal focus of this paper.
This paper describes a service model which facilitates responsiveness and
maximises the influence and positive effect of specialised services working
with children and young people. It provides a means whereby services with Table 1: Pros and cons of specialist provision
particular expertise can be used in a way that supports professionals, young
people and their families. The model of provision is applicable in any situation Pros Cons
where more specialist expertise of any kind is required to support existing
services in areas about which they may feel anxious or unskilled. Furthermore, Expertise and specialist knowledge Can have very small caseload and be
expensive for relatively small gain
it has been used and evaluated in services specifically working with children
256 and young people under 18 that cover catchments of differing populations High level of input in complex situations Can be difficult to access and approach 257
and geographical area and are targeted at young people who are traditionally
considered ‘hard to reach’, have frequently had traumatic experiences, and Contain anxiety among professionals Can become divorced from local
whose needs have been difficult to meet1. To be effective, it is vital that any and families, and at times may need to provision if aloof or covers too large a
inject anxiety and promote action geographical area
service model incorporates trauma-informed understanding of young people’s
difficulties that explicitly combines application of specialist knowledge with Can identify necessary strategic May not make use of expertise outside
appreciation of the needs and views of the young people in question. developments arising from gaps in the core team
provision
May cover a large geographical May have limited and rigid service
2. Key principles and considerations catchment and/or large population responses to referrals
The development of optimal services for children and young people who have
experienced adversity requires the initial creation of a set of principles or
considerations that can inform any subsequent service design. While some of b. The importance of ethos
these considerations will be specific to the area of focus of any specific service
(for example, harmful sexual behaviour or experience of sexual abuse), many All services working with high risk/high concern young people clearly need
such considerations are relevant to services for young people in general. A to have highly developed governance structures so that they, their clients
number of these principles will now be considered. and families and society in general can be reassured about safety and good
practice. Such matters frequently become the principal focus of development
work once a service is commissioned. Less frequently is attention paid to the

Chapter 19 Rethinking specialist and liaison services for young people who have experienced adversity or trauma
ethos of the service and, in particular, the way in which the team would wish to and advice within the construction of a cross-agency care plan focussing on
be perceived by others – its service users and professionals seeking advice and identification of unmet need and general measures fostering attachment and
support. resilience such as continuity of professional input, support for existing positive
relationships and educational/occupational provision. Particularly when there
Frequently, the ‘authoritativeness’ of the service (its ability to provide clear are multiple professionals involved in a young person’s care, it is important that
answers in relation to its area of expertise) can mean that accessibility to those it is the young person’s needs rather than professional anxiety that underpin
who are asking for its intervention and support can become restricted. While any care plan. In line with this, direct intervention with the young person
in areas of complexity and high need it is not always possible for specialist should be delivered where possible by individuals already trusted by and/or
provision to meet all expectations, service models should aspire to being engaged with them6.
both accessible and authoritative. It is also not enough for such an ethos to
be evident in the circles, arrows and boxes of a service diagram or the text Given the above, a service should offer a consultation and liaison model to
of a service specification, it should also be evident in the approachability and support universal services in understanding the impact of early adversity and
flexibility of approach of individuals within a team. Equally, the service should trauma and to ensure that the appropriate level of specialist support is made
fit around the needs and view of the young person, rather than a young person available. This model should offer the possibility of direct specialist input but
‘fitting’ around predetermined inclusion criteria.2 only when other consultative input has demonstrated that this is needed.
c. Building resilience in individual young people’s and professional networks d. Response to concern
A key consideration when working with young people who have experienced A specialist service working with young people who have experienced
258 childhood adversity is that of not inadvertently creating greater levels of adversity and/or trauma who may be difficult to engage should understand 259
complexity or indeed harm. Frequently, the higher the concern, the more the wide variety of complex circumstances and situations in which young
professionals are drafted in to contribute to an increasingly complex solution3. people find themselves and also the range of professionals with whom they
This can be counterproductive (as reported by young people and their may come into contact. In such circumstances, the service should not expect
families), tends to lead to multiple assessments and interventions becoming an initial contact from professionals to be perfectly formed and extensively
part of a professional care plan, and can lead to a young person or family documented.
(who may already be demonstrating considerable mistrust or apprehension)
disengaging further from well-meaning attempts to provide help and support. A referring professional may be highly experienced in working with and
Furthermore, in the cases of some young people who are known to have been understanding young people but may not be well-versed in the language and
subject to serious adversity or maltreatment in the past, the quest for them to format of making referrals (for example they may have a concern about a
‘address’ this or talk about it can become the focus of a multi-agency solution young person’s mental health but may not be able to phrase this in diagnostic
when the child is in no position to do this or actively does not wish to do so. It terms). Equally a service receiving written referrals from professionals
is important first to build resilience and ensure sufficient safety (both in the working with this particular population may wish to explore further with the
young person’s system and within themselves) before focusing explicitly on referrer and others involved before deciding on the best course of action. In
any trauma that they may have experienced4. general, even the most specialist services should be accessible by whatever
means for initial contact so that they can ensure that strict criteria for
A specialist service (supplementing existing provision for children who have processing of referrals do not discourage some professionals from contacting
experienced adversity) may frequently not to be directly involved with a child the service with appropriate concerns.
about whom there are high levels of professional concern. At the same time it
is important that staff are provided with “access to high quality … advice when
and where it is needed”5. In many cases such a service can provide support

e. An ‘ecological’ and stepped approach to need Equally, grounded in the first phase of any trauma-informed intervention with
young people, should be the development of a sense of safeness and stability
It is highly unlikely when working with young people with complex difficulties that clearly takes into account the child’s hierarchy of need8. Figures 1 and
who may have experienced significant adversity, that a single intervention or 2 highlight the importance of joint consideration of ecology and hierarchy of
agency will provide a single solution. In general, complex situations require need and underlines how important more general consideration of factors
complex solutions and good cross-agency collaboration focussed on achieving such as physiology, safety and social needs may be before more complex areas
consensus is likely to have the most productive results. This requires a such as self-esteem and self-actualisation can be addressed.
specialist service to recognise and consider the dynamic interplay between a
young person, their family, and their social environment (see Figure 1). Such an
approach is frequently referred to as ‘ecological’ and planning should include Figure 2: Hierarchy of needs (following Maslow)
assessment of risks/vulnerabilities and protective factors on each level7.
Figure 1: An ecological approach to understanding a young person’s needs
Self
Actualisation
SOCIAL Esteem
260 261
Social
PROFESSIONALS
Safety
SCHOOL
Physiological
FAMILY
Thus, for example, in line with guidelines for working with complex trauma
presentations, it is important to ensure that a young person is ‘safe enough’ to
YOUNG make use of specialist individual interventions (such as psychological therapy)
PERSON before they are instigated9. A specialist service, in such circumstances, is thus
not defined by how specialist the interventions are that it can provide, but
rather, by its ability to identify and recommend what may be the most useful
intervention for a child given a specific set of circumstances.
Often, such recommendations involve a focus on core needs and strengths

which can be provided by professionals already involved with the child (as long consensus can bring to their case. In such situations, protocols alone can rarely
as they are reassured that a specialist service will continue to support them provide a meaningful solution and it is most likely that existing collaborative
and will become more directly involved if needed). This is a key issue for the relationships at a senior level between agencies will provide the best means of
credibility and perceived usefulness of a specialist service: a service which this being achieved. Specialist services should consider it a vital part of their
provides advice and consultation alone without demonstrating a willingness role to understand hierarchies within their own and other agencies and also to
to become more directly involved in cases when the need arises is unlikely to have established meaningful links with senior colleagues so that the possibility
foster confidence or contain anxiety within professional systems10. of escalation of concern can be undertaken quickly and lead to a return to a
collaborative response to the young person in question.
f. Flexibility of response and knowing the catchment

Flexibility of response to requests for service involvement requires a 2. Building a responsive service model
combination of a flexible service model (discussed further later in this paper),
an ethos fostering accessibility (already discussed) and good knowledge of A working model which allows a service to adhere to the principles outlined
catchment. above should have a number of particular attributes (see Box 1). The type
of model which best meets these demands is a ‘liaison’ model which reflects
If a specialist service is to fulfil effectively its identified function working with practice and process traditionally used in mental health practice in general
young people who have experienced adversity, it is crucial that it knows its hospital environments11. For some reason, the application of such a model
geographical catchment both in terms of the range of services available to beyond such settings has rarely been described. The authors feel that it is
young people and the relative strengths and limitations of those services. This applicable in all environments that are busy, constantly changing, frequented
262 kind of information is crucial for a service seeking to identify when it may need by multiple professionals from a range of different disciplines and are where 263
to become directly involved with a young person (rather than being involved in complexity abounds and, for this reason, it fits with specialist services working
a more consultative way with professionals). Circumstances dictating this may with young people with complex needs.
not always be because of the identified needs of the young person but because
of the relative lack of provision in his/her home area. The converse is also true,
if there is a particular strength in service provision in a given area (such as a Box 1: Requirements for an effective specialist service
particularly experienced local practitioner or service) there may be less need
for direct involvement by a specialist service. A working model for a service working with young people with complex
needs and experience of adversity should:
g. Escalation of concern and development of relationships across • facilitate the maximum use of the expertise of the team
agencies (in addition to protocols)
• allow easy initial access to potential referrers
As mentioned previously, complex situations involving young people who
have experienced adversity frequently mean that multiple agencies and • provide a level of service commensurate with identified need
professionals become involved in individual cases. In certain circumstances,
a situation can become so difficult that it becomes stuck to the extent that • allow 2-way (‘socratic’) interaction between all parties and
professionals cannot jointly effect change or that a lack of progress leads facilitate consensus planning
to professional disagreement and recrimination. Such outcomes usually
impact most upon the young person who then is not only aware of the adult • be transparent and allow clear identification of responsibility
disagreements but also fails to experience the benefits that professional

Figure 3: Distribution of functions within a liaison service model

Box 2: Strategic functions of a specialist service
A working model for a specialist service should include the following

strategic functions:
Direct
• raise awareness of the team and ensure that ease of initial
intervention
access is understood
• provide training for professionals working with children and Assessment

targeted supervision/enhanced liaison with identified services
Complex liaison
• identification of gaps in service provision and showing
leadership in development of effective means to address them
Consultation
• evaluating provision and disseminating findings locally,
regionally or nationally as appropriate Advice
264 The key features of a liaison service model address the need for involvement 265
in individual casework at a number of possible levels and a range of strategic a. Initial accessibility and advice
functions (see box 2). The model can maximise the potential strengths
and minimise or reverse the pitfalls of specialist provision. In practice, the Any service working to a particular geographical catchment needs to ensure
casework model comprises a stepped approach which is based on initial that it is available to the patient/client group for whom it is designed. In
accessibility and, as necessary, provision of advice, formal consultation, practice this can prove difficult when working with complex young people
assessment and intervention. Such an approach enhances the flexibility who may be in contact with a multiplicity of agencies with differing skillsets,
of a team’s response for reasons discussed above rather than relying on a levels of experience, professional backgrounds and cultures. For this reason it
more rigid ‘one size fits all’ response to referrals and requests for service is important that initial contact with such a service should be welcomed from
involvement. In addition, it ensures that the skills of the team are applied as any source that has a concern relating to the provision offered by the service
efficiently as possible. The proportional distribution of such functions within in question; it is sufficient in such circumstances for individuals to realise that
an overall caseload is outlined in Figure 3, opposite. they are uncertain and that an initial point of contact is available. The service in
question should welcome such contact and make this clear.
Once contact has been made the service can undertake a brief discussion
3. Key components of a responsive liaison model with the referrer during which it will be possible to ascertain whether further,
more formal input is required. If it is not, the service may be able to suggest
Below we have summarised the key components of a responsive liaison model, or facilitate access elsewhere in relation to the concern in question. If formal
based on our work in Oxfordshire. These can act as a guide to commissioners input is considered necessary this begins via a process of formal consultation.
and providers in establishing liaison services in their local area.

b. Formal consultation than professionals and families may consider to be the case. Thus, overall,
a specialist service working with young people with complex needs may be
Involves a more detailed case discussion led by an experienced specialist involved more frequently in recommending simple ‘generic’ interventions and
service team member. For this process, relevant background documentation less frequently in providing the highly specialist interventions which they have
should be available. The time for such a discussion should be clearly identified at their disposal (see Figure 3). This does not mean that the team is shirking its
but it can be undertaken either face to face or by phone or videolink. The key responsibilities but rather that it is providing levels of support to young people,
issue in this process is that the discussion should be sufficiently detailed to families and professionals in accordance with individual need.
satisfy both parties and to facilitate the development of a mutually agreed
plan of action. This may involve the referrer taking a lead in delivering such a
plan, involvement of the specialist team in further cross-agency discussion or 4. Conclusion
formal process without direct involvement with the patient/client (‘complex’
liaison) or a decision for the team to become directly involved in assessment. This paper has outlined a set of principles and a systemically-informed model
Wherever possible, collaborative or joint working between parties should be for specialist teams working with young people with complex needs who
prioritised and the case should remain open to the specialist team to monitor have normally experienced significant adversity or trauma. The authors have
and, if necessary, revise any agreed plans. Such plans should also be confirmed repeatedly emphasised the necessity both for flexibility of working models and
in writing. ethos in such work but at the same time they would wish to emphasise that
this should not be at the expense of good professional practice or the provision
of authoritative opinion. A service working with high risk/high concern young
c. Assessment people needs to be very clear about the nature of its remit and about ensuring
that all concerned are aware of their particular responsibilities. Above all,
266 A decision for the specialist service to undertake assessment should be teams need to work to ensure that their contribution is in the best interests of 267
prompted by clear identification of concern or need within the team’s remit. young people and their families.
Ongoing uncertainty following formal consultation regarding the client/
patient’s level of need the lack of progress of a plan needs to be agreed at
the formal consultation stage. Wherever possible, assessment involving the
specialist team should involve the referrer. Subjecting a child or family to serial
assessments when not strictly needed should clearly be avoided.
d. Interventions
Broad interpretation of ‘intervention’ should accompany implementation of
the service model. Thus, any of the levels of input provided by the team could
be considered an intervention. This applies to case management advice and
achievement of consensus within multiagency planning. Even a decision at the
time of initial contact not to proceed with specialist team input falls into this
category.
Specialist direct interventions for a young person will be available from a

specialist service. However, the circumstances where such interventions are,
for reasons already discussed, likely to be required are often less frequent

Chapter 19
References 20. Addressing adversity through

1 Such services include a ‘regional’ forensic CAMHS service covering four counties, a service
for young people with sexually harmful behaviour, and a service for young people who have
alternative education
experienced sexual trauma both covering smaller, but clearly defined catchments.
Betsy de Thierry
3 YoungMinds (2014) Report on Children, Young people and Family Engagement (for The Chil- This paper includes extracts taken from the following three papers with the
dren and Young People’s Mental Health and Wellbeing Taskforce). London: YoungMinds
kind permission of the author, de Thierry. B. (2015):
4 Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L.,
Lanius, R., Stolbach, B.C., Spinazzola, J., Van der Kolk, B.A. and Van der Hart, O. (2012) The
ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults: https://www. • Teaching the Child on the Trauma Continuum, London, Grosvenor
istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Com- Publishing (2016);
plex-PTSD-Updated-060315.pdf
McFetridge, M., Swan, A.H., Heke, S., Karatzias, T., Greenberg, N., Kitchiner, N. and Morley,
• The Simple Guide to Child Trauma. What it is and how to help, London,
R. (2017) Guidelines for the Treatment and Planning of Services of Complex Post-traumatic
Stress Disorder in Adults: http://www.ukpts.co.uk/guidance_11_2920929231.pdf Jessica Kingsley Publishers (2017);
5 Department of Health / NHS England (2015) Op. Cit.
6 YoungMinds (2014) Op. cit. • ‘Understanding the impact of trauma on children in the classroom’
7 Bronfenbrenner, U. (1979) The Ecology of Human Development. Cambridge: Harvard Univer- in: D, Colley, Emotional Development and Attachment in the Classroom:
sity Press theory and practice for students and teachers, London, Jessica Kingsley
Jack, G. (2000) ‘Ecological influences on parenting and child development’ British Journal of Publishers (2017).
268 Social Work 30: 703-720.
269
8 Maslow, A.H. (1943) ‘A theory of human motivation’ Psychological Review 50: 370-396.
9 Cloitre et al. (2012) Op. cit. and McFetridge et al. (2017) Op. cit.
10 Menzies-Lyth, I. (1959) ‘The functioning of social systems as a defence against anxiety’ Human
Relations 13: 95-121.
1. Introduction
11 Woodgate, M. and Garralda, M. E. (2006) ‘Paediatric liaison work by child and adolescent
mental health services’ Child and Adolescent Mental Health 11: 19-24. This paper explores the need to have alternative provision across the UK that
is trauma-informed and focusing on the recovery from childhood trauma, and
not the management of behaviour. The paper will look briefly at assessment, the
framework of our provision and the key theoretical underpinnings of the work.
The primary underpinning philosophy of the Trauma Recovery Centre’s (TRC)

Oakside Creative Education Centre1 and the Therapeutic Mentoring Rooms2
is that children can recover from the impact of trauma when they are able to
engage in an appropriate intervention for the level of trauma experienced, the
trauma symptoms presented and the environmental capacity in their setting.
When they are able to recover, their behaviour, emotions, relationships and
learning can then also recover from the impact of the trauma.
Recovery from trauma involves repetitive, rewarding, nurturing, long-term

relationships that facilitate co-regulation as an essential step before self-
regulation and also include creative therapy that is trauma-informed.

Chapter 20 Addressing adversity through alternative education
2. The Trauma Recovery Centre and Therapeutic 3. The impact of trauma on a child and the knowledge
Mentoring Rooms that recovery is possible
The Trauma Recovery Centre and Therapeutic Mentoring Rooms are Abuse, neglect and trauma in childhood affect a child’s psychological
organisations that provide trauma-informed, recovery focused provision functioning, their neurological (brain) responses, their relationships and their
for children and young people who have suffered trauma. The BdT Ltd capacity for hope3. It is known that from early infancy through to adulthood,
organisation provides training to schools, police and organisations in trauma- trauma can change how we perceive ourselves and the world around us, how
informed practice and has therapeutic mentoring rooms within mainstream we process information, and how we behave in response to our environment4.
schools that attach a trauma-informed psychotherapist to a school to offer Without appropriate intervention these altered cognitive processes and
clinical supervision and assessment of significantly traumatised children to behavioural responses can lead to long-term problems, such as difficulties
avoid exclusion. The TRC has therapy centres with teams of qualified art, in learning, self-regulation and/or behaviour5. Trauma is stored in the
music and play therapists in four cities and provides alternative education for subconscious and the body and as such cognitive or behavioural approaches
excluded children which use the creative therapy spaces and also uses forests are unhelpful and ineffective and the children and young people need trauma-
and outdoor space. informed psychotherapy to process the trauma.
Our primary underlying ethos is that children and young people have a right It is in times of great stress, or trauma, that the brain activates its deeply
to recover. However, the majority of alternative provision on offer elsewhere instinctive, ‘fight, flight, or freeze’ survival responses. These responses to
is ‘managing’ their behaviour and not facilitating recovery and this is creating threat are ancient, primal mechanisms that prioritise surviving over the higher
significant problems long term with rising mental health issues and rising functioning thinking, judging or evaluating that takes place in the prefrontal
270 criminal justice issues. cortex (neocortex). The responses to threat or perceived threat are located 271
in the brain stem, which is the area of the brain that is fully formed by birth.
The other primary underpinning knowledge that we hold as central is that It is responsible for breathing, heart rate, body temperature and also these
trauma affects a child’s emotions, behaviour, learning, relationships and automated threat responses. The brain stem, on alert, immediately sends
memory. The Trauma Recovery Centre offers therapy with parenting support messages to an area of the brain called the amygdala that is located in the
groups and alternative education centres in buildings that are not on school limbic area – just above the brain stem.
sites and include forest school spaces. This alternative setting offers a neutral,
homely environment for those who need to find a safe place to recover that is In our work in the Therapeutic Mentoring Rooms and at the Trauma Recovery
not associated with schools or clinical settings. Centre, in the context of respectful relationships towards the children for
their courage to survive terror, we spend time with the children exploring how
The Therapeutic Mentoring Rooms work from the same theoretical the brain is working and how the brain is processing information and stimuli
framework as the TRC and yet work within the school setting offering a from the environment. We tell the children that the amygdala is like a smoke
different but complementary service to prevent exclusion. The Therapeutic alarm, and alerts the body to the threat (perceived threat or clear danger) and
Mentoring Rooms do not work as intensively with the parents but can offer adrenaline and cortisol gets pumped around the body so that it is ready to
more frequent sessions of support from a known and specially trained staff have enough energy to react in an emergency.
member at school, who are clinically supervised by a trauma-informed
psychotherapist and this provision requires less out of school time and less When the limbic areas of the brain are fully alert and active, the consequence
transport challenges. is that the prefrontal cortex goes ‘off line’. As trained therapists, we explain
to the children that when this happens, our ability to be rational, reasonable
and thoughtful is hindered. We believe that this physiological response
to trauma needs to be explained to the children to reduce the shame and

shock that they often feel about their responses. Reducing shock and shame 5. Trauma-informed underpinnings
enables relationships to be built which can facilitate recovery. It is also why
we recognise that interventions such as cognitive behaviour therapy can be Both projects are based on theories that are foundational to the work of
unhelpful and frustrating for the traumatised child cannot access their pre psychotherapists and which maintain that the process of recovery includes
frontal cortex to reflect or think about their behaviour or thoughts. processing the traumatic experience, which may need the help of a clinical
trauma specialist.
Too often, an adult’s first reaction to an incident of high emotion, hurt or
aggression in school is to say to the child “why are you doing this?” while As a teacher and a psychotherapist I know the importance of both professions
expressing frustration or even anger. The problem here is that most children working well together and the centrality of both the clinician’s professional
are desperately wanting to say, “I don’t know, you tell me – you’re the adult! training (in understanding the subconscious where the impact of trauma
I am more terrified than anyone else by what I am doing. I did not want to do resides) and the teacher’s ability to build a consistent relationship and
this and I’m scared!” They cannot articulate this as their ability to reflect or be nurturing culture in the classroom. I believe that education staff are positioned
rational is still ‘off line’. As adults, we need to wait until the ‘emotional brain’ has to be able to focus on the importance of relationships and emotional literacy
calmed and the ‘thinking brain’ has re-engaged before we can begin to reflect and the vital underpinning philosophy that ‘behaviour is communication’.
on the incident. Meanwhile, the partner clinicians can unpick and unravel the subconscious
aspects that may be driving behaviour and reactions because this has become
stuck and muddled due to the trauma.
4. Being curious and the ability to learn The other primary theories that underpin the work in both projects that I have
started are those that are central to play and arts therapy such as Axline6 and
272 Due to the brain changes that occur in the aftermath of trauma, a child Oaklander7 alongside contemporary research regarding neuroscience and 273
has a different physiological approach to learning. Listening with focus, relationships from other clinicians such as Bruce Perry8 and the life works of
remembering what was taught, following sequential instructions, remaining Bessel Van der Kolk9. These clinicians offer research findings and practical
focused and thinking can all be challenging for children whose brains are frameworks for all who work with the traumatised child but offer an ideal
overtaken with the primary task of surviving. framework for a team around the child of teacher, parent and clinician to work
together with similar emphasis but differing roles. The foundational child
As such, when education staff expect the traumatised child to study subjects development theories also offer a strong foundation to our work as we can
which seem irrelevant to survival, it can cause behaviour which we know to be then identify behaviour that is inappropriate to the child’s biological age and
trauma symptoms but would often be understood as defiant or naughty. We therefore could indicate a possible conflicting emotional age of the child.
need professionals and Ofsted to understand that when a child is healthy, they
learn naturally. When a child is happy they are curious and want to know about When working with complex trauma we work within the Trauma Recovery
life. When the child is neurologically wired for survival due to experiencing ‘Complex Trauma Framework’, which is a synergy of the structural dissociation
terror and powerlessness, learning is painful and can cause significantly theory of Van der Hart, Nijenhuis and Steele10 along with Watkins’11 ego state
increased turmoil and then subsequent escalation to the trauma symptoms. theory and the Daisy Theory of my own12.

The other factors that need to be reflected upon when using the continuum
6. The ‘Trauma continuum’ are factors such as the trauma experienced; the trauma symptoms manifest;
the current environment of the child (primarily the parenting capacity) and
The trauma continuum13 (Figure 1) enables professionals to discuss how mild the support system including the length of time that support system has
or severe a traumatic experience is in order to plan an appropriate intervention been in place. A sliding continuum enables a discussion to be had that leads
that can facilitate recovery rather than manage the trauma symptoms. to an agreed place on the line for that child at that time; thus an appropriate
intervention can be put in place.
Figure 1: the trauma continuum
The Type I or ‘simple trauma’ is usually defined as a one-off traumatic
incident or crisis. Simple trauma is difficult and painful and has the potential
to cause injury to the child. This level of trauma, however, usually has less
stigma associated with the experience and therefore other people are often
responsive and supportive to those who have experienced these traumatic
incidents. This results in Type I trauma being placed at the beginning of the
I II III trauma continuum; especially if this is an experience within the context of a
stable family where processing difficulties is a normal cultural expectation, as
TYPE I TRAUMA TYPE II TRAUMA TYPE III TRAUMA this could significantly limit the damage. Examples of Type I trauma include a
Single incident trauma Multiple traumas Multiple pervasive car accident where the emergency services are involved but there is no long-
traumas from early age
that continue over term harm, or a child who has to adapt to their parents’ divorce but this was
length of time handled with care, thereby limiting the emotional damage to the child.
274 275
The continuum progresses according to the degree of trauma experienced, the
amount of different traumatic experiences and the level of social support and
The trauma continuum needs to be considered together with the parenting family attachment a child has to enable them to process and recover. Type III
or environmental capacity continuum (Figure 2), which illustrates how much or complex trauma is positioned at the furthest end of the continuum, such as a
resilience the child’s context and environment offer them. child who experiences multiple abuse and/or neglect over many years, without
a family setting in which the traumatic experience could be processed or spoken
about in a recovery-focused manner, due to either parents’ absence, neglect or
Figure 2: the parenting capacity continuum inability themselves to cope with the trauma. Complex trauma usually involves
interpersonal violence, violation or threat and is often longer in duration. It
is almost always an experience that causes a strong sense of shame due to
community stigma, which can lead to the person feeling isolated and different.
For example, sexual abuse, trafficking, torture, organised abuse or severe
neglect. The child or young person facing Type III trauma requires a trauma-
informed clinician to lead the recovery plan for a team of professionals to enable.
The trauma continuum places the Type I, II, or III trauma along the line with
reasons for the placement. It enables professionals to discuss the impact of the
WARM CARING BULLYING AND NO FURTHER PUNISHMENT trauma as a natural response to any presenting behaviour that causes concern
VERBAL PROCESSING IF SPOKEN ABOUT within school or home and thus should lead to appropriate recovery focused
work.

7. Contrasting the approaches Through our alternative education children and young people are provided
with:
As a nation we cannot afford to continue to manage children who have
trauma symptoms in contexts that accentuate stress. The groups are too • Adults who can offer consistent, empathetic, respectful relationships
large, the professionals not trained to understand trauma symptoms and how over the long term with no changes and ‘new staff’
to facilitate recovery and there is little expectation of recovery. The prison
population is full of people with trauma histories who had no trauma recovery • Adults who understand the neuroscience about how such a
intervention and the mental health system is the same. Early intervention into relationship can facilitate recovery and then teach the children
trauma recovery is vital to save our communities. We are in a national crisis
and yet the answer is relatively simple. • Non clinical, non judgmental homely environments, where children can
go to recover and feel safe if they need to
Currently paediatricians, educational psychologists, clinical psychologists,
psychiatrists, teachers, social workers, police, health visitors and all other • Therapeutic Mentors undergo a 14 day training to provide the
professionals working with children, families or adult survivors of trauma are equivalent training of nurses in the medical system to facilitate trauma
rarely trained in the content of this short paper in their qualifying courses. recovery alongside the psychotherapists who can take the role of
Their response to such knowledge is often tearful relief yet frustration that doctors and consultants
they had not learned the vital information.
• Trauma trained clinical professionals who use creative psychotherapy
Currently most traumatised children experience the following: (and not cognitive therapy that demands more on the part of the brain
that is struggling to stay ‘online’) who take the role of doctors and
276 • They are told off, rejected, punished and socially isolated consultants who can enable a child or young person to process their 277
subconscious and body memory of the trauma to reduce the symptoms
• They are labelled and medicated and impact of the trauma
• Education staff focus on educational outcomes rather than recovery • Homely settings which offer sensory, warm, caring places to recover,
within mainstream schools and in other buildings
• Professionals are stressed and burnt out
• Parent training support and help for them to process their trauma.
• Therapists are not trained in trauma, use cognitive methods and usually
have 6-12 weeks of sessions which don’t work and cause further
ruptured attachments
• The focus is on management/coping not recovery
• The emphasis is rarely on the trauma being processed from the

subconscious and body
• Children are managed until adulthood when they need to access

mental health services or enter the criminal justice system.

Chapter 20
References 21. Embedding a trauma-informed approach

1 for more information see: www.trc-uk.org in the community and voluntary sector
(YMCA)
2 for more information see: www.betsytraininguk.co.uk
3 de Thierry (2015) Teaching the Child on the Trauma Continuum. London. Grosvenor Publish-
ing.
4 Cozolino, L. (2006) The Neuroscience of Human Relationships. attachment and the social
brain. New York: Norton publishers.
Dr Kristine Hickle
5 Cattanach. A. (1992) Play Therapy with Abused Children. London: Jessica Kingsley Publishers.
6 Axline, V. (1947) Play Therapy. Massachusetts: Houghton Mifflin.

7
Axline, V. (1964) Dibs: In search of self. Massachusetts: Houghton Mifflin.
Oaklander, V. (1997) ‘The Therapeutic Process With Children and Adolescents’ The Gestalt
1. Trauma-informed approaches
Review 1(4): 292-317.
8 Perry, B. D. (2006) ‘The Neurosequential Model of Therapeutics: applying principles of A ‘trauma-informed approach’ was conceptualised in the United States by
neuroscience to clinical work with traumatized and maltreated children’ in Boyd Webb, N. (ed) Harris and Fallot1 in response to a growing awareness that traumatised
Working with Traumatized Youth in Child Welfare. New York: The Guilford Press. p. 27-52.
children, young people, and adults interact with health and human service
Perry, B. D. (2009) ‘Examining child maltreatment through a neurodevelopmental lens: clinical
application of the Neurosequential Model of Therapeutics’ Journal of Loss and Trauma 14:
systems that are not designed to recognise the impact of trauma in their
240-255. lives. They envisioned a paradigm shift, which required stakeholders across
9 c.f. van der Kolk, B. (2005) ‘Developmental trauma disorder: toward a rational diagnosis for these systems to focus on returning “a sense of control and autonomy to the
children with complex trauma histories’ Psychiatric Annals 35(5): 401-408. [trauma] survivor”2. The idea developed purchase throughout the USA and
10 Van der Hart, O., Nijenhuis, E. R. S. and Steele, K. (2006) The Haunted Self: structural dissocia- in 2005 the Substance Abuse and Mental Health Services Administration
278 tion and the treatment of chronic traumatization’ New York: W. W. Norton.
(SAMHSA) created the National Centre for Trauma-Informed Care3. 279
11 Waktins, H. H. (1993) ‘Ego-State Therapy: an overview’ American Journal of Clinical Hypnosis
35(4): 232-240.
12 de Thierry. B. (2015) Op. cit.
Several evidence-based models, such as Sandra Bloom’s Sanctuary Model4
13 ibid. were identified as best practice in adopting a trauma-informed approach
(TIA). A TIA is an inherently relational and strengths-based way of working5.
It requires practitioners to understand the ways in which a service user’s
present difficulties “can be understood in the context of the past trauma”6. An
organisation that adopts a TIA should be better able to help improve survivors’
ability to function and manage distress7.
The small but growing body of research on TIA indicates positive effects such
as a reduction in seclusion, improved mental and physical health, increased
treatment retention and shorter inpatient stays8. However, TIA is still an
inherently complex concept, requiring numerous interventions that make
measuring change difficult.
Despite strong endorsement from SAHMSA, TIA is still not widespread in

the USA or other countries where research has been conducted, such as
Canada, Australia and New Zealand9. To date, very little evidence of TIA
implementation in the UK is available10. Sweeney and colleagues11 identified
some of the barriers to implementing TIA in the UK (and elsewhere), including:

Chapter 21 Embedding a trauma-informed approach in the community and voluntary sector (YMCA)
• widespread resistance to the notion that prior trauma has such a composed of management from across the organisation (e.g. including the
significant impact on current functioning; facility maintenance department). They also employed someone part-time to
coordinate the TIA agency-wide implementation.
• practitioners’ own reluctance to confront the ‘horror’ of people’s
suffering; YMCA DLG contracted with the University of Sussex to evaluate the TIA
implementation in Autumn 2015. A realist evaluation methodological
• confusion regarding the difference between trauma-informed and approach was employed (Pawson and Tilley, 1997) to capture the contexts,
trauma specific treatment services; mechanisms and outcomes of any change across the organisation during
an 18-month evaluation timeframe, from September 2015-March 2017. In
• a general wariness of having to take on new tasks in the face of service keeping with a realist evaluation approach, multiple sources of quantitative
cuts and a strained workforce, and inconsistent access to supervision. and qualitative data have been collected to inform the first phase of the
evaluation conducted, from October 2015-January 2016 (see Table 1).
2. Learning from the experience of YMCA Downslink Group Table 1: Data sources
The YMCA Downslink Group (DLG) serves children, young people and families Data source Sample size and description
across South East England, and began implementing a new agency-wide TIA
in Autumn 2014. They developed a theory of change, informed by SAHMSA Staff-wide quantitative survey n=95, approximately 20% of total staff
administered in 2015 population, including volunteers and
guidance and the Sanctuary Model12. Desired outcomes included: paid staff
280 281
• reduction in staff sickness and absenteeism; TI one-day training evaluations, n=75, a random sample of approximately
primarily involving open-ended 25% of the total 309 evaluations
(qualitative) questions completed
• increased staff retention;
Quarterly safeguarding and service user Quarters 1, 2 and 3 for 2015
• improved communication with external partners and internal partners incident data
(i.e. across departments within the organisation);
Three staff focus groups 15 staff members:
• increased capacity among young people to engage with support; Focus group 1) 5 management level staff
Focus group 2) 3 staff members
• improved peer relationships, self-esteem and the ability to manage Focus group 3) 7 staff members
difficult feelings;
Two service user focus groups 8 young people:
• reduction in harmful risk taking behaviour; Focus group 1) 4 young people
Focus group 2) 4 young people
• and young people feeling an increased sense of ownership over YMCA
DLG.
Following several careful readings of the focus group data, themes were
The agency provided all staff with 1-day TIA trainings delivered by a clinical developed deductively (i.e. from the questions asked in the focus group
psychologist, began implementing reflective practice supervision (RPS) sessions) and inductively (themes that arose from the discussions). Basic
groups across the organisation, and organised a ‘TI development forum’ descriptive statistics were used to analyse quantitative survey data, and

a thematic analysis of the evaluation questionnaires from TIA training support project, and normally we average about two a quarter…it’s about
workshops was also conducted. when you’re looking at that aggressive behaviour – I think as a staff team, we
are really good at not taking it personally.”
This paper provides a reflection upon the first phase of the project, drawing
upon all sources of data to identify four key points of learning, summarised as: Staff members also described TIA as a “broad awareness of trauma in every
context” and helpful in enabling staff to be mindful, reflective, and “aware of
i. TIA: an organisational culture change your own reactions”. They described it as helpful in maintaining professional
boundaries and managing young people’s expectations of them. One staff
ii. ‘Trauma’ is a tricky word member from an alternative education setting said:
iii. Safe people might act in unsafe ways “It [TIA] helps me not only with my staff members, my client group, my
students – but interactions with everybody in any walk of life, in any
iv. Safe staff are transparent, persistent and share power scenario. Because it makes me question where they’re coming from...And
that automatic filter goes through my brain and I think, ‘okay, so why are
Each of these key points aligns with the growing body of research on TIAs and they saying that’?”
will be discussed in detail below.
Staff members were more ambivalent when considering how peripheral
services involving maintenance, housekeeping and catering professionals can
a. TIA: an organisational culture change approach their work in a TI way, and several indicated that the initial 1-day
trainings were not sufficiently adapted for these roles. However, they also
282 The first key area of learning to emerge from the evaluation project involved spoke about the close contact that many of these professionals have with 283
the importance of an agency-wide strategy for introducing TIA. This aligns young people and how understanding young people’s behaviours within the
with the way in which Harris and Fallot13 initially envisioned TIA as an context of past trauma is useful for them as well. For example, a member of
organisational paradigm shift, and the Sanctuary Model’s understanding of a maintenance staff may be called to clean up something that has been broken
“full system approach”14. or destroyed by a young person. A member of staff working in food service
may interact daily with young people, and adopting a TIA can help them avoid
Feedback following the day-long TIA trainings indicated that many participants emotional burnout and respond more sensitively in their interactions with
felt this approach provided an explicit framework for elucidating some young people.
of the unspoken complexities and challenges of working with trauma,
and acknowledged the role that organisational culture plays in keeping Several of the young people participating in focus groups re-affirmed the
both service users and staff members safe. When prompted to discuss need for an agency-wide approach, as they described the importance of first
the implementation of this new approach in focus groups, staff members impressions and initial interactions with staff members not tasked with direct
described it as a more authentic and empathetic way of working, and an service provision.
approach that allows them to feel unified with members in their departments
and departments across the agency. One young person, Hannah (pseudonym) described interacting with a
receptionist:
One manager involved in housing services reflected on the impact that TIA has
had on service provision among his staff team: “One thing I get really irritated, when I first used to come in, I used to open
the door and she’d [receptionist] be like: ‘name, age’. All right, can you not do
“I do think TI has helped us. I think we were definitely doing that work that? Now, she’s like, ‘all right, sit down’.”
anyway, but in the space of 12 months, I evicted one person from a high-

These first impressions of a new environment, and a continual reassessment of you? Yes, so I think... Well what other word are you going to use? You may as
safety within that environment, demonstrates the way in which hypervigilance well not bother sugar coating it…”
manifests in vulnerable young people accessing housing, advice and support
services. For example, ‘Sam’ spoke about knowing if a staff member is This discussion highlights the ways in which these staff members are working
trustworthy and safe by watching them closely: through their own understanding of what a ‘trauma’ label might mean. As
‘R’ pointed out, some ambivalence in using the term may also be related to
“You can’t really explain it but you can see if they want to be there, [or if] the emotional weight of confronting and acknowledging trauma. Others
they’re constantly looking at the clock. The ones who want to be there will felt that coming to understand trauma as a ‘spectrum’ helped them become
make an effort to speak to you about any problems you’ve had or anything. comfortable with the term.
The ones who don’t want to be there, will be like in the kitchen making food.”
When young people were asked in focus groups for their views regarding the
This careful observation is a necessary skill when exposed to dangerous and ‘trauma-informed approach’ the organisation was taking, they presented with
threatening circumstances, and continues to shape the way in which young less ambivalence. Danielle said:
people like Sam assess new environments intended to be safe. In Sam’s case, he
needs all the staff he interacts with to understand hypervigilance, and how to “There are so many different types of trauma. I’ve got so many different
respond in a way that feels trustworthy and safe. types. I’ve got post-traumatic stress disorder alongside loads of other things.
My biggest one is attachment disorder because of childhood trauma…so I
think with the staff, yes it is becoming more trauma aware, knowing that a
b. ’Trauma’ is a tricky word lot of stuff that you do today is because of what’s happened to you.”
284 When asked in the agency-wide staff survey if they could understand what For Danielle, it was less important that staff knew the details of her traumatic 285
a trauma-informed organisation ‘looks’ like, only half of participants agreed. experiences and more important that they understood the impact of these
Approximately one-quarter of participants either disagreed (6.7%) or experiences on her life today. Others agreed, saying that they felt that it was
provided a neutral response (20%) when asked if they saw themselves as a important for staff members to be trained in understanding mental health
‘trauma-informed professional’. A reluctance surrounding the word trauma and the impact of traumatic experiences even if they did not share these
may be an issue resolved through consistent messaging and a more clearly experiences with the staff. Greg spoke about the way in which TI staff might
communicated vision, but may also be indicative of barriers to implementing help normalise his experiences and make him feel less isolated:
TIA identified in research, discussed above15.
“When I have something difficult to speak about, I think sometimes it’s quite
In focus groups, ambivalence was evident in the way that participants nice for someone to just say, ‘it’s okay to think about or see things that way’
questioned using the word ‘trauma’. For example, a staff member, ‘W’ felt that because of some of the stuff I’ve been through…Sometimes it’s nice just to
using the word trauma could be “incredibly patronising or making assumptions think if someone just thinks that it’s okay, you’ve been through this, and you
of ‘how dare you say I’m traumatised’?” She was not “personally comfortable can move away from it.”
with the word trauma in how others... and especially young people, could
potentially perceive it.” Staff member ‘R’ disagreed, saying that he felt the word While focus groups included a small (non-representative) sample of young
trauma was honest: people receiving services from only two YMCA DLG programmes, their views
support the way in which TIA was initially defined by Harris and Fallot16.
“It’s like, yes, really horrific shit happens, and what are you going to do? You
know, pretend it isn’t real? So I think it’s okay to put it out there a little bit. I
mean, it is true, I find it really hard, you know? It wears me out sort of looking
and reading about stuff. But what’s... You know, you’ve got to face it, haven’t

c. Safe people may act in unsafe ways authenticity, and most importantly, a willingness to share power and control.
Transparency involved being honest and direct; predictable and persistent
A primary aim in implementing TIA is to increase service users’ sense of staff were physically present, reliable, and would ‘go the extra mile’ to check in
safety and their ability to manage difficult feelings and behaviours17, and it with a young person or provide the opportunity to talk.
was acknowledged early on by service managers that as young people feel
safer, staff may begin to see more difficult behaviours and become aware of Authenticity was evident when staff genuinely seemed to care, and sharing
additional safeguarding concerns. power and control (most frequently identified by the young people as an
indicator of safety in relationships with staff) was recognised among staff
Following the TIA implementation, safeguarding alerts for children under age members who asked for permission before sending a referral or provided
18 rose 8.5% in Quarter 2 and 51% in Quarter 3, primarily due to increased evidence for how they had taken young people’s views into consideration. One
reports of self-harm and suicidal ideations. Safeguarding alerts for young young person’s experience of being supported by staff through self-harming
people aged 18-25 also increased slightly (+11%) in the third quarter, also and feeling suicidal provides an example:
because of self-harm and suicidal ideations. This data alone is not sufficient
to draw conclusions regarding the impact of the TIA on safety concerns. “I only really just recently moved in…and I self-harmed and was suicidal.
However, responses from young people and staff members in focus groups They had to follow the procedure, they called the paramedic and an
help provide some context for this data. ambulance turned up for me, and I think the way they relayed that to me
and they helped me with my own care was by saying, ‘do you want us to
In a discussion about safety in one focus group, a young person ‘Ethan’ come with you?’ While I’m getting shoved into the back of an ambulance.
described putting on “another persona” when he feels unsafe, which is “99% of And going through the safeguarding form afterwards, they didn’t just forget
the time”. He said: it, they didn’t just say, ‘we will contact you if you want us to.’ It was, ‘come
286 downstairs and we’ll go through a safeguarding form with you, which is how 287
“I find my other self a lot more confident than me as myself. I feel I can we can help you to stop this from happening again, because we care about
escape to this other person and do things that I normally wouldn’t do…the you’. It wasn’t just forgotten or left about like other places do. They just go,
[staff] would see that I’m a lot more confident and I feel a lot happier than I ‘I’m sorry that’s happened to you’. This one [YMCA service] was, ‘we don’t
normally do…” want this to happen again for your own safety’.”
Other participants agreed with him, describing how they put up “a front” that is This example demonstrates a young person’s acceptance of the safeguarding
less open and less receptive to connecting to staff when they feel unsafe. Their process staff were required to follow, and provides a helpful example of how
descriptions align with the way staff members described young people in focus staff can follow these processes while embodying safety through transparency,
groups. Namely, that young people may appear less emotionally stable, have persistency, authenticity and power sharing. The ways young people defined
increased emotional outbursts and in many ways present as “less safe” when safety here resonate with basic principles of TIA promoted by SAHMSA18 and
they are feeling more safe and more contained by staff members. Staff then others19.
have an opportunity to help young people begin developing self-awareness
and coping strategies to better manage trauma triggers in the future.
3. Learning from the YMCA DLG experience
d. Safe staff are transparent, persistent and they share power While the effectiveness of this new approach in achieving the ambitious
outcomes that the YMCA DLG originally envisioned remains unknown, the
Young people also provided insight into how staff might help them when they first phase of the evaluation indicates that their TIA is promising in its ability
do experience difficult emotions or trauma triggers. They spoke about several to meet the needs of both staff and service users. Other organisations can
key traits in ‘safe’ staff members: transparency, predictability, persistency, learn from the YMCA DLG’s innovative approach, particularly regarding their

emphasis on a comprehensive implementation, including each department References

within the organisation.
1 Harris, M. and Fallot, R. D. (2001) ‘Envisioning a trauma-informed service system: a vital para-
Key areas for future work identified in survey and focus group data include the digm shift’ New Directions for Mental Health Services (89): 3-22.
need to implement Reflective Practice Supervision groups more consistently 2 ibid: 16.
3 Substance Misuse and Mental Health Services Administration (2015) Trauma-Informed
across the entire organisation. Given the size and diversity of the organisation,
Approach and Trauma-Specific Interventions: www.samhsa.gov/nctic/trauma-interventions
identifying supervisors and resolving logistical barriers (e.g. time/schedule
4 Bloom, S. L., and Sreedhar, S. Y. (2008) ‘The sanctuary model of trauma-informed organization-
clashes) remains a difficult but necessary task as reflective supervision can al change’ Reclaiming Children and Youth 17(3): 48.
provide space to support staff in embedding TIA into their professional 5 Sweeney, A., Clement, S., Filson, B., and Kennedy, A. (2016) ‘Trauma-informed mental health-
identities, everyday interactions and routine tasks. Another key area for further care in the UK: what is it and how can we further its development?’ Mental Health Review
Journal 21(3): 174-192.
development is in staff members’ understanding of vicarious trauma in their
6 Knight, C. (2015) ‘Trauma-informed social work practice: Practice considerations and challeng-
own lives, as both survey and focus group data indicate a lack of understanding
es ‘Clinical Social Work Journal 43(1): 25-37.
regarding vicarious trauma and the impact it can have on practice.
7 Gold, S. (2001) ‘Conceptualising child sexual abuse in interpersonal context: recovery of peo-
ple, not memories’ Journal of Sexual Abuse 10: 51-71.
8 Sweeney, A., et al. (2016) Op. cit.
9 ibid
10 Rose, S., Freeman, C., and Proudlock, S. (2012) ‘Despite the evidence: why are we still not
creating more trauma informed mental health services?’ Journal of Public Mental Health 11(1):
5-9.
11 Sweeney, A. et al. (2016) Op. cit.
288 12 Bloom, S. L. and Sreedhar, S. Y. (2008) Op. cit.

289
13 Harris, M. and Fallot, R. D. (2001) Op. cit.
14 Bloom, S. L. and Sreedhar, S. Y. (2008) Op. cit.
15 ibid.
16 Harris, M. and Fallot, R. D. (2001) Op. cit.
17 Knight, C. (2015) Op. cit.
18 SAHMSA (2015) Op. cit.
19 i.e. Knight, C. (2015) Op. cit.

A youth-led approach to tackling adversity
22. A youth-led approach to tackling 2. What needs to change?

adversity Young people find much about traditional health care services challenging and
those involved in gangs or antisocial behaviour are often regarded by health
Andy Bell professionals as a difficult group. However, these young people are often
the poorest and most excluded in our society, dealing with poverty, racism,
deprived communities, domestic violence, abuse, neglect, leaving care and
homelessness2.
1. Introduction
Child and Adolescent Mental Health Services (CAMHS) are not well
This paper summarises a Centre for Mental Health evidence review1 gathered designed for this group and have lacked adequate resources to meet their
from an evaluation of three projects in London run by the mental health needs3. Barriers to this group accessing traditional mental health services
charity MAC-UK. are geographical (such as clinics located in unsafe areas), structural (such
as services that do not have capacity and training to ‘reach out’), and
Excluded and vulnerable young people, including those in contact with the psychological (such as the mistrust of professionals by young people)4. Young
criminal justice system, often experience multiple risk factors for poor mental people often struggle to engage with and navigate the many professional
health, exacerbated by services that are experienced as ‘hard-to-reach’, leading relationships required of them in the current service provision5.
to wide health inequalities. The MAC-UK INTEGRATE approach harnesses
the power of young people themselves to be part of the solution. INTEGRATE A new approach to interventions for excluded young people is urgently
seeks to wrap holistic and responsive support, including mental health and required to better meet their needs. MAC-UK therefore developed an
290 emotional wellbeing provision, around excluded young people. alternative approach, co-produced with young people, to deliver services for 291
them6. This became the INTEGRATE model.
The INTEGRATE model was developed at the very first MAC-UK project,
Music and Change, in Camden. This project launched in 2008 and closed
towards the end of 2015. From the very outset Music and Change
incorporated co-production with young people and this is a key feature of 3. Key features and principles of the INTEGRATE approach
all projects. Positive Punch opened in 2011, also in Camden but focusing
on a different peer group in and around a different estate. Positive Punch
was funded through Camden Community Safety Board and ran for three Phase 1: Reaching young people, engaging and peer referral
years, closing in late 2014. The third INTEGRATE project, RO|O , launched
in Southwark in 2012 with funding from the Guy’s and St Thomas’ Charity, Within the INTEGRATE approach, engagement and relationship-
and completed in 2015. While the Music and Change project worked in building with excluded young people is put front and centre; to build
partnership with both statutory sector and voluntary sector partners in the trust is the only agenda and if young people ask for support later that
borough, both Positive Punch and RO|O were established, co-commissioned is then responded to. No professional referrals are taken, although
and staffed by both NHS and local authority staff as well as MAC-UK. partners, such as the local authority, help identify which young people
would benefit from an INTEGRATE designed service.
Centre for Mental Health provided evaluations for all three completed
INTEGRATE projects. Although each project was different (reflecting lessons
learned from previous projects and particular local needs) the evaluation
methodology across all three was very similar and utilised both quantitative
and qualitative methods.

Chapter 22 A youth-led approach to tackling adversity
Phase 2: Co-producing activities and relationship-building Phase 4: Building bridges
As relationships build, it becomes possible to actively ask for help from Young people can quite quickly start to ask for help with a range of
young people to design a project that they want with the resources needs, while continuing to also co-produce the project. This can include
the INTEGRATE team brings. The INTEGRATE team explain that housing support, benefits applications, applying for passports and bank
the project is about doing ‘with’ young people, not ‘for’ them. Young accounts. Again, at the young person’s pace, staff may offer or be asked
people choose, design and run a range of activities from music or sport to support with CV writing, job applications or support and advocacy
to drama based on their passions and interests. Their help is actively during their experiences of the youth justice system. As part of meeting
requested in all aspects of the activities and young people can take up these needs, the team will draw on the project’s wider partners and
explicit leadership roles such as ‘Head of Music’ or ‘Gym Project Lead’, relationships, building bridges between these resources and the young
promoting a sense of ownership and responsibility. people. All of this helps to prepare young people to ‘bridge out’ of the
project, becoming more stable, independent and able to access and use
Young people can be employed on an ad hoc and part time basis to carry other services. Co-producing the project can often provide them with
out some of the project work. Employed or voluntary, INTEGRATE experience enough to gain entry level employment.
project activities provide opportunities for young people to develop
professional skills, gain relevant work experience and earn a live Building bridges in the other direction is also key. The INTEGRATE team
employer’s reference. It also means almost daily contact between staff supports community services and agencies to adapt to meet the needs
and young people, who are all part of the same team. Young people are of young people more effectively, for example encouraging them to
encouraged to support each other. come to the project to hold appointments or initially meeting the young
292 people with project staff to broker trust. This could be physical health 293
services, such as sexual health or dentistry, through to housing advice
and job centre staff. This is part of the ‘systems change’ component of
INTEGRATE projects and ideas for it are often generated directly by
Phase 3: Streetherapy and psychologically-informed young people.
environments
INTEGRATE projects have mental health and wellbeing support

built in by supporting a psychologically-informed environment and a
‘Streetherapy’ approach. INTEGRATE teams are led by mental health Phase 5: Creating systems and social change
professionals and made up of workers with lived experience and other
professional staff, such as youth workers, all of whom are trained in Often young people find they can trust their relationships with the
mental health. The teams apply evidence-based psychological theory INTEGRATE team enough to express their frustrations with their social
to their everyday practice with young people; this includes attachment worlds. This is encouraged and facilitated by the team, understanding
theory, lifespan developmental theory and community psychology that community and social context factors contribute vastly to
theory, as well as systemic practice, including narrative therapy. young people’s mental health. Through dialogue with young people,
The teams regularly draw on the Adolescent Mentalization-based INTEGRATE teams can find ways to work in partnership with young
Integrative Treatment (AMBIT) framework for their clinical practice7. people to create social change. This may involve young people co-
producing training, campaigns and lobbying activities.

4. The impact of the INTEGRATE approach Change and RO|O established that around one third of the young people
in the samples reported a level of wellbeing that would warrant referral to a
Below we summarise the impact of the INTEGRATE approach as identified mental health service.
through the three evaluations undertaken by the Centre for Mental Health.
A consistent finding across all sites was that mental health awareness
increased in young people and that stigma around it reduced during their
a. Enhancing engagement and co-production: involvement with the projects. Young people and staff across all three projects
reported that young people’s mental wellbeing improved through contact
All three projects were incredibly successful in engaging with groups of with them. Clinician-rated measures of mental wellbeing confirmed young
young people who were marginalised, and who were engaged in offending people’s reports, showing significant improvements in needs associated with
or at risk of offending. Over the period Centre for Mental Health conducted mental wellbeing across all three projects, over the course of young people’s
the evaluations, the projects worked with approximately 360 young people engagement. However, across all three sites there remained a reluctance to
in total. These young people were typically facing multiple and complex use mainstream mental health services.
challenges in their lives, such as housing, education, employment, offending
and poor mental health.
c. Working with young people entering or re-entering education, employment
On all three sites, key local individuals supported the initial contact with young and training:
people. In each case these were local people with credibility among the young
people who endorsed the project. Most young people who engaged with the three projects wanted support
in entering or re-entering education, employment and training (EET). The
294 Co-production was at the very heart of everything that the INTEGRATE INTEGRATE projects were very successful in bridging young people into 295
projects took part in, and each of the projects started with activities that were these. For example, at Music and Change between 2013 and 2014, the
wanted by the young people and co-produced with them. These included proportion of young people accessing EET increased, from 43% to 74%. At
music projects, sports projects, cookery projects and others. Through co- RO|O , access to employment increased from 23% to 54% over the first two
production, the projects positioned young people as experts in their own lives years.
and sought to build a service that would be accessible and relevant to them.
Co-production was key in building firm relationships between the INTEGRATE At the outset a young person might be shown opportunities and given all the
staff and young people. support necessary in taking their first steps towards these, from support in
writing a CV to accompanying a young person to interview. The aim was that
Young people described how INTEGRATE staff “checked in” on them, the young person would be able to do this more independently over time.
maintaining engagement with young people not only directly at the projects However, because of the nature of employment contracts (often temporary
and their activities but also through regular phone calls, texts and emails. This and/or zero hour contracts), especially for young people seeking unskilled jobs,
meant for some young people, who had not attended the project for a period, there was both a flow in and out of employment.
that they always felt there was an open door for them when they had need of
support in the future.
d. Diversion from further offending:
b. Improving mental wellbeing: Most of the young people Centre for Mental Health spoke to stated that
they had been in trouble with the police and that their involvement in their
The young people engaged in the project had high levels of need relating to INTEGRATE project was having a significant role in keeping them “away from
mental health and wellbeing. Self-rated data on mental wellbeing at Music and trouble”.

Young people described how the support regarding offending at INTEGRATE References
enabled them to think about the choices in their life, opening up different
options. INTEGRATE workers provided a very flexible service and would 1 Durcan, G., Zlotowitz, S. and Stubbs, J. (2017) Learning from INTEGRATE’s work with exclud-
attend court attendances to support the young person and provide evidence ed young people: https://www.centreformentalhealth.org.uk/Handlers/Download.ashx?IDM-
F=f549e7a6-3ed0-4559-8a87-ebb7439323b7
and statements on the positive changes young people were trying to make.
2 Youth Justice Working Group (2012) Rules of Engagement: Changing the heart of youth
justice. Retrieved from: http://www.centreforsocialjustice.org.uk/library/rules-engagement-
Some young people engaged with the project did receive prison sentences changing-heart-youth-justice
during their period at the project (sometimes for offences committed prior 3 Department of Health (2015) Future in Mind: Promoting, protecting and improving our chil-
dren and young people’s mental health and wellbeing.
to their engagement by INTEGRATE) and the projects continued to support
4 Flanagan, S.M. and Hancock, B. (2010) ‘Reaching the hard to reach: lessons learned from the
them while in prison. The young people Centre for Mental Health spoke with
VCS (voluntary and community sector). A qualitative study’ BMS Health Services Research 10:
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Practice, Training, 40: 215-225.
5. Conclusions 5 Bevington, D., Fuggle, P., Fonagy, P., Asen, E. and Target, M. (2012) ‘Adolescent Mentaliza-
tion-Based Integrative Therapy (AMBIT): a new integrated approach to working with the most
hard to reach adolescents with severe complex mental health needs’ Child and Adolescent
Mental Health 18: 46-51.
INTEGRATE’s approach would enable other services to engage and support
6 Zlotowitz, S., Barker, C., Moloney, O. and Howard, C. (2016) ‘Service users as the key to service
children and young people facing adversity more effectively. Specifically,
change? The development of an innovative intervention for excluded young people’ Child and
positioning young people as experts in their life and co-producing a project Adolescent Mental Health 21(2): 102-108.
296 with them results in a service which is accessible, relevant and in line with 7 Bevington, D., et al (2012) Op. cit. 297
young people’s needs. Taking a strengths-based approach (one which
builds on young people’s strengths and interests) empowers young people
to make sustainable changes in their lives. And services underpinned by
therapeutic principles of unconditional positive regard, acceptance and non-
judgement support young people to build trust and repair relationships with
professionals. Services should adopt a holistic approach which supports young
people where they are at and with whatever need or problem they bring,
underpinned by evidence based psychological approaches.

Trauma-informed commissioning for substance misuse amongst young people
23. Trauma-informed commissioning for young people are attempting to navigate the confusing journey from childhood
substance misuse amongst young people

through to adulthood. As roles and responsibilities change, so does the
chemical and hormonal make up of the human body. Teenagers experience
higher levels of impulsivity, which is linked to the ongoing development of the
Agnes Aynsley, Rick Bradley, Lindsay Buchanan, adolescent brain.4 Such limitations around consequential thinking explain why
Naomi Burrows and Dr Marc Bush some young people expose themselves to, or engage in, greater risk-taking.
Substance misuse is just one form of risk-taking behaviour, but it can also be
an indicator of other (potentially hidden) difficulties with identity formation
1. Young people and substance use or childhood adversity. For some young people, the use of drugs or alcohol
is a form of ‘self medication’, which enables them to relieve stress, or block
Public misconceptions about both the prevalence of young people’s use emotionally distressing thoughts. This usage can be heightened among groups
of substances, and their motivation for using them, are compounded by of children who face additional complexity in their lives, including: looked-after
sensationalist accounts of drug use in the popular media. This media coverage children, those seeking asylum, those witnessing or involved in violence and
frequently draws attention away from the fact that substance use among those making sense of their gender identity or expression and sexuality.
young people has been broadly in decline since 20011. Despite the high profile
of New Psychoactive Substances (NPS)2 in recent years, alcohol and cannabis
remain the most commonly used substances among adolescents.
2. Young people’s experiences of adult substance misuse
Every young person has their own story about what led them to try a particular
298 substance. For many, they do so having already researched the potential risks Adverse Childhood Experiences (ACEs) are events that have a traumatic and 299
involved, aiming to manage their usage so it remains as safe and enjoyable lasting effect on the mental health and emotional wellbeing of young people.
as possible. The vast majority of young people’s substance use is either Childhood adversity can include experiences of neglect, abuse or violence
experimental or recreational, and most people are capable of managing their within the family, being forced to take on adult responsibilities (as in the case of
intake of legal and/or illicit substances so that any unwanted consequences are young carers), or living in households where people are misusing substances.
minimised.
Substance misuse can significantly impact people’s capacity to parent. This
However, there are still many young people for whom substance use can may include:
become problematic. In 2015-16, 17,077 young people accessed specialist
treatment services – a drop of 1,272 or 7% compared to 2014-153. There • increased volatility within the family or home environment.
are a wide number of determinants that might lead one individual into more
dependent use of substances, where others may be able to desist. Recognised • unsettling changes in the mood or behaviours of an adult resulting
features that can play a key role in protecting people from risk include: having from intoxication.
positive relationships with friends and family, engaging well in school or
college and living in a stable home environment. Conversely, there are factors • withdrawal from parental responsibilities, which might include
that may leave young people vulnerable to harm related to substance use, not providing food or clothing, or asking children to take on adult
including: living in deprived areas, being excluded from mainstream education, responsibilities during periods of withdrawal or relapse.
and not feeling able to turn to others for support.
• withdrawal, mistrust or aggression towards the child’s wider social
Substance use can be further complicated by young people’s experiences network, including their school, wider family or local community.
during adolescence. This can be a period of great uncertainty, a time when

Chapter 23 Trauma-informed commissioning for substance misuse amongst young people
• misattunement and an inability to meet the emotional needs of the Smoking, heavy drinking and cannabis use in adulthood all increase with the
child. number of childhood adversities that a young person has experienced. This is
echoed in recent research from England that found that two thirds (of a target
• disorganised, ambivalent or avoidant attachment patterns formed sample of people misusing substances) had experienced four or more ACEs13.
between children and those with parental responsibility.
Many of the young people and adults who go on to misuse substances, or
• isolation within the community, wider family, or from peers because of who become dependent on them, will have faced multiple adversities in their
the stigma associated with using substances. childhoods. It is therefore important to acknowledge that these behaviours
can be attempts by young people to soothe, numb, cope with, or make sense of
the trauma that they have experienced. Rather than expressions of criminality,
In addressing substance misuse within families, we need to take a trauma- they represent forms of risk-taking behaviour that are considered as
informed approach, as there is a cyclical relationship between childhood normative responses to the social, emotional and somatic impacts of childhood
experiences of, and exposure to, adult substance misuse, and subsequent adversity and trauma.
misuse of substances in adolescence and adulthood. As the World Health
Organisation suggests, those affected by ACEs are at increased risk of Young people may use substances (following experiences of adversity and
exposing their own children to ACEs (including substance misuse), and, as trauma) in order to:
such, this intergenerational cycle constitutes a “cycle of violence”5.
• ‘escape from’ or avoid invasive thoughts, images or memories.
• increase attention at school, or in their social life, to address the impact

300 3. Childhood adversity and substance misuse that chronic hyperarousal, and hypervigilance, has on their nervous 301
systems, levels of anxiety and sleep patterns.
Experience of one or more childhood adversities has been linked to poorer
physical and mental health outcomes in adolescence and adulthood6. The • strengthen trauma bonds and patterns of relationships that draw
study of ACEs in England found that those adults who had experienced four or them closer to adults or peers who will expose them to further
more adversities in their childhood, were two times more likely to binge drink, adverse events (for example participating in sexual or violent acts),
and 11 times more likely to have gone on to use crack cocaine or heroin7. or make them reliant on them for the supply of alcohol, legal or illegal
substances.
The research from England also shows that the traumatic impact of living
in a household with an adult who misuses substances can have a long-term, • self-harm through (for example) overdosing, and self-punishing their
negative impact on these children’s life satisfaction and emotional wellbeing8. bodies by ingesting or injecting performance enhancing substances.
This reflects international research describing the strong relationship
between childhood adversity, and the development of enduring mental health
conditions in adulthood, which include anxiety, depression and symptoms of Research demonstrates that the development of traumatic-stress often
traumatic-stress9. precedes the use or dependence on chemical substances, which are used to
cope with the associated symptoms14. Trauma can cause a heightened sense of
It has been shown that the higher the number of ACEs, the higher the threat, where the child or young person is constantly in a state of alert in order
likelihood that the child will go on to misuse substances, in part to manage the to freeze, fight or flight in the face of further adversity.
overwhelming emotional and somatic sensations associated with trauma10.
The chances of developing a dependence on substances double if a child has If children regularly use substances from an early age it can have a substantial
also experienced sexual abuse11 or other forms of violence12. impact on their neurobiological and cognitive development, as well as affecting

their ability to acquire skills that enable them to self-soothe or self-regulate more likely that these may be linked to more general social functioning, their
in the face of further emotional distress15. Some young people ‘self-medicate’ experiences in childhood and their relationships with others.
to numb the overwhelming emotional distress that comes from constantly
scanning for threats in their environment. It can offer an altered, and more It is important to note that most young people who misuse substances do not
tolerable, state of perception where young people can recall memories that experience psychosis. However, substance misuse increases the probability
would otherwise be intolerable for them. of an experience of psychosis. The risks are different for different substances.
Research suggests that adolescents who misuse cannabis double their risk of
Ultimately this ‘self-medication’, numbing or suppression only acts as a experiencing psychosis by the time they reach adulthood17.
temporary solution, and in the mid- to longer-term has a negative impact
on the physical and mental health of these young people. Recreational use Drug-induced psychosis is a historical term referring to psychotic symptoms
of (for example) illicit drugs can lead to the traumatic release of memories, occurring after the use of substances. Psychotic symptoms can include
resulting in more extreme forms of disassociation during the ‘come down’ or delusions (i.e. persistent false beliefs), hallucinations (i.e. hearing or seeing
withdrawal. It also risks growing a dependence on substances, or pushing them things that are not actually there), unusual behaviour, and disorganised
towards other forms of health- or self-harming behaviour. However, for some, thinking. Substances associated with drug-induced psychosis include:
‘self-medication’ and ‘micro-dosing’ enables them to connect with repressed amphetamines, cocaine, cannabis, LSD and certain types of NPS, such as
emotions, and strengthen positive or protective relationships with their peers. synthetic cannabinoids. The term ‘drug-induced psychosis’ is deceptive, and
does not necessarily imply that the substance has caused the psychosis.
Drug-induced psychosis might be short-lived, lasting only while the user is

4. Substance misuse and young people’s mental health intoxicated or withdraws. On other occasions the psychosis might last for
302 many weeks. During that time the young person needs to be supported within 303
Evidence suggests that there are some mental health conditions that may a safe environment and if this is the first episode of psychosis, it is likely that
be more likely to be exacerbated by substance use than others, including they will be referred to the local Early Intervention Psychosis (EIP) service18.
experiences of psychosis, schizophrenia, bipolar and depression16. Once the crisis is over, many young people will make collaborative plans with
the clinicians at the EIP team, an addiction specialist (if appropriate) and
The impact of drug or alcohol use on young people’s mental health varies possibly a crisis mental health team. This support is put in place to help the
depending on the age, genetics, and psychology of the young person, as well young person to make sense of their experience of psychosis, to manage any
as the context in which it is being taken. The younger a person is, the greater resulting mental health or addiction-related needs, and to plan for any further
the intensity of the drug in question, and the more frequently it is used, the escalation in need or experience of crisis.
higher the likelihood of negative or unwanted effects being generated. For
example, a 12 year old smoking a strain of cannabis high in delta-9-THC (often More broadly, substance use clearly can trigger changes in young people’s
colloquially known as ‘skunk’) on a daily basis is likely to be more vulnerable to behaviour, attitude or mood. As well as having a negative impact on their
experiencing mental ill health, than a 17 year old taking a milder strain on an physical health, it impairs their cognitive development and comprehension19.
infrequent basis. Furthermore, substance misuse can leave some young people feeling distant
or disconnected from the peers and adults who may previously have been their
Much of the media reporting around drug use and mental ill health becomes support networks. Persistent and problematic substance use can trigger low
confused because of sensationalist headlines that lack the context of the levels of motivation, negatively impacting on daily routines and diminishing
detailed (and often conflicting) research that underpins them. For example, engagement in positive recreational activities. This can impact adversely on a
media coverage around psychosis masks the reality that most young people young person’s ability or desire to engage in education, training or employment
who try substances are unlikely to experience serious or long-lasting mental which affect their chances of progressing into further education or with career
health problems. Where negative consequences do occur, it is perhaps choices.

education in all primary schools, relationships and sex education in secondary

Problematic substance use can affect a young person’s likelihood of becoming schools, and extend Personal, Social, Health and Economic Education (PSHE)
involved in the youth justice system20. Due to a significant number of to all schools22. For example, the Amy Winehouse Foundation Resilience
substances remaining illegal, young people who buy, transport, or consume Programme23 uses the lived experience of people in recovery to explore with
them are at risk of being criminalised by authorities. Once consumed, the young people the thoughts, feelings, behaviours and underlying issues that can
effect of substances may impact the decision making skills of the young person, make people more susceptible to substance misuse. This is reinforced through
and due to a lack of inhibition they may be more likely to partake in behaviour skills-based sessions that seek to develop resilience, so that young people can
they would normally avoid (for example aggressive, sexualised or exhibitionist make better informed decisions.
behaviours). These behaviours can also lead to interaction with the police,
criminal justice or disciplinary systems in schools and colleges. Finally, for
those for whom substance use has become engrained within their lifestyle, b. introduce routine enquiry within urgent and emergency care, and specialist
criminal activities may be a way of access or funding their use. drug and alcohol services
Routine enquiry about childhood adversity should be introduced into both

A&E , urgent care, and specialist drug and alcohol services.
5. Responding to childhood adversity and
substance misuse Routine enquiry involves training frontline professionals to sensitively
gather information about whether someone’s thoughts and behaviours are
Recently, Public Health England published a support pack for commissioners a symptom of a childhood adversity or trauma they have experienced. This
to strengthen substance misuse services and interventions for young people21. might include adding a key line of enquiry into A&E assessment conversations
304 We recommend that commissioners work through the comprehensive list when a young person has a serious first presentation of self-harm through 305
of questions to assess the sufficiency of their local offer. In addition to these intoxication, or if a trend of recurrent harm through intoxication is identified.
prompts, we have included priorities for commissioners to consider when This opportunity is frequently missed if an A&E or urgent care doctor does
creating trauma-informed practice around young people’s mental health and not deem the young patient to have a level of mental ill health that would meet
substance misuse. their threshold for contacting the hospital’s dedicated mental health team.
Likewise, if a young person is already in contact with a specialist drug and

a. embed psycho-education in the universal education offer alcohol service, initial assessment should include enquiry on childhood
adversity to identify whether the health-harming behaviours seen in
While it is a minority of adolescents who develop a problematic relationship substance misuse are related to the ‘self-medicating’, coping or management
with substances, it is important that all young people receive universal-level of trauma-related symptoms. For example, young people who access
drug and alcohol education. This age-appropriate education should include specialist treatment support with Addaction will undertake a comprehensive
considerations of risk, relationships and how to build resilience in relation to assessment. Questions within this focus on the motivations for the young
decision making, experimentation and use of drugs and alcohol. To ensure it is person’s use, whether this is a form of escapism, and if so what the situation
trauma-informed, those delivering the training, or supporting teaching staff to they are ‘escaping from’. This question is combined with others which cover the
do so, should have a good knowledge of the relationships between childhood young person’s family life, physical and mental wellbeing, as well as risk-taking
adversity, trauma responses, mental ill health and use of substances. behaviour.
Commissioners, mental health providers and specialist drug and alcohol Routine enquiry should involve a warm transfer to trauma-informed models
services should take a collaborative role in supporting local schools to develop of rehabilitation, psycho-education and harm-mitigation. This would include
and deliver programmes meeting the requirement to embed relationships referral to safeguarding leads if any child or adult safeguarding flags are

triggered during the enquiry. Pathways to support from routine enquiry should Successful early intervention can result in young people being less likely to
be designed collaboratively by local commissioners, social services (depending require specialist support later in adulthood, and can reduce overall reliance
on the circumstances of the young person and parents), young people and on public services.
service providers.
c. invest in early intervention models Addaction’s Mind and Body programme

(Cornwall, Kent and Lancashire)
The charity Mentor UK has usefully summarised the factors that protect
against, and increase the risk of, substance misuse (see table 1)24. Research The Addaction Mind and Body programme aims to support young
shows that the age of a young person’s use of substances is a strong predictor people (aged 13 to 17) who are involved in, or may be vulnerable to,
of the severity of their use later on in their life. Early intervention should be self-harming behaviours. The programme looks to support those who
initially targeted towards those children who have a known risk factor, and are do not meet CAMHS thresholds but who could benefit from specialised
listed as belonging to a vulnerable group. input that universal services are often unable to provide.
A short online screening survey is used to help identify young people

who might be at risk and to assess whether the programme would be
Table 1: Protective and Risk Factors right for them. Referrals may also come from local health partners and
schools, while young people can self-refer too.
Protective
306 factors
Risk Factors The programme was developed from RisKit 25, an early intervention 307
initiative which has a proven evidence base in risk-reduction outcomes.
• Positive Belonging to a Social and cultural Interpersonal and In 2016-17 Mind and Body was delivered in Kent, Cornwall and
temperament vulnerable group: factors: individual risk Lancashire with over 600 young people completing the programme.
• Intellectual • Looked-after • High levels of factors:
ability children neighbourhood • Physiology and Mind and Body comprises of eight group sessions, accompanied by
• Positive and • School non- poverty and decay psychology
three one-to-one sessions with a practitioner for needs-based support.
supportive attenders • High levels of factors
The diagram on the following page outlines the core themes within each
family • Having mental neighbourhood • Family
environment crime dysfunction of the group discussion sessions.
health problems
• Social support • Drug misuse by • Easy drug • Behavioural
system availability difficulties An independent evaluation by the University of Bath found that the
parents
• Caring • Widespread social • Academic screening processes identified young people who were ‘under the
• Abuse within the
relationship family acceptance of problems radar’, and who were not known to be at risk of harm.
with at least one alcohol and drug • Association with
• Homelessness
adult use peers who use As a result of the programme activities:
• Young offenders
• In education, • Lack of knowledge alcohol and drugs
employment or • Young sex and perspective of • Early onset of • eight in ten young people experienced a decrease in self-
training workers drug-related risks tobacco smoking harming thoughts, or did not think about self-harm at all
• Early onset of while they engaged in the programme.
alcohol and drug
use

adult substance misuse. The service works directly within family homes to
• nine in ten young people experienced a decrease in self- establish routines and pro-social family behaviours, as well as providing
harm actions or did not self harm at all while they engaged specialist alcohol and drug services to mitigate the impact of substance misuse
in the programme. on children. In addition to this BtC provides parenting support, advice and
advocacy, consultation with children, and signposting or referral to targeted
• three in four young people reported an increase in their statutory, primary care and voluntary community based services.
mental wellbeing.
The service builds on early attachment theory, and aims to provide an
More information can be found at: http://tiny.cc/Mind_Body opportunity for families to foster resilience and positive adaptation, despite
adversity they have faced individually and collectively as family members.
Families who are motivated to participate in family-focussed recovery plans
tend to benefit from Breaking the Cycle, with an ambition to sustaining
Talking Identifying their recovery and providing a different life for their children, to give them a
about mental risks
health different trajectory to the pathway associated with substance misuse.
Reflecting e. establish inter-agency collaboration

on the Communicating
programme
Assessment Young people affected by substance misuse are often involved with other
agencies because of the criminalisation, stigma and associated behaviours (e.g.
308
and one-to-one increase in impulsivity) associated with it. As such, local agencies need to adopt 309
sessions (x3) a holistic and collaborative approach to ensure that all of the young person’s
Reviewing Managing
emotions needs are being addressed26. This is an important starting point for all service
process interventions as it allows for a trauma-informed model of care, where the
(1 of 2)
young person’s needs are contextualised within the network of adversity they
have experienced. Furthermore, such inter-agency working can help to identify
Managing
Making emotions moments in the care pathways, or gaps between service provision, where
changes these young people are at risk of being re-traumatised.
(2 of 2)
The Kent Youth Drug Intervention Scheme
d. build targeted parental and whole family support models Addaction works jointly with local police to deliver The Kent Youth
Drug Intervention Scheme (KYDIS). This is a restorative justice process
It is vital that parents, and care givers, who are misusing substances are given for young people who are found in possession of a Class B or C drug,
targeted support to both promote their recovery from addiction, and to where they are offered a diversionary activity to avoid criminalisation.
address the additional adversity they are exposing their children to. The young person has the option to attend a session with an Addaction
worker in which the topics of substance awareness and education,
For example, Breaking the Cycle (BtC) is Addaction’s family-focussed consequential thinking and the legality of their actions are covered. If
service, offering interventions to families where children are affected by

References
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drinking and drug use among young people in England in 2014: http://natcen.ac.uk/me-
dia/1006810/Smoking-drinking-drug-use-2014.pdf
Similarly, Addaction are also currently piloting an innovative way of
2 NPS are drugs that are designed to replicate the effects of other illegal substances. People
working in partnership with a local provider. Addaction have seconded may refer to these drugs as “legal highs”, but all psychoactive substances are now either under
a member of staff to work as a Dual Diagnosis Navigator within a local the control of the Misuse of Drugs Act [1971] or subject to the Psychoactive Substances Act
agency who are delivering a programme to young people to support [2016].
Around 1 in 40 (just 2.6%) young adults aged 16 to 24 took an NPS in 2016/17, which is a
their transition into adulthood. The service works with young people
similar proportion to the estimates for 2014/15. For more information see: ONS / NHS Digital
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5 World Health Organization (2013) European Report on Preventing Child Maltreatment:
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6 Bellis M. A., Hughes K, Leckenby N, Perkins C, Lowey H. (2014) ’National household survey
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experiences and personal alcohol abuse as an adult’ Addictive Behaviors 27: 713-25.
10 Douglas, K. R., Chan, G., Gelernter, J., Arias, A. J., Anton, R. F., Weiss, R. D., and Kranzler, H. R.
(2010) ‘Adverse childhood events as risk factors for substance dependence: partial mediation
by mood and anxiety disorders’ Addictive Behaviors 35: 7-13.
11 Simpson, T. L. and Miller, W. R. (2002) ‘Concomitance between childhood sexual and physical
abuse and substance use problems: a review’ Clinical Psychology Review 22(1): 27–77.
12 Douglas, K. R., et al (2010) Op. cit.
13 Bellis, M. A., Lowey, H., Leckenby, N., Hughes, K. and Harrison, D. (2014) ‘Adverse childhood
experiences: retrospective study to determine their impact on adult health behaviours and
health outcomes in a UK population’ Journal of Public Health 36(1): 81-91.
Public Health Wales (2015) Welsh Adverse Childhood Experiences Study: Adverse Childhood
Experiences and their impact on health-harming behaviours in the Welsh adult popula-
tion: http://www2.nphs.wales.nhs.uk:8080/PRIDDocs.nsf/7c21215d6d0c613e80256f-
490030c05a/d488a3852491bc1d80257f370038919e/$FILE/ACE%20Report%20
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Chapter 23
14 McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., and Back, S. E. (2012) ‘Posttraumatic stress
disorder and co-occurring substance use disorders: Advances in assessment and treatment’ 24. Trauma-integrated psychotherapy
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16 NICE (2016) Coexisting severe mental illness and substance misuse: community health
Dr Sarah Bendall,
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es-pdf-1837520014021
Professor Eoin Killackeya and Professor Henry Jackson
17 Kuepper, R., van Os, J., Lieb, R., Wittchen, H-U., Höfler. and Henquet, C. (2011) ‘Continued
cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up
cohort study’ BMJ: http://www.bmj.com/content/bmj/342/bmj.d738.full.pdf
18 NICE / NHS England (2016) Implementing the Early Intervention in Psychosis Access and
Waiting Time Standard: https://www.england.nhs.uk/mentalhealth/wp-content/uploads/
sites/29/2016/04/eip-guidance.pdf
1. Childhood trauma and psychosis
19 Newbury-Birch, D., et al (2009) Impact of Alcohol Consumption on Young People: a systematic
The pervasiveness of childhood traumas and their devastating long-term
review of published reviews: http://dera.ioe.ac.uk/11355/1/DCSF-RR067.pdf
impact on those children’s mental health across their lives have only come
20 Hammersley, R., Marsland, L. and Reid, M. (2003) Substance Use by Young Offenders: http://
webarchive.nationalarchives.gov.uk/20110218135832/rds.homeoffice.gov.uk/rds/pdfs2/ to light in recent years. Startlingly high rates of childhood trauma have
r192.pdf been found in young people accessing early psychosis services with over
21 Public Health England (2016) Young People – Substance Misuse JSNA Support Pack 2017-18: 65% reporting sexual, physical, emotional abuse or neglect1. Not only does
commissioning prompts (good practice prompts for planning comprehensive interventions):
childhood trauma lead to increased risk of developing psychosis, it also leads to
http://www.nta.nhs.uk/uploads/jsna-support-pack-prompts-young-people-2017-final.pdf
22 Department for Education (2017) Policy Statement: Relationships Education, Relationships
a more distressed and disabled clinical picture in those with early psychosis2.
312 and Sex Education, and Personal, Social, Health and Economic Education: https://www.gov.uk/ This clinical picture includes more severe hallucinations and delusions, 313
government/uploads/system/uploads/attachment_data/file/595828/170301_Policy_state- depression, suicidality, and post-traumatic stress disorder (PTSD) as well as
ment_PSHEv2.pdf
poorer social functioning and engagement with treatment3.
23 For more information see: http://www.addaction.org.uk/help-and-support/young-persons-ser-
vices/amy-winehouse-foundation-resilience-programme
24 For more information see: http://mentor-adepis.org/risk-protective-factors
Specific interventions for the effects of trauma in those with chronic psychosis,
25 Stevens, A., Coulton, S., O’Brien, K., Butler, S., Gladstone, B. and Tonkin, J. (2014) ‘RisKit: The
adjunctive to standard treatment, are beginning to be evaluated with very
participatory development and observational evaluation of a multi-component programme for promising results4. The most recent and largest of these found that 8-week,
adolescent risk behaviour reduction’ Drugs: Education, Prevention and Policy 21(1): 24-34. exposure-based interventions significantly reduced PTSD symptoms in
26 HM Government (2010) Reducing Demand, Restricting Supply, Building Recovery: Supporting those with chronic schizophrenia compared with waitlist control5. However,
people to live a drug free life: https://www.gov.uk/government/uploads/system/uploads/at-
tachment_data/file/98026/drug-strategy-2010.pdf
alongside specific interventions directly targeting PTSD such as these,
there is a widely identified need for trauma-informed care, a broad, service-
wide understanding of, and intervention for, trauma-exposed mental heath
consumers that goes beyond the treatment of PTSD6. Despite excellent face
validity, trauma-informed care has yet to be well evaluated in clinical services.
There is a need in psychosis treatment services for both trauma-specific and
trauma-informed approaches7. There is also need for trauma treatments
specifically for those with early psychosis8.

Chapter 24 Trauma-integrated psychotherapy for psychosis (TRIPP)
2. Trauma-integrated psychotherapy for psychosis (TRIPP) Many young people with early psychosis may have had no or little prior contact
with mental health services, have very little conceptualisation of talking
Over the past five years, our team has developed and piloted TRIPP, a trauma- therapies and may have very little experience of prolonged face-to-face talk
integrated treatment approach that: a) has been developed using principles of with adults. This means that it may take them some time to trust in the clinical
trauma-informed care; b) operationalises guidelines for addressing trauma in team to be helpful. Trust is central to therapy for trauma symptoms as trauma
early psychosis services, and c) provides a flexible intervention strategy based can involve betrayal by trusted individuals and thus clinicians can be seen as
on evidence-based elements for PTSD. The intervention is integrated into potentially untrustworthy. Engagement is important throughout TRIPP therapy
routine case management and can vary in duration from 3–12 months. but it is particularly central during the safety module where the young person
can build confidence in how the clinician will approach trauma memories.
This paper will focus on a description and rationale for the intervention.
The therapy comprises five modules set within a background of continual
engagement and a strengths-based perspective (see Figure 1). b. Screening
There is broad consensus10 and national guidelines stipulate11 that all people
Figure 1: overview of the TRIPP model accessing early psychosis services should be screened and assessed for trauma
exposure and symptomatic effects. However, there is evidence that only a
minority of patients are screened for trauma in psychosis treatment settings12.
Engagement This is due to concerns about the potentially distressing and destabilising
effect of screening and assessment for trauma and clinicians’ lack of skills
Screening to address any trauma that is reported13. In the TRIPP model screening and
314 assessment are separated with the screening module developed as a way of 315
gathering necessary information but having the young person approach the
trauma memory as briefly and superficially as possible. A full assessment of
n
tio
Safety
uca
trauma and its effects (see timeline below) is completed only after emotion
-ed
Timeline regulation skills had been learnt (see safety module below).
cho
Psy
Screening is completed for every young person via three written screening
tools to very briefly assess for trauma exposure, PTSD and dissociation
Formulation symptoms. This screening is introduced to the young person with some
brief psycho-education regarding the high rates of trauma in early psychosis
Strengths-based approach services and its importance as regards symptoms and functioning. The young
person’s permission is asked to complete the screening and young people
are expressly told they do not need to do anything further than complete
the written screeners. If they do however want to discuss the content of the
a. Engagement screeners further then they have that opportunity. If trauma is detected then
young people move onto the safety and psycho-education modules.
Engagement is a key component of early psychosis service delivery9. It creates
a collaborative therapeutic alliance that allows young people to trust clinicians.
It is important to note that, in contrast to many people accessing mental health c. Safety
services, young people who attend early psychosis services are often not
treatment seeking, and many may be ambivalent about the need for care. The safety module of TRIPP involves the assessment and treatment of safety

concerns such as suicidality, self-harm and substance abuse alongside skills d. Psychoeducation
development for noticing and communicating in-the-moment distress levels
(using subjective units of distress (SUDS)) and learning and practice of distress One of the central tenets of early psychosis treatment is the early focus on
coping strategies for use in and out of therapy. Emotion regulation and coping comprehensive psychoeducation regarding psychosis for both the young
skills have been identified as evidence-based strategies for managing the person and their family. Early psychosis services have developed and deliver
distress that can accompany trauma assessment and treatment14 and are high quality, youth-friendly, optimistic, tailored, collaborative psychoeducation
particularly important for young people15, those with more severe childhood for their clients in both written and face-to-face forms20. A recent review of
interpersonal trauma16, and with co-morbidities such as depression or the common elements of a variety of evidence-based psychotherapies of PTSD
anxiety17. We have added a specific strategy to enable the clinician to monitor found that psychoeducation about the nature and process of post-trauma
the young person’s feelings of distress, in response to widespread concerns reactions and the discussion of strategies for managing distress is a core part
that talking about trauma may be particularity distressing for young people of all evidence-based treatments for PTSD. The aims of psychoeducation for
with early psychosis and may exacerbate psychotic symptoms18. both psychosis and post-trauma reactions align in that relapse prevention and
engagement of the person in the treatment process are highly important in
While all aspects of the safety module cannot be covered here, the “distress treatment for both.
thermometer” (SUDS ratings), which is a core element of the module, will be
described. Young people are shown a visual depiction of a thermometer with In the TRIPP model psychoeducation is carried out concurrently with the safety
ratings of 0-100 and asked to rate their current in-the-moment “distress” on and timeline modules. Psychoeducation is delivered from a broadly cognitive-
the thermometer. The thermometer is placed prominently and referred to behavioural perspective and core elements include: post-trauma intrusions,
often throughout TRIPP therapy. The young person is asked at least twice but post-traumatic avoidance, hyper-arousal and dissociation. These elements are
often more during each session to rate their distress. introduced if/when the symptoms are discussed in the timeline module. One
316 of the main aims of psychoeducation is to normalise post-traumatic reactions. 317
Early in the safety module, the case manger and young person experiment with Psychoeducation may be distressing for a young person as it asks them to focus
relaxation, grounding, mindfulness and visualisation techniques (see Lanktree on their trauma experiences (even if they are not talking about them in detail).
and Briere19 for a description of such techniques) that are designed to reduce Thus it is linked with the safety module so the young person remains in control
thermometer ratings. As the timeline module is started, thermometer ratings of distress levels even when receiving psychoeducation. Metaphors are used
are taken more frequently when distressing past material is described or when possible to explain concepts (e.g. the filing cabinet analogy for intrusive
discussed and the young person’s repertoire of identified distress tolerance trauma memories and post-traumatic avoidance).
techniques are used to reduce distress. The thermometer strategy enables
young people to identify, communicate and take control of their feelings of
distress in session, which can be generalised to other parts of their life. It e. Timeline
also allows the clinician to know the young person’s subjective experience of
distress as, in our experience, this cannot be determined by how the young The timeline involves the young person describing major events or experiences
person looks or acts in a therapy session. over the course of their life, and reactions to those events. The description
of these is noted on a written timeline, which is worked on collaboratively
One of the overarching aims of the safety module is to increase young people’s between clinician and young person in session. Included in the timeline are
confidence and motivation in being able to feel in control when approaching traumatic experiences, and other important events throughout life. When
trauma memories and other emotionally difficult situations. The duration of traumatic experiences are placed on the timeline little detail is gained about
the safety phase can vary widely depending on the needs and motivation of the actual traumatic experience. However, the effect of the experience on the
the young person. Integrating TRIPP into routine case management (up to two client and on the family system immediately and over time are explored and
years of care) means that slower, lower intensity safety module work can be noted on the timeline. Other traumas and the development and change in
integrated with other case management tasks. symptoms are then noted.

As the timeline comes closer to the present, more close-in descriptions of underpinnings of a person’s difficulties, highlighting factors that may have
effects/symptoms are explored. As one of the functions of case management in caused, precipitated and maintained these difficulties25. There is high utility
early psychosis is to monitor current symptoms, this function is incorporated in using formulation in both a trauma-informed and a trauma-specific
into the current end of the timeline and thus symptoms (e.g. post-trauma intervention in early psychosis, as both models stress the importance of both
intrusions, avoidance, dissociation and hallucinations and delusions) are clinician and client understanding the role of the trauma and peri-traumatic
tracked and the temporal relationship between them is explored. effects on presenting symptoms26.
The timeline is primarily designed to elicit enough information about trauma Within TRIPP, formulation occurs over 1-2 sessions at the conclusion of the
and its effects in order to provide psychoeducation about symptoms (see timeline and operates from the following principles and assumptions:
above) and make a collaborative formulation (see below). However, in
practice we have found that young people can demonstrate high distress i. Until TRIPP treatment, young people may have made no connection
thermometer ratings (see above) during this process. We conceptualise this as between their trauma experiences and the experiences/symptoms
part of a PTSD avoidance process whereby young people feel intense fear of that have brought them to mental health services, and indeed may not
approaching trauma memories. have conceptualised their traumatic exposures as adverse, out of the
ordinary, or potentially psychologically harmful.
The timeline module was designed to provide information for a trauma-
integrated formulation and a platform for psychoeducation. It is possible, ii. Young people with trauma and early psychosis often present with a
however, that it acts as exposure to the traumatic memory and emotions variety of symptoms, which may or may not be directly trauma-related:
associated with that memory but within a safe context, a common factor in PTSD intrusions and avoidance, dissociation, hallucinations and
PTSD treatment21, as has been suggested with other comprehensive PTSD delusions, other psychiatric symptoms.
318 assessments in those with PTSD and psychosis22. 319
iii. There are many comprehensive evidence-based psychological models
We suggest the possibility that the much less intense engagement with the to formulate post-traumatic intrusions and avoidance and, to a lesser
trauma memory in the current intervention may be sufficient to reduce PTSD degree, dissociation27.
for some young people. This population may be more amenable to a less
intense dose of exposure treatment than others because they may have fewer iv. Psychological models of trauma and psychotic symptoms are currently
years of PTSD symptomology than adults. They may also have less severe early in development and empirical testing. Thus, we are not yet able to
(and also sub-threshold) PTSD symptoms. This possibility accords with the use a specific model in clinical practice.
clinical staging model of mental disorder that purports that those at earlier
stages of the development of mental disorders may be more responsive to v. The basic principles of CBT can guide formulating of psychotic
treatment and should be delivered more benign treatments23. This supposition symptoms in relation to trauma28 together with emerging models of
is speculative and requires empirical testing. Our forthcoming publications on trauma and psychotic symptoms if appropriate29.
our pilot of TRIPP will begin to answer such questions.
vi. Formulating regarding hallucinations and delusions and trauma
symptoms is exploratory, idiosyncratic, and based directly on each
f. Formulation young person’s own experience. Formulating can conclude, based on
the young person’s experience, that hallucinations and/or delusions are
A comprehensive formulation is considered to be central to cognitive not trauma-related.
behavioural therapy (CBT) with particular utility in situations where
empirically-supported treatment protocols are insufficient24. Formulation vii. The formulation includes personal strengths and important social
involves making a collaborative hypothesis about the psychological supports.

viii. While the formal formulation is conducted at the end of the timeline
the building blocks of the formulation will already have been explored The hallucinations are formulated to occur more often due to the
with the young person during the timeline and psychoeducation current distress and fear the young person still felt in the presence of
modules. the past perpetrator. That current fear was validated as understandable
even though the abuse was not still occurring.
ix. There is a collaboratively-written document of the formulation which
is given to the client. This ensures that there is a record both for the
young person and in the clinical file for possible future contact with
mental health services. g. Strengths-based approach
We also take a strengths-based approach when conducting TRIPP. Strengths
are defined by McQuaide and Ehrenreich30 as “the young person’s ability and
Examples of formulations made in relation to psychotic symptoms capacity to cope with difficulties, to maintain functioning in the face of stress,
in TRIPP to bounce back in the face of significant trauma, to use external challenges as a
stimulus for growth and use social supports as a source of resilience”. Thus, in
A young person had a delusion that her body and mind were being the timeline module, we ask the young person to highlight social supports and
taken over by a powerful malevolent force. She regularly experienced the ways that they have coped with the traumas they have experienced. These
intense depersonalisation (in this case the young person felt detached are noted on the timeline and incorporated into the formulation.
from both her body and mind) and amnesia at times. These dissociative
symptoms were formulated as having developed as a way of mentally
320 coping with ongoing trauma as a child (based on timeline evidence) 321
but had generalised to become a way of coping when faced with a 3. Conclusions
wide range of difficult situations. Depersonalisation had not been
understandable to the young person and had been interpreted as We have designed and developed TRIPP as we believe that it is essential to
having her body taken over by an external force hence becoming a develop and research not only specific treatments for PTSD but also broader
delusion. approaches that support safe and effective screening, assessment and psycho-
education in early psychosis from a trauma-informed perspective. Our in-
A young person had auditory verbal hallucinations of an unknown voice depth qualitative assessments of young people’s experience of TRIPP therapy
saying “you’re an idiot”. During the timeline the young person described tell us that, while it can be challenging for young people to undertake, TRIPP
being bullied at school and the development of PTSD intrusions of the therapy is very worthwhile31. Randomised trialling is needed to establish the
high-school bullies teasing him including saying “you’re an idiot”. The effectiveness of the intervention.
young person tried to push these unwanted PTSD intrusions away and
avoided many situations where he was reminded of the bullying. The We envisage TRIPP or its adaptation as potentially useful in work with young
hallucinations were formulated as potentially part of the same post- people with a range of mental health problems. It may be particularly potent
traumatic process as the PTSD symptoms. in situations where young people have not conceptualised their experiences
as traumas or their symptoms as trauma-related, and/or where young people
A young person had more frequent and intense hallucinations when a are reluctant to engage in, or decline exposure-based treatments. It is possible
past perpetrator of abuse was present. During the timeline the young that an adaptation of the model could be used as preparation for evidence-
person described the fear caused by the perpetrator in childhood. based treatments for PTSD in these situations. It may also be useful in
treatment settings where clinicians are not therapists or trauma-specialists.

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Supporting children who experience loss and bereavement
25. Supporting children who experience 2. Recognising the needs of bereaved children and
loss and bereavement young people
Dr Rebecca Adlington, Dr Russell Hurn, Dawn Hewitt CHUMS began in 1996 as a small voluntary service. In 2000, funding was
and Jan Cooper received from the NHS allowing CHUMS to establish itself as a countywide
child bereavement service. Nevertheless, CHUMS remained a small service
comprising two employed staff members and several volunteers, and receiving
only a small number of referrals annually. In the ensuing years, the growth
1. Introduction of the service was staggering, and by 2011 there were 11 members of staff,
and over 70 volunteers, supporting approximately 350 children and young
CHUMS child and adolescent mental health and emotional wellbeing service people per year. During this period, CHUMS developed a unique, high-quality,
is a community investment company offering front-line psychological support evidence-based service, which prioritised and held the needs of children
to children in Bedfordshire with mild to moderate mental health problems. In and young people and their families at its heart. However, in the context of
the last year, it is estimated that CHUMS offered support to 1,700 children mounting strain on staff and resources, it was felt that for CHUMS to continue
and young people, and their families, while also providing input into schools to deliver effective bereavement support, it was necessary to establish the
and the wider community. In this way, CHUMS has become a multifaceted service as a social enterprise. This would enable CHUMS to access alternative
organisation which aims to meet the emotional wellbeing needs of the local sources of funding, provide a more cost-effective service, and reinvest in the
community. However, at the heart of CHUMS is a drive to support families community, allowing the service to expand and respond to needs as they arose.
affected by adversity, trauma and loss. It was this agenda that fuelled CHUMS
324 to break away from the NHS in 2011, and it is through our continued drive to Among those factors informing the decision to become independent from the 325
deliver targeted services for children and young people and families affected NHS, was an understanding of the challenges faced by children and young
by loss that CHUMS is now recognised as a benchmark service both regionally people who had been bereaved, and the prevalence of this. In the bid to
and nationally. establish CHUMS as a social enterprise, it was stated that 22,000 children and
young people in Bedfordshire alone would likely experience a bereavement1.
In this paper we consider the reasons why there is inherent value in This was based on National Statistics reporting that approximately 4% of
supporting families through periods of loss, with reference to the evidence children and young people under 18 years have been bereaved of a parent/
base and consideration of how this informed CHUMS’ decision to establish sibling, 13% have been bereaved of a grandparent, and 6% have been bereaved
an independent service. We then give an overview of the support CHUMS of a friend2. Research has shown that of these deaths, approximately 25%
provides to those who have been bereaved, and how we continue to transform occurred suddenly, with this figure rising to 42% if the number of people who
our services and develop understanding of how to help children and young died unexpectedly from chronic/long-term conditions were included3.
people and their families in response to the evidence base and service user
feedback. Finally, we will provide a summary of the key features which may be
adopted by the NHS and children and young people services more generally,
if we are to meet the needs of children and young people who experience loss
and bereavement. 2in50
children and young people under 18 years
MUM
have been bereaved of a parent or sibling

Chapter 25 Supporting children who experience loss and bereavement
Further to the risks to emotional wellbeing, studies have demonstrated
3in50
FRIEND
that experiencing a bereavement in childhood may have other deleterious
effects. Worden9 found that in the first year after a death children and young
people were more likely to experience a serious physical health problem or
have been bereaved of a friend somatic symptoms in the clinical range, with further studies demonstrating
an increase in risk-taking behaviours10 and the use of tobacco, alcohol and
illicit substances11. Furthermore, there is some evidence to suggest that
experiencing a bereavement in childhood, specifically that of a parent, may
7in50
GRAMPS
impact on attainment in school12, and increase the risk of unemployment
in adulthood13. Parental death has also been associated with increased
criminality14.
have been bereaved of a grandparent
Reflecting on the above, the evidence clearly highlights the significant impact
of bereavement on the emotional wellbeing of children and young people and
the consequential risks to their future and society. The need for specialised
support for these children and young people and their families is paramount.
Nevertheless, a survey of all local authorities and the former Primary Care
Trusts in England, conducted by the Child Bereavement Network (CBN)
to ascertain the provisions in place to support children and young people,
received low response rates and discrepancies in responses. This suggested 3. Becoming an independent organisation
326 that bereaved children and young people’s needs may not be recognised as the 327
particular responsibility of any department or aspect of children and young Under the Department of Health’s Right-to-request programme, which
people services4. This lack of specialist support was something that CHUMS encourages NHS staff to establish independent social enterprises, CHUMS
were acutely aware of and keen to address. made its successful bid to become independent from the NHS in 2011. Since
that time, the service has continued to expand, developing in response to need
While death is commonly perceived as an event that people encounter in and tailoring services according to service-user feedback and audit data, as
adulthood, the reality is that it affects a large number of children and young well as guidance from organisations such as the CBN. Consequently, CHUMS
people. now aims to provide interventions consistent with the tiered approach
recommended by CBN15 while also considering on a case-by-case basis the
The needs of children and young people who have been bereaved may be type of support needed. The interventions we provide are detailed in table 1
extensive. Fauth, Thompson, and Penny5 found that 5-16 year olds who on the next page.
experienced a bereavement were 1.5 times more likely to be diagnosed
with a mental health disorder. More specifically, they reported an increase
in problems with anxiety and alcohol use related to the death of a parent or
sibling, whereas the death of a friend increased the risk of conduct problems. 4. What informs our interventions?
While the directionality of the link between mental health problems and
bereavement cannot be inferred from the data used by Fauth and colleagues, While we recognise that most children and young people who are bereaved
their findings are consistent with other studies demonstrating that following a may not need professional support16, we know that where support is required,
bereavement, children and young people may display a range of emotional and it needs to be developmentally appropriate, sensitive to the degree of distress
behavioural symptoms including anxiety, low mood6, low self-esteem and low associated with the loss17, and be delivered in a timely manner18. Concerning
self-efficacy7, with 20% going on to experience a psychological disorder8. the latter, studies have shown that often support is offered too late, leading

Table 1: Summary of CHUMS interventions are ideally placed to support children and young people with other difficulties
that might prevent them from processing a death. As poor mental health prior
to a death is associated with increased difficulty following the bereavement20
Intervention type Description
we recognise that some of those who access our service may have additional
General • Brief individual interventions of 4-6 sessions needs that require targeted interventions in the first instance. As many of
Bereavement • Specialised interventions for cases of traumatic loss our staff work across multiple parts of the service, we are in a position to
Support • Group workshops (child and parent) facilitate continuity of care, helping the young person and their family to feel
• Telephone support contained and supported throughout their time with CHUMS. In addition, the
• On-going groups bereavement referrals are now considered as part of a Single Point of Entry
• Teenage workshops pathway developed with CAMHS. This has raised the awareness of the needs
• Residential weekends
of bereaved children and young people and provided a greater multiagency
approach to cases.
• Remembrance Services
• Training and support to other professionals who may be
involved in supporting families who have been bereaved An awareness of the factors that mediate the impact of childhood
(e.g. school staff, social care) bereavement on wellbeing informs how we support children and young people
• Training for volunteers and their families. There is much that can be done both at the individual and
family level to reduce the likelihood that a CYP might experience long-term
Specialist Services • Neonatal service: includes an on-going group, brief difficulties following a bereavement21. Concerning the individual level first,
interventions, and telephone contact
studies have demonstrated that the way in which a child and young person
• Pre-bereavement service: brief interventions and
makes sense of a death and relates to the loss can have a profound impact
facilitated transition to the bereavement pathway
328 • Crises Response Service: supporting families following
on subsequent wellbeing22. Consequently, a fundamental role of all our 329
a death by suicide or one that occurred in unexplained interventions is to provide children and young people with the opportunity
circumstance. Service aims to provide practical help in to make sense of their loss. Our interventions therefore support children
the weeks leading up to inquest, as well as an on-going and young people to develop a narrative around the death. Furthermore, in
support group.
our bereavement workshops children and young people are provided with
the opportunity to put questions to a doctor and undertaker, who can in age
appropriate ways, help the young person to understand what happens when
to a reduction in the effectiveness of the intervention19. Consequently, we someone dies.
aim to ensure that every family referred gets the best possible care within
a time frame that meets their needs. However, we have learned that what is In addition, we understand that emotional wellbeing following a bereavement
meant by a ‘timely manner’ may differ between families, with some requiring is impacted by factors such as poor self-esteem23 an external locus of control24
immediate support following a death, while others may not be ready to and fewer coping strategies or a belief that coping strategies do not work25.
access support until months, or even years, later. We therefore ensure that Therefore, both our interventions aim to promote self-esteem and develop
families are contacted within a week of CHUMS reviewing their referral, coping strategies such as decision making, problem solving and other life skills
and if appropriate, that we offer an assessment soon after. From there, we that might reduce distress and increase function.
acknowledge that the type of support also needs to be in keeping with the
family’s needs, whether it be individual or group intervention, brief telephone At the family level, the extent to which a child feels secure26 and perceives their
contact, on-going groups, or access to our remembrance services. Thus, we circumstances as stable27 can influence wellbeing following a bereavement.
aim to offer support to all bereaved families with the understanding that not all Several studies indicate the need for whole family support28, with Haine and
will need it, but that some may come back to it when the time is right. colleagues29 recommending that bereavement interventions should facilitate
Moreover, as CHUMS offer a wide range of emotional wellbeing services, we positive parent-child communication and relationships, increase parental

warmth and effective discipline, reduce parental distress and increase the young people who have experienced death (e.g. school staff, social care,
opportunity for positive family interactions while reducing the child’s exposure school nurses etc.)
to negative events.
• Consultation and guidance
With this in mind, we do not support the child in isolation, but aim to involve
parents, siblings and extended family in the work that we do; helping other • Development of volunteers from the local community
family members to process the loss themselves as well as exploring how they
might support the child. Our workshops and remembrance services provide • Apprenticeship programmes to promote the continued development of
a facilitated space where families may begin to talk more openly about death children and young people
and foster positive shared experiences. We also encourage families to access
other services including adult mental health services where we feel this • Service user involvement
would benefit the long-term wellbeing of the family. Consequently, CHUMS
continually strives to keep up-to-date with locally available services and to • Networking and educational events to promote CHUMS and make
make links with other agencies. links with other organisations
The involvement of volunteers is a particular strength of CHUMS, enabling the

Case Study: benefits of inter-agency working delivery of a cost-effective service. We currently have over 100 volunteers,
many of whom have used our service and so have first-hand experience of
A 13-year-old boy suffered the unexpected and traumatic loss of his the challenges our families face. As members of the local community they
330 sister and step-family. The impact of this devastating event on him and provide local knowledge and raise the profile of CHUMS in their area, helping 331
his mother proved to decimate their social network and prevented us to reach individuals that might not ordinarily access services. Their diverse
him from joining his new school at the point of transition. In addition backgrounds bring added richness and skills that we are able to employ
to the personal and family support CHUMS has offered we are also not only clinically through their support in our workshops and short-term
working closely with the medical needs team to ensure he maintains his interventions, but in other areas of the service such as fundraising and
education and can be integrated back into his school and social network administration.
in a graded and structured way. Helping his mum to identify how she
could facilitate this with her own gradual return to work has also been a Feedback from volunteers, as well as service-users in general, is welcomed.
crucial part of the work. We ask all service-users to complete a feedback form at the end of their
intervention, carry out a service user survey annually, and use the Session
Rating Scale30 to get a better understanding of the salient aspects of our
interventions. We also have a service-user participation group who contribute
to all aspects of the organisation from the development of resources and
5. Working with the local community selection of staff members, down to the look of our clinic rooms and waiting
areas. The feedback and involvement of our service-users ensures that all
As a social enterprise, a core value of CHUMS is investment in the local developments hold the best interests of the child at their core.
community.
As we are not the only organisation that are likely to come into contact with
CHUMS works with the local community through: children and young people who have experienced death, much of our work in
the community aims to provide other professionals with the knowledge and
• Providing training for professionals who may work with children and skills to be able to support this client group. For example, we regularly deliver

training around loss and bereavement to staff working in Central Bedfordshire intended that over the coming year, we will see an increase in this figure with
and Bedford Borough schools as part of a comprehensive package designed goal progress charts being brought into every session (where appropriate),
to promote emotional wellbeing in schools. Moreover, we provide regular and end of therapy measures being completed during the last session of an
consultation sessions for school staff and school nurses to discuss cases and intervention, rather than being sent to clients to complete. It is hoped that
share learning. Studies of school based interventions have produced mixed through these steps, we may be able to get a better understanding of the
results31, however there is support for the notion that it is helpful for staff efficacy of our services, informing best practice which we may then share with
to be able to acknowledge a death and provide words of encouragement other services dedicated to supporting CYP who have experienced death.
or support32. In accordance with these findings, by training school staff to
work with bereavement, it is hoped that they may be in a position to support Finally, we set out the learning points from CHUMS’ experience of working
students known to them, allowing the continuity of relationships that are with children and young people who have been bereaved, which could be
helpful to the children, young people and families. embedded into NHS and children’s services.
• Bereavement services must be flexible to the needs of the young

person and their family, and be able to provide support in a time frame
6. Future development and learning for services that is meaningful to them.
Part of CHUMS’ success stems from the fact that we continually seek to • There is a need to provide adequate information addressing any
improve our services, allowing us to grow, and to learn from our mistakes. anxieties or questions in an age appropriate way which is respectful
Accordingly, we have piloted services in response to perceived need, which of the family’s values and beliefs, and informs the development of a
proved unsuccessful. The first, an evening helpline, was set up to try to coherent narrative about the death including consideration of how to
332 accommodate working families who might be unable to talk during our continue to remember their loved one. 333
normal 9-5 hours. However, few families made use of this service and it was
discontinued after only a brief period. We also developed a buddy system, • Bereavement services should provide support to the system around
whereby volunteers were assigned to families to regularly check-in with them the child to ensure everyone can work together to meet the child’s
and offer support. Again, very few families engaged in this service. Both these needs, with specific emphasis on facilitating a positive parent-child
experiences served to remind us that families will only engage in interventions relationship in which families are encouraged to have fun together.
that are meaningful and relevant to them, and often where this is the case, will
make contact with us when the time is right. • Bereavement services should make good links with other local agencies
to ensure that families get a holistic service where effort is made to
Looking to the future, we wish to continue to ensure that we provide an provide continuity of care.
effective service. Service-user feedback and outcome data form an important
part of this process. However, this in itself is an area for further development. • Training volunteers to support the delivery of interventions may
While we excel in obtaining qualitative feedback from our service-users, we ensure the long-term cost-effectiveness of services, while also bringing
have encountered difficulties retrieving quantitative data. In line with the added richness, a diverse skillset, and promoting the organisation
principles of Children and Young People’s Improving Access to Psychological within the local community.
Therapies (CYP-IAPT) we routinely attempt to monitor outcomes using
a range of nationally recognised measures, as well as through the use of • Services should ask for feedback, both qualitative and quantitative,
measures specific to the challenges faced by bereaved families. However, which may be regularly reviewed and used to revise the interventions
the response rate for data collection is lower than the national average33. In available.
our experience, the timing of data collection is a crucial factor and something
which we continue to experiment with to generate higher response rates. It is

References 17 Akerman, R., and Statham, J. (2011) Childhood Bereavement: a rapid literature review. Child-
hood wellbeing research centre: http://webarchive.nationalarchives.gov.uk/20130401151715
18 Currier, J. M., Holland, J. M., and Neimeyer, R. A. (2007) ‘The effectiveness of bereavement
1 Hewitt, D. (2011) CHUMS-CIC – Towards a social enterprise supporting children and young interventions with children: A meta-analytic review of controlled outcome research’ Journal of
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2 Child Bereavement Network (2017) National Statistics: www.childhoodbereavementnetwork. 19 ibid
org.uk/research/key-statistics.aspx 20 Melhem, N. M., Porta, G., Shamseddeen, W., Walker Payne, M., and Brent, D. A. (2011) ‘Grief in
3 Blackmore, S., Pring, A., and Verne, J. (2011) Predicting Death: estimating the proportions of children and adolescents bereaved by sudden parental death’ Archives of General Psychiatry
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4 Penny, A., (2010) Survey of Support for Bereaved Children and Young People. London: Nation- 21 Sandler, I. N., Wolchik, S. A., and Ayers, T. S. (2008) ‘Resilience rather than recovery: a contextu-
al Children’s Bureau. al framework on adaptation following bereavement’ Death Studies 32(1): 59-73.
5 Fauth, B., Thompson, M., and Penny, A. (2009) Associations Between Childhood Bereavement and 22 Harrison, L. and Harrington, R. (2001) Op. cit.
Children’s Backgrounds, Experiences, and Outcomes: secondary analysis of the 2004 Mental Health Ratnarajah, D., and Schofield, M. J. (2007) ‘Parental suicide and its aftermath: a review’ Journal
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6 Dowdney, L., (2000) ‘Annotation: childhood bereavement following parental death’ Journal of Ribbens McCarthy, J. (2007) ‘“They all look as if they’re coping, but I’m not”: the relational pow-
Child Psychology and Psychiatry 7: 819-830. er/lessness of “youth” in responding to experiences of bereavement’ Journal of Youth Studies
Haine, R. A., Wolchik, S. A., Sandler, I. N., Millsap, R. E., and Ayers, T. S. (2006) ‘Positive parenting 10(3): 285-303.
as a protective resource for parentally bereaved children’ Death Studies 30(1): 1-28. Ribbens McCarthy, J., and Jessop, J. (2005) Young people, Bereavement, and Loss: disruptive
7 Worden, W. J. (1996) Children and Grief: when a parent dies. New York: Guilford Press. transitions? London: National Children’s Bureau
8 Dowdney, L., (2000) Op. cit. 23 Haine, R. A., Ayers, T. S., Sandler, I. N., Wolchik, S. A., and Weyer, J. L. (2003) ‘Locus of control
9 Worden, W. J. (1996) Op. cit. and self-esteem as stress-moderators or mediators in parentally bereaved children’ Death
Studies 27: 619-640.
10 Muniz-Cohen, M., Melhem, N. M., and Brent, D. A. (2010) ‘Health risk behaviors in parentally
bereaved youth’ Archives of Paediatric Adolescent Medicine 164(7): 621-624. 24 Silverman, P. R., and Worden, J. W. (1992) ‘Children’s reactions in the early months after the
death of a parent’ American Journal of Orthopsychiatry 62(1): 93-104.
334 11 Brent, D., Melhem, N., Donohoe, M. B., and Lindsay, C. (2009) ‘Piloting a therapeutic residential
for children, young people, and families bereaved through suicide in Northern Ireland’ Child 25 Wolchik, S. A., Tein, J.-Y., Sandler, I., and Ayers, R. S. (2006) ‘Stressors, quality of child-caregiver 335
Care in Practice 15(2): 81-93. relationship, and children’s mental health problems after parental death: the mediating role of
self-system beliefs’ Journal of Abnormal Psychology 34: 221-238.
Parsons, S. (2011) Long-term Impact of Childhood Bereavement: preliminary analysis of the
1970 British cohort study (BCS70). London: Child Well-being Research Centre. 26 Mandelco, B. L., and Peery, J. C. (2002) ‘An organisational framework for conceptualising
resilience in children’ Journal of Child and Adolescent Psychiatric Nursing 13(3): 99-113.
Sweeting, H., West, P., and Richards, M. (1998) ‘Teenage family life, lifestyles, and life chances:
associations with family structure, conflict with parents, and joint family activity’ International 27 Haine, R. A., et al (2008) Op. cit.
Journal of Law, Policy and the Family 12(1): 15-46. Raveis, V., Siegel, K., and Karus, D. (1999) ‘Children’s psychological distress following the death
Wilcox, H. C., Kuramoto, S. J., Lichtenstein, P., Långström, N., Brent, D. A., and Runeson, B. of a parent’ Journal of Youth and Adolescence 28(2): 165-178.
(2010) ‘Psychiatric morbidity, violent crime, and suicide among children and adolescents ex- Thompson, M. P., Kaslow, N. J., Price, A. W., Williams, K. and Kingree, J. B. (1998) ‘Role of sec-
posed to parental death’ Journal of the American Academy of Child and Adolescent Psychiatry ondary stressors in the parental death-child distress relation’ Journal of Abnormal Psychology
49(5): 514-523. 26: 357-366.
12 Abdelnoor, A. and Hollins, S. (2004) ‘The effect of childhood bereavement on secondary school 28 i.e. Abdelnoor, A., and Hollins, S. (2004). Op. cit.
performance’ Educational Psychology in Practice 20(1): 44-54. Lin, K. K., Sandler, I. N., Ayers, T. S., Wolchik, S. A., and Luecken, L. J. (2004) ‘Resilience in
Haine, R. A., Ayers, T. S., Sandler, I. N., and Wolchik, S. A. (2008) ‘Evidence-based practices for parentally bereaved children and adolescents seeking preventive services’ Journal of Clinical
parentally bereaved children and their families’ Professional Psychology: Research and Prac- Adolescent Psychology 33(4): 673-683.
tice 39(2): 113-121. 29 Haine, R. A., et al (2008) Op. cit.
13 Parsons, S. (2011) Op. cit. 30 Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., Johnson, L. D.
14 Harrison, L., and Harrington, R. (2001) ‘Adolescents’ bereavement experiences. Prevalence, as- (2003) ‘The session rating scale: preliminary psychometric properties of a “working” alliance
sociation with depressive symptoms, and use of services’ Journal of Adolescents 24: 159-169. measure’ Journal of Brief Therapy 3(1): 3-12.
Wilcox, H. C. et al (2010) Op. cit. 31 For a helpful summary see Akerman, R., and Statham, J. (2011) Op. Cit.
15 Penny, A. and Stubbs, D. (2014) Bereavement in Childhood: what do we know in 2014? Lon- 32 Holland, J. (2001) Understanding Children’s Experiences of Parental Bereavement. London:
don: National Children’s Bureau. Jessica Kingsley Publishers.
16 Harrison, L. and Harrington, R. (2001) Op. cit. 33 Edbrooke-Childs, J., Calderon, A., Wolpert, M., and Fonagy, P. (2015) Children and Young
People’s Improving Access to Psychological Therapies Rapid Internal Audit (National Report)
https://www.ucl.ac.uk/ebpu/docs/publication_files/CYPIAPT-nationalreport

Re-thinking family interventions from an ACE perspective
26. Re-thinking family interventions from 2. The problem

an ACE perspective
Clare Wightman and Rob McCabe Case study
‘T’ (10 years old at the time) heard a thud, when he went downstairs he
found his mother who had died instantly. He stayed with his mother’s
1. Introduction body for about half an hour in which time the children (siblings) became
extremely distressed, at one point T ‘closed’ his mother’s eyes because
Young people in Birmingham are being expelled from schools for exhibiting she was staring and this was upsetting his siblings. Doctors had later
educational and behavioural issues and are being wrongly placed into told T’s Grandmother that the impact of his mother’s death had in effect
special schools and settings for those with Special Educational Needs and caused T to ‘shut down’ emotionally. Grandmother stated that T has
Disability (SEND). Many of these children and young people have mental never ‘recovered’, nor has he cried about his mother’s death or allowed
health problems, rather than special educational needs, which arise from the anyone to broach the subject in any meaningful way.
trauma they have experienced at home and in care. In our experience, schools
recognise they cannot provide the support these pupils need, because of
their focus on educational outcomes, which are driven by a national focus on
academic outcomes, also embedded in Ofsted ratings. The sheer weight of emotions that many students in Birmingham’s special
schools bear is difficult to comprehend. Research conducted in 2012 and 2014
336 A multi-agency pathfinder in Birmingham is aiming to address this problem. has shown how violent, traumatic and disturbing experiences like those of T 337
Six schools specialising in Social, Emotional and Mental Health (SEMH) and six dominate their thoughts and memories, and give rise to the behaviour that has
mainstream schools are offering a new kind of intensive and relational support, seen them placed into SEMH schooling.
wrapped around by a multi-agency team, dedicated to the most troubled
pupils, and their families. Results are showing that family members feel The first of these two reports on the lives of pupils at a school in Birmingham
more able to disclose the real problems that need resolution. Staff share an looked at the interaction of pupils with the criminal justice system, the level
understanding of the multiple and complex needs of their clients. As a result, of risk at schools and the huge financial costs of not providing the right
help is reaching families earlier and more quickly, meaning that positive and support to these young people. The second report in 2014 left costings aside
longer-term relationships create more capacity in families to enable sustained to detail their real lives. Social service records of pupils and their families
change. were examined, producing an upsetting report showing intergenerational
violence, abuse, trauma and the impact on their lives. High levels of exposure
This paper draws on learning from this pathfinder programme in Birmingham to domestic abuse, alcohol or substance misuse, criminality, self-harm, and
to suggest ways of ensuring that family interventions take an approach sexually harmful behaviour were revealed. Retrospective police checks on
informed by understandings of Adverse Childhood Experiences (ACEs), and former pupils painted a picture of escalating offending behaviour, which in
better recognition of the relationships between problematic behaviours, some cases led to imprisonment.
criminality and experiences of individual and inter-generational trauma.
For example, currently, there are approximately 800 children in five SEMH
schools, 80% of whom (according to Troubled Family Team data) are known
to social services. Last year there were 89 convictions from a cohort of less
than 500 secondary school age pupils. In May 2016, a fight between two of
them resulted in one pupil being stabbed four times. The victim of that attack

Chapter 26 Re-thinking family interventions from an ACE perspective
meanwhile is serving a custodial sentence for stabbing a female victim in a children, whose behaviour was seen as ‘out of control’ and at risk of ‘becoming
separate incident committed earlier in the year. In November 2016 a pupil was criminal’, were treated in isolation from their wider family and community
attacked in school by youths armed with machetes. experiences. For example, the drivers of a traumatised young person’s
behaviour resulting from 25 care placement moves were not known or not
Students were typically born into families and communities with entrenched acknowledged by workers in the care system, only emerging as mitigating
cultures of violence and intimidation, and this had been either witnessed or factors when a court report was being prepared after the onset of criminal
experienced from an early age. In addition to this, families were contending behaviours.
with severe poverty and disadvantage.
The majority of these pupils’ families were well-known to social services, local b. lack of meaningful engagement with families
health services and the criminal justice system in Birmingham. Despite this,
there seemingly had been limited success in bringing information, insight and The service and client divide was very pronounced in both the education
intelligence together to form an understanding of the whole picture of these and criminal justice systems, with little real engagement with families – who
children’s and families’ lives until the independent reports. primarily were generally not seen as being a capable, or a strong source of
solutions.
The pathfinder found that schools recognised they cannot provide the support
such pupils need because of their focus on educational outcomes, driven by
national policy and Ofsted ratings. They suggested they risked further harming c. services working in isolation and fragmenting young people’s needs
the students by simply “hot housing” together a population of traumatised
and reportedly ‘unstable’ young people. This was exacerbated by schools Worryingly, statutory and non-statutory services that might have helped
338 attempting to contend with restrictions on their funding, resulting in the families were disconnected from one another, limiting the depth of response 339
number of social workers, nurses and classroom assistants being reduced. that could be offered to young people. As a result, families reported frequent
returns to agencies for short periods of support, that were uninformed by
To leave the present system unchanged would mean many families continuing previous interactions, intelligence known about the family’s circumstances and
to live with significant disadvantage, children exposed to significant levels knowledge of what events and interventions had gone before. Analysis found
of adversity and trauma, which would have a wider impact on the levels of that there was no effective way to share, and flag, evidence of young people’s
violence and crime across Birmingham. and familial involvement, so that professionals could see if levels of adversity
or symptomology were escalating.
3. Systemic concerns d. time-limited support from services did not match the complexity of need
Analysis from our pathfinder programme, reveals that four core issues seem to Families separate interventions were offered on a relatively short-term basis,
be complicating and concealing the problem: compared with the complexity and depth of the adversity, intergenerational
trauma and rising concerns involved. Six months was the longest consistent
period of intensive family support available, which was felt to be inadequate to
a. lack of understanding of multiple and complex needs (and trauma) ensure recovery and to acquire new resources to support family resilience.
within the education and criminal justice systems. In particular there was no
consideration of the wider social context of the poverty, abuse and adversity
that underlay young people’s behaviour and enactment of criminality. Instead

4. The Birmingham pathfinder approach a range of meetings and facilitating interventions and programmes for both
pupils and families. The team undergo a raft of training to further develop their
The Birmingham SEMH Pathfinder Project is a collaborative response to this skills including an understanding of Psychologically Informed Environments
systemic failure. Six special SEMH schools and six mainstream schools are (PIE) and Mental Skills Training. PALS use an ACE-informed assessment tool
participating in a new way of working. A new kind of intensive and relational called My Concern, (likely to soon be replaced by an ACE routine enquiry tool)
support is provided via a re-worked Pastoral And Learning Support (PALS) role, as they begin their work. The programme will soon adopt assessment software
and wrapped around by a multi-agency team dedicated to the most troubled that will help them properly map family support networks and skills. In addition
pupils and their families. That team, located together with PALS, includes to this, they undergo specialist training so they themselves will be able to offer
dedicated workers from the Department for Work and Pensions, Child and interventions of mentoring in specialisms such as Sexually Harmful Behaviour,
Adolescent Mental Health Services (CAMHS), the Aquarius substance misuse alternative educational approaches, as well as emotional resilience and
agency, school nurses, a proposed domestic violence and abuse specialist from parenting strategies.
Birmingham and Solihull’s Women’s Aid and a proposed specialist in positive
masculinity from Call to Men UK. The PALS team members can work with young people in this way throughout
their school career, and the pathfinder as a whole can potentially work with
At the very heart of the approach is the strength and quality of the relationship families after statutory school involvement. The intention is that maintaining
between all Pathfinder staff (both PALS and Multi Agency staff) and the regular contact with young people and families when they leave school will
family. It is a relationship characterised by a desire to understand the adverse divert young people away from engaging in criminal behaviour as they get
experiences, and wider circumstances of a family, and to enable them to use trusted help, referrals and supported signposting to housing advice, mental
their strengths to overcome barriers affecting their lives. By demonstrating health services, education, training and employment advice.
a more Adverse Childhood Experience (ACE) informed collaborative, or ‘co-
340 resolve’, approach to building stronger families the pathfinder is attempting to The multi-agency team wrapped around these PALS have the flexibility to work 341
re-imagine the ‘statutory service-client’ relationship. with all family members, and are released from a single issue or single client
focus. Service involvement with a family is being streamlined so that a family
A Parent’s Forum has been established and aims to shift family awareness has one regular, named worker, rather than many, such as one school nurse or
from ‘what’s wrong with my child?’ to ‘what’s happened to my family?’ and, as one substance misuse worker per family. As part of its day to day involvement
confidence grows, to develop a more systemic understanding of the problems in the team, CAMHS are exploring how it can improve the relationship and
they face. Parents produce a manifesto and establish their voice in both the flow between its services and families from the pathfinder schools.
development of the pathfinder and the West Midlands Combined Authority
(WMCA) work on those with multiple and complex needs. At this early stage of This co-location and joint caseload allow all team members to develop a shared
the programme, it’s all about establishing protected time for parents and care- understanding of individual and family needs that are multiple and complex. It
givers, and to give them ample positive regard. Having fun and meeting others allows for joint case reviews to be undertaken and most, with the exception of
with shared and common experience, is an important emotional investment School Nurses, who are NHS staff, are able to use the My Concern system as a
that we see as paying dividends in the future for both the family’s development way of consolidating information, insight and learning.
and the longer-term engagement with the programme.
Currently, PALS from pathfinder schools are released for one day per week to
work with two families each for as long as needed. They already have a wealth 5. Emerging impact from the pathfinder
of experience in engaging in a relationship with those who are seen to be
‘resistant’ and/or ‘difficult to reach’. The Birmingham pathfinder model is still forming and learning, and more
attention will be paid to underpinning what has been described so far with
PALS acts as a conduit between involved agencies and the family, attending adversity and trauma-informed practice. That said, the early impact shows that:

• Working together throughout the school life of the student offers 6. Building towards system change
families, and professionals, an opportunity for longer-term and more
positive relationships. Already we have started to see how this creates The Pathfinder, with statutory partners and the support of Lankelly Chase
more family capacity offering the prospect of sustained change. Foundation, is now planning to bring people from across Birmingham together
so that they can decide together what needs to happen at the end of each of
• Parents, many of whom tell us of the high turnover of social workers in its phases, and to build a shared vision for and commitment to system change.
their lives, are disclosing adverse experiences and difficulties for the Our shared aim is that local systems will have a more strategic awareness
first time. They say this is also the first time they have ever felt listened for those whose profile indicates that they will have life-long involvement
to. The real problems that need resolution can emerge. with statutory agencies. This should help produce early and effective ways of
responding to their difficulties, circumstances and experiences. Recent West
• Practical help is reaching families earlier and more quickly than it would Midlands Combined Authority involvement also allows learning from the
otherwise. PALS has been effective in identifying problems early that Pathfinder to inform the ‘Multiple Complex Needs’ strand of its ‘Public Sector
could have otherwise thrown families into a state of crisis or chaos, Reform’ work, and vice versa.
and warranted additional statutory involvement. One of the very first
pathfinder client assessment visits found that a family had £2,500 of
housing arrears, and were at risk of eviction. Pathfinder staff involved
the DWP, and now a court process is underway to clear the debt.
• Sustainable impacts are more likely because of a focus on clients rather

than on tasks of each individual agency. The staff pathfinder role is
342 open-ended and ‘humanistic’, with more flexible professional role 343
boundaries.
• Staff are now closer to a shared understanding of the multiple and

complex needs of their clients, and the impact of adversity and trauma
on their lives.
• PALS, some of whom have worked at schools across two or three

generations of the same families, have become more motivated
and act as an impassioned and energised resource for families. The
pathfinder has given team members much greater levels of investment
in their development, clear direction and new responsibilities. It has
fully recognised, developed and utilised their expertise and skills in
engagement and relationship building.
• As a result of the above, families are reporting that they too feel
energised and more confident with the support they are receiving.

Chapter 26
Conclusion
An agenda for change
344 345

Addressing adversity – an agenda for change
27. Addressing adversity

to respond to these children and young people’s needs by ensuring they take
a holistic view in embedding adversity and trauma-informed pathways and
– an agenda for change

provision in their local area. In this way, Directors of Public Health, local clinical
and authority commissioners can make a significant contribution to forwarding
this agenda by implementing three urgent actions that would address
Sarah Brennan OBE childhood adversity and trauma in their local area.
As we have noted previously these actions include:
This collection sets out an ambitious, and implementable, vision for what 1. making childhood adversity and trauma a local commissioning
adversity and trauma-informed care should look like for children and young priority.
people in England. Addressing Adversity extends the proposals I put forwards
as co-Chair of the Vulnerable Groups and Inequalities Task and Finish Group, 2. creating a common identification and enquiry framework for
along with my colleagues who served on the Independent Taskforce that identifying mental health need.
created Future in Mind1.
3. investing in adversity and trauma-informed models of care.
In the preceding papers, contributors provide a compelling case for
addressing the common mental health needs that arise from traumatic and
adverse childhood experiences. The evidence cited clearly demonstrates the
urgent need to intervene early in order to mitigate and address the impacts 3 urgent actions to address childhood adversity and trauma
346 of adversity and trauma on children’s health, wellbeing and outcomes in 347
adulthood.
We must ensure that the local transformation of children and young people’s
mental health becomes the impetus for more sustainable models of adversity
1 Making childhood adversity and trauma
a local commissioning priority
and trauma-informed support. As the papers in this collection suggest, this can
Creating a common identification and enquiry
2
only be achieved by increasing the awareness, knowledge and competence of
all workforces who work with children and young people. This is a message framework for identifying mental health need
we have heard time and time again from the frontline professionals who
have attended our YoungMinds workforce training in adversity and trauma-
3 Investing in adversity and

informed practice kindly funded by Health Education England in 2017.
trauma-informed models of care
In addition to this, models of provision must aim to increase the understanding
and skills of children and young people themselves, as well as those who care
for them – be they parents, carers or the State. Building individual, collective
and workforce reliance, through adversity and trauma-informed care, enables
us to intervene early in emerging problems that otherwise would become
lifelong and enduring mental health problems.
References
1 Children and Young People’s Mental Health and Wellbeing Taskforce (2015) Vulnerable
It is clear that there will always necessarily be a place for adversity-specific Groups and Inequalities Task and Finish Group Report: https://www.gov.uk/government/up-
pathways and models of care. That said, all commissioners and providers need loads/system/uploads/attachment_data/file/414326/Vulnerable_Groups_and_Inequalities.pdf

Chapter 27
Annexes
Reproduced with the permission of BioMed Central
(BMC Medicine and BMC Public Health)
348 349

Annexes Annex A: National household survey of adverse childhood experiences
and their relationship with resilience to health-harming behaviours in England
Bellis et al. BMC Medicine 2014, 12:72 Bellis et al. BMC Medicine 2014, 12:72 Page 2 of 10
http://www.biomedcentral.com/1741-7015/12/72 http://www.biomedcentral.com/1741-7015/12/72
Although HHBs such as drug misuse, smoking, vio- Methods

RESEARCH ARTICLE Open Access lence, and poor nutrition are apparent in all sectors of A national household survey of adults resident in England
society, they are typically more prevalent in the poorest was undertaken between April and July 2013. Ethical ap-
National household survey of adverse childhood communities [7-9]. However, even in such communities,
most individuals in high-income countries do not abuse
proval was obtained from Liverpool John Moores University
and the study adhered to the Declaration of Helsinki.
experiences and their relationship with resilience alcohol, take illicit drugs or smoke, and their diet and
exercise regimens remain sufficiently balanced to at least
The study used an established survey tool [16] that
includes questions on participant demographics, ACEs,
to health-harming behaviors in England

avoid obesity (for example, in England [10]). Equally, and HHBs. ACE questions used the Centers for Disease
although often at a lower prevalence, HHBs are far from Control and Prevention short ACE tool, which forms
absent in more affluent communities. Consequently, part of the US Behavioral Risk Factor Surveillance System
Mark A Bellis1,2*, Karen Hughes1, Nicola Leckenby3, Clare Perkins4 and Helen Lowey5 although socioeconomic gradients are strong predictors of [18]. The tool includes 11 questions on different childhood
HHBs, additional factors are required to explain the resili- exposures to abuse and family dysfunction. These form
ence and susceptibility of individuals to developing HHBs nine distinct categories of ACE covering: physical, ver-
Abstract throughout the life course. bal, and sexual abuse; parental separation; exposure to
Over the past two decades, studies have begun to explore domestic violence; and growing up in a household with
Background: Epidemiological and biomedical evidence link adverse childhood experiences (ACEs) with how early life experiences impact on behavior and health mental illness, alcohol abuse, drug abuse, or incarceration
health-harming behaviors and the development of non-communicable disease in adults. Investment in during adolescence and adulthood. Adverse childhood ex- (Table 1). The HHB outcomes examined in this study were:
interventions to improve early life experiences requires empirical evidence on levels of childhood adversity and the perience (ACE) studies show that adult health profiles re- early sexual initiation (<16 years); unintended teenage preg-
proportion of HHBs potentially avoided should such adversity be addressed. late to the abuse individuals experienced during childhood nancy (<18 years); daily smoking; binge drinking; cannabis
Methods: A nationally representative survey of English residents aged 18 to 69 (n = 3,885) was undertaken during as well as to other childhood stressors such as parental sub- use (lifetime); heroin or crack cocaine use (lifetime);
the period April to July 2013. Individuals were categorized according to the number of ACEs experienced. Modeling stance misuse, incarceration, and domestic violence [11,12]. violence perpetration (past year); violence victimization
identified the proportions of HHBs (early sexual initiation, unintended teenage pregnancy, smoking, binge drinking, The initial ACE study in the USA emerged from work iden- (past year); incarceration; poor diet; and low levels of
drug use, violence victimization, violence perpetration, incarceration, poor diet, low levels of physical exercise) tifying strong relationships between ACEs and adult obesity physical exercise (see Table 2). Although other HHBs,
independently associated with ACEs at national population levels. [13]. Since then, ACEs have been related to increased pro- such as suicide attempt [11], have also been strongly linked
Results: Almost half (47%) of individuals experienced at least one of the nine ACEs. Prevalence of childhood sexual, pensity for substance use (alcohol, tobacco, and drugs), to ACEs, our pilot survey [16] identified increased
350 physical, and verbal abuse was 6.3%, 14.8%, and 18.2% respectively (population-adjusted). After correcting for
sociodemographics, ACE counts predicted all HHBs, e.g. (0 versus 4+ ACEs, adjusted odds ratios (95% confidence
anti-social behavior, and ultimately development of car-
diovascular disease, cancer, chronic lung disease, and
questionnaire length as detrimental to compliance, and
therefore not every HHB could be included. 351
intervals)): smoking 3.29 (2.54 to 4.27); violence perpetration 7.71 (4.90 to 12.14); unintended teenage pregnancy diabetes [11,12]. Critically, studies have established that Questionnaires were completed by participants in their
5.86 (3.93 to 8.74). Modeling suggested that 11.9% of binge drinking, 13.6% of poor diet, 22.7% of smoking, 52.0% the quantity of stressors (that is, the ACE count) is places of residence, under the instruction of a professional
of violence perpetration, 58.7% of heroin/crack cocaine use, and 37.6% of unintended teenage pregnancy an important predictor of poor behavioral and conse- survey company directed by the research team. All sampled
prevalence nationally could be attributed to ACEs. quently poor health outcomes over the life course. households were sent a letter providing study information
Moreover, exposure to multiple stressors in childhood is and the opportunity to opt out prior to the surveyor
Conclusions: Stable and protective childhoods are critical factors in the development of resilience to
also associated with subsequent unintended pregnancies visiting. At the door, surveyors again explained the
health-harming behaviors in England. Interventions to reduce ACEs are available and sustainable, with nurturing
[14], and being a victim or perpetrator of violence, in- study and its voluntary and anonymous nature, and
childhoods supporting the adoption of health-benefiting behaviors and ultimately the provision of positive
cluding intimate partner violence [15]. Together, these provided a second opportunity for individuals to opt
childhood environments for future generations.
sexual and violent behaviors create a mechanism for out. Participants were offered the choice of completing
Keywords: Child abuse, Childhood, Alcohol, Smoking, Violence intergenerational passage of ACEs and their health the questionnaire through a face-to-face interview using
consequences [16]. a hand-held computer (with sensitive questions self-
Through a range of evidence-based interventions, ACEs completed; n = 3,852), or to self-complete using paper
Background of the most common causes of NCDs, alcohol use and
are a modifiable factor in children’s lives [17]. However, questionnaires (n = 158). The questionnaire took an
Non-communicable diseases (NCDs) have risen to become tobacco smoking (including second-hand smoke), are
there is currently little understanding of the potential im- average of 13 minutes to complete.
the greatest contributors to burden of disease globally, now the leading risk factors for burden of disease and
pact of reducing ACEs independent of socioeconomic fac-
accounting for two thirds of all deaths (34.5 million [1]) and injury in 15 to 49-year-olds, and globally attributed to
tors (for example, deprivation) that are also associated with Sample selection
54% of disability adjusted life years (DALYs; 1.3 billion [2]) around 800,000 and 565,000 deaths respectively in this
poor health choices and anti-social behavior. Consequently, A target sample size of 4,000 was based on ACE prevalence
in 2010. In high-income countries this proportion is typic- age group in 2010 [4]. Obesity and drug use contributed
here we used a national ACE survey to measure levels of identified in a pilot study [16]. Sampling used a random
ally much higher, reaching 87% in western Europe [3]. Two an additional 325,000 and 107,000 deaths, respectively
ACEs across England, calculated the prevalence of exposure probability approach stratified first by region (n = 10, with
[4]. Thus, at global [5], regional (for example, Europe [6]),
to multiple ACE counts, and examined the relationships inner and outer London treated as two regions) and then
* Correspondence: [email protected] and national levels, tackling NCDs and the health-harming
1
Centre for Public Health, World Health Organization Collaborating Centre for between ACE exposure and HHBs. After accounting for small area deprivation in order to provide a sample repre-
behaviors (HHBs) that cause them are health and eco-
Violence Prevention, Liverpool John Moores University, 15-21 Webster Street, deprivation and other demographic effects, we modeled the sentative of the English population. Samples for each region
Liverpool L3 2ET, UK
nomic priorities.
2
impact of reduced ACE prevalence on resilience to HHBs. were proportionate to their population. Within each region,
Public Health Wales, Hadyn Ellis Building, Maindy Road, Cardiff CF24 4HQ, UK
Full list of author information is available at the end of the article We considered how supportive childhoods allow individ- lower super output areas (LSOAs; geographical areas
uals to resist the commercial, cultural, and environmental with a population mean of 1,500 [19]) were categorized
© 2014 Bellis et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
pressures that promote substance use, obesity, and anti- into deprivation deciles based on their ranking in the
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain social behavior throughout the life course. 2010 Index of Multiple Deprivation (IMD; a composite
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Bellis et al. BMC Medicine 2014, 12:72 Page 3 of 10 Bellis et al. BMC Medicine 2014, 12:72 Page 4 of 10
Table 1 Adverse Childhood Experiences (ACEs) (13.4%) were ineligible, and 4,010 completed a study ques- retrospective cohorts (0 ACEs, n = 2,084; 1 ACE, n = 881;
All ACE questions were preceded by the statement “While you were growing up, before the age of 18…” Responses listed are those categorized tionnaire. Thus, compliance was 59.6% across eligible occu- 2–3 ACEs, n = 597; 4 + ACES, n = 323). Bivariate analyses
here as an ACE. pied households visited, and 53.5% including those opting used χ² tests with conditional binary logistic regression
ACE Question Response out at the letter stage. (LR) to examine independent relationships between ACE
Parental separation Were your parents ever separated or divorced? Yes counts and HHBs of interest. Best-fit LR model parame-
Domestic violence How often did your parents or adults in your home ever slap, hit, kick, punch, Once or more than once Statistical analysis ters were used to calculate the numbers and proportions
or beat each other up? All analyses were undertaken using PASW Statistics v18. of each HHBs relating specifically to ACE count. Thus,
Physical abuse How often did a parent or adult in your home ever hit, beat, kick, or physically Once or more than once Only individuals with complete data relating to all ACEs, for each HHB, model parameters for age, sex, ethnicity,
hurt you in any way? This does not include gentle smacking for punishment age, sex, ethnicity, and IMD quintile were included in the and deprivation were applied to national and sample
Verbal abuse How often did a parent or adult in your home ever swear at you, insult you, More than once analysis, yielding a final sample size of 3,885. Although populations with ACE count parameters set to the ob-
or put you down? ethnicity was initially collected through self-identified UK served values, and then with ACE count parameters set
Sexual abuse How often did anyone at least 5 years older than you (including adults) ever Once or more than once to Census categories, these were combined into White, Asian to zero ACEs.
touch you sexually? any of the three questions and Other because of the small numbers within individual
How often did anyone at least 5 years older than you (including adults) try to ethnic groups (Table 3). Where individuals did not answer Results
make you touch them sexually?
all relevant questions, adjusted sample sizes are presented The sample was not significantly different from the over-
How often did anyone at least 5 years older than you (including adults) force in the tables. all English population for either deprivation or ethnicity.
you to have any type of sexual intercourse (oral, anal, or vaginal)?
Owing to highly significant correlations between all However, the ACE sample had an over-representation of
Mental illness Did you live with anyone who was depressed, mentally ill, or suicidal? Yes ACE types (see Additional file 1: Table S1), and consistent females and included a higher proportion of individuals in
Alcohol abuse Did you live with anyone who was a problem drinker or alcoholic? Yes with ACE study methodology elsewhere [11,12], ACE the age category 60 to 69 years, with a corresponding un-
Drug abuse Did you live with anyone who used illegal street drugs or who abused Yes counts were calculated for all individuals as a proxy for derrepresentation of those aged 18 to 29 years (Table 3).
prescription medications? severity of childhood adversity and classified into four Individual ACEs ranged in prevalence from 3.9% with a
Incarceration Did you live with anyone who served time or was sentenced to serve time in Yes drug-using household member during their childhood to
a prison or young offenders' institution? Table 3 Sample demographics and comparison with the 22.6% experiencing parental separation or divorce. After
English national populationa correction to national population demographics, these
measure including 38 indicators relating to economic, made on all days of the week and between the hours of Sample Population χ² P prevalences increased to 4.1% and 24.3% respectively.
352 social, and housing issues [20]). Two LSOAs were ran-
domly selected from each deprivation decile in each
09.30 and 20.30 hours. At least three attempted visits at
differing days/times were made before an address was Age, years
n % n % Overall, 46.4% of the sample had experienced at least one
ACE (population-adjusted 47.9%; Table 4). Higher ACE 353
region for sampling (n = 200 LSOAs). Within each removed, with sampling completed once the target sample 18 to 29 815 21.0 8623299 24.2 counts were associated with deprivation, and were lower
sampled LSOA, between 40 and 120 addresses were size was achieved. in Asian ethnicity populations, males, and the oldest age
30 to 39 772 19.9 7051522 19.8
randomly selected from the Postcode Address File®, Inclusion criteria for the study were: residence in a group. In childhood, living with a drug user, parental sep-
40 to 49 795 20.5 7773559 21.8
with 16,000 households initially sampled to allow for selected LSOA; age 18 to 69 years; and cognitive ability aration, having a household member incarcerated, and liv-
non-response, ineligibility, and non-compliance. to participate in a face-to-face interview. A total of 9,852 50 to 59 699 18.0 6426080 18.1 ing with an alcohol abuser all increased in prevalence with
Of all sampled households, 771 (4.8%) opted out fol- households were visited, of which 7,773 were occupied. 60 to 69 804 20.7 5719911 16.1 72.016 <0.001 deprivation and reduced with increasing age (Table 4).
lowing receipt of the study letter. Household visits were Of the occupied households, 2,719 (35.0%) opted out, 1,044 Sex Experience of physical abuse, verbal abuse, or domestic
Male 1749 45.0 17685329 49.7 violence within the childhood household was also highest
Table 2 Outcome variables in the most deprived quintiles. For all ACEs, Asian ethnicity
Female 2136 55.0 17909042 50.3 33.837 <0.001
Outcome Question (text in brackets is the response indicating behavior) had the lowest prevalence while ‘Other’ ethnicity had the
Ethnicity
Unintended teenage pregnancy Did you ever accidentally get pregnant or accidentally get someone else pregnant before you highest prevalence for each ACE except living with a house-
Whiteb 3354 86.3 30499391 85.7 hold member with mental illness or alcohol abuse. Differ-
were aged 18 years? (Yes)
Asianc 308 7.9 2912044 8.2 ences by ethnicity did not reach significance for any ACE
Early sexual initiation How old were you the first time you had sexual intercourse? (<16 years)
Smoking In terms of smoking tobacco, which of the following best describes you? (I smoke daily)
Otherd 223 5.7 2182936 6.1 1.471 0.479 type. Variations in prevalence of ACE types by gender were
Deprivation quintile significant for childhood sexual and verbal abuse and
Binge drinking How often do you have 6 or more standard drinks on one occasion (Weekly or daily or almost daily)a
1e
782 20.1 7149675 20.1 having a household member with mental illness or alcohol
Cannabis use How often, if ever, have you taken the following drugs…cannabis? (any level of use) abuse, with the prevalence being higher in females.
2 758 19.5 7305972 20.5
Heroin/crack cocaine use How often, if ever, have you taken the following drugs… heroin/crack cocaine? (Any level of use) In bivariate analysis, the prevalence of all HHBs except
3 766 19.7 7199331 20.2
Violence perpetration How many times have you physically hit someone in the past 12 months? (Any frequency) low levels of physical exercise increased with ACE count
4 773 19.9 7054694 19.8 (Table 5). Thus, prevalence of having had or caused
Violence victimization How many times have you been physically hit in the past 12 months? (Any frequency)
Incarceration How many nights have you ever spent in prison, in jail or in a police station? (Any number of nights)
5 806 20.7 6884699 19.3 6.423 0.170 unintended teenage pregnancy and all violence and
a
Population data obtained from Office for National Statistics, Lower Super criminal justice outcomes (violence perpetration, violence
Poor diet On a normal day, how many portions of fruit and vegetables (excluding potatoes) would you usually eat Output Area population estimates mid-2012 [21].
(one portion is roughly one handful or a full piece of fruit such as an apple)? (<2 portions) b
victimization, incarceration) was more than five times
Including White British, White Irish, White Gypsy or Irish Traveller,
White Other. higher in those with 4+ ACEs (versus those with none).
Low physical activity Usually, how many days each week do you take part in at least 30 minutes of physical activity that c
makes you breathe quicker, like walking quickly, cycling, sports or exercise? (<3 days) d
Including Indian, Pakistani, Bangladeshi, Chinese, Other Asian. All HHBs except binge drinking were also associated
Including Mixed/Multiple ethnic group, Black/African/Caribbean/Black British,
a
Questions on alcohol consumption were drawn from the AUDIT C tool, and participants were provided with information on what constitutes a standard drink Other ethnic group.
with deprivation; for example, prevalence of early sexual
(UK = 10 mg of alcohol). e
From 1 (least deprived) to 5 (most deprived). initiation increased from 12.0% in the least deprived

Table 4 Bivariate relationships between participant demographics, individual ACEs and ACE count Table 5 Bivariate association between health-harming behaviors and ACE count
Individual ACEs ACE count Outcome All ACE count, % χ²trend P
Parental Childhood abuse Household member 0 1 2 to 3 4+ % n 0 1 2 to 3 4+
separation
Verbal Physical Sexual Mental Domestic Alcohol Incarceration Drug Sexual behavior
illness violence abuse abuse
Unintended teenage pregnancy (<18 years) 5.5 3836 2.9 5.6 8.3 17.0 106.097 <0.001
Prevalence, % 22.6 17.3 14.3 6.2 12.1 12.1 9.1 4.1 3.9 53.6 22.7 15.4 8.3
Early sexual initiation (<16 years) 16.8 3374 10.0 19.4 23.0 37.8 164.629 <0.001
Age, years
Substance use
18 to 29 34.6 17.4 11.4 4.8 13.1 10.2 10.1 6.7 6.1 47.2 25.0 19.1 8.6
Smoking (current) 22.7 3885 17.7 21.8 28.3 46.4 127.022 <0.001
30 to3 9 25.1 18.9 14.6 6.0 12.7 14.0 11.3 5.8 6.3 52.8 21.8 14.2 11.1
Binge drinking (current) 11.3 3885 9.3 13.2 12.6 16.7 18.579 <0.001
40 to 49 25.9 19.5 15.6 7.2 13.0 14.2 10.4 3.6 3.9 51.1 23.6 14.6 10.7
Cannabis use (lifetime) 19.5 3878 12.2 21.5 27.0 47.7 241.570 <0.001
50 to 59 16.6 17.3 16.7 7.4 11.6 12.6 8.3 2.7 2.1 58.2 19.3 14.2 8.3
Heroin or crack cocaine use (lifetime) 2.2 3882 0.9 1.5 4.0 9.0 84.106 <0.001
60 to 69 10.1 13.4 13.7 5.6 10.1 9.7 5.3 1.2 1.0 59.5 23.1 14.4 3.0
Violence and criminal justice
χ² 161.302 12.498 10.329 6.548 4.889 13.253 21.283 41.206 46.586 71.239
Violence victimization (past year) 5.3 3883 2.4 4.2 10.7 16.1 137.578 <0.001
P <0.001 0.014 0.035 0.162 0.299 0.010 <0.001 <0.001 <0.001 <0.001
Violence perpetration (past year) 4.4 3884 2.0 3.6 8.7 13.9 119.609 <0.001
Sex
Incarceration (lifetime) 7.1 3879 3.1 8.1 10.2 24.5 182.58 <0.001
Male 21.4 15.8 14.9 4.5 10.0 11.5 7.9 3.7 3.8 54.3 23.8 15.0 6.9
Diet, weight and exercise
Female 23.6 18.5 13.9 7.5 13.8 12.6 10.0 4.4 4.0 53.1 21.8 15.6 9.5
Poor diet (current) 15.6 3879 13.3 15.9 18.3 25.1 31.679 <0.001
χ² 2.802 5.116 0.888 14.729 13.093 1.097 4.994 1.355 0.097 9.628
Low physical exercise (current) 43.0 3881 44.1 41.4 41.2 42.7 1.434 0.231
P 0.094 0.024 0.346 <0.001 <0.001 0.295 0.025 0.244 0.755 0.022
Abbreviations: ACE adverse childhood experience.
Deprivation quintilea
1 16.8 12.7 10.4 5.1 10.6 8.3 5.2 1.4 1.8 59.1 24.9 11.6 4.3
individuals experiencing violence in the past year, either as ACEs on engagement in anti-social behavior and problem-
2 21.8 17.2 13.6 5.3 11.5 12.8 9.1 3.3 3.4 52.5 25.1 14.8 7.7 a perpetrator or a victim. At a national population level, atic drug use appears particularly marked. Over half of cases
354 3
4
22.5
24.3
15.5
18.4
14.2
14.9
5.2
7.6
12.9
11.3
11.2
12.3
8.4
10.1
3.0
5.8
3.1
5.4
54.2 23.1 15.9
53.8 18.9 17.3
6.8
10.0
this would account for over a million individuals being
assaulted and just under 900,000 assaulting someone else
of violence perpetration, violence victimization, incarcer-
ation, and heroin/crack cocaine use could be explained by 355
(most deprived) 5 27.7 22.6 18.5 7.4 14.1 15.8 12.5 6.7 5.8 48.8 21.5 17.1 12.7 at least once in the past 12 months (Table 7). Similarly, ACEs. These HHBs represent major health, social, and eco-
modeling suggested that nationally 37.6% of individuals nomic burdens across communities, and when expressed in
χ² 28.715 29.779 21.916 8.875 6.075 21.608 27.001 37.976 23.569 66.372
who have experienced an unintended pregnancy before family environments mean subsequent generations are ex-
P <0.001 <0.001 <0.001 0.064 0.194 <0.001 <0.001 <0.001 <0.001 <0.001
the age of 18 years (equivalent to 826,352 individuals) could posed to ACEs. Moreover, we found that ACEs accounted
Ethnicity be accounted for by ACEs. for around a third of individuals reporting early sexual initi-
White 23.9 17.7 13.9 6.4 12.6 11.9 9.5 3.9 3.9 52.1 23.9 15.7 8.3 ation and unintended teenage pregnancy. Such pregnancies
Asian 5.5 10.4 12.7 3.2 7.1 11.7 5.8 2.9 2.9 70.1 14.6 10.1 5.2 Discussion can mean that individuals are born into settings typically
Other 26.5 20.2 22.9 7.2 11.2 15.2 8.1 8.1 5.8 54.7 14.8 18.4 12.1 Results suggest that nearly half of all individuals in less prepared for the needs of children, with fewer resources
England are exposed to at least one adverse experience for child-rearing, poorer parenting skills, and consequently
χ² 56.670 12.028 14.390 5.136 8.109 2.221 4.738 10.425 2.959 49.138
during childhood, and 9% experience four or more ACEs greater opportunity for child abuse [25], again ensuring in-
P <0.001 0.002 0.001 0.077 0.017 0.329 0.094 0.005 0.228 <0.001
(Table 4). ACEs and HHBs were both associated with tergenerational transmission of ACEs and related harms.
Adjusted ACE prevalenceb 24.3 18.2 14.8 6.3 12.0 13.1 9.7 4.3 4.1 52.1 22.8 16.1 9.0 deprivation. Thus, four or more ACEs were reported by Although the ACE methodology has been refined and
Abbreviations: ACE adverse childhood experience.
a
4.3% of individuals in the most affluent quintile, rising extensively tested [26], it remains prone to issues associated
From 1 (least deprived) to 5 (most deprived).
b
Adjusted to English national population by age, sex, ethnicity and deprivation quintile of residence. Sources for population data: Office for National Statistics
to 12.7% of those in the most deprived. Equally, all HHBs, with any cross-sectional study. Results rely on accurate
Lower Super Output Area population estimates mid-2012, [21] and 2011 Census [22]. with the expected exception of binge drinking [23] increased recall and willingness to report ACEs even after assurances
with deprivation. However, we identified a strong relation- of anonymity. In older individuals especially, recollection of
quintile to 22.3% in the most deprived, and prevalence remained significant for unintended teenage pregnancy, ship between ACEs and HHBs, independent of deprivation childhood issues may be limited, although studies elsewhere
of smoking increased from 12.9% to 38.1%, respectively early sexual initiation, smoking, binge drinking, incarcer- (Table 6). Modeling suggested that ACEs contributed to as suggest that false-positive reports are rare [27]. Moreover,
(see Additional file 1: Table S2). After using LR models to ation, poor diet, and low exercise levels after accounting many as one in six individuals smoking and one in seven although prospective studies may allow more immediate
account for the confounding effects of deprivation and for relationships with ACE counts. with poor diet and binge drinking (Table 7). Links between recording of ACEs, they are ethically problematic if identi-
other demographics, odds of all HHBs except low physical For each HHB, the best-fit LR models were used to such behaviors and childhood circumstances are likely fication of ACEs in children does not lead to intervention
exercise were significantly higher in those with 4+ or 2 to calculate expected HHB prevalence in the sample and to operate through the impact of ACEs on the develop- [28]. Further, our measures of ACEs are in part subject-
3 ACEs (versus none). Having one ACE (versus none) was national population if no ACEs were experienced. Al- ing brain. Thus, early life trauma can lead to structural ive, with individuals having to self-identify childhood
associated with a significant increase in unintended teenage though causality could not be established in this study, and functional changes in the brain and its stress regu- abuse and other stressors relating to household mem-
pregnancy, early sexual initiation, binge drinking, can- modeling estimated that nationally 13.6% of poor diet and latory systems, which affect factors such as emotional bers (for example, mental health problems). However,
nabis use, violence perpetration, violence victimization, up to 58.7% of heroin or crack cocaine use is related to regulation and fear response, and this may predispose despite definitional differences, independent comparable
and incarceration (Table 6). The impact of deprivation ACEs. ACEs also accounted for approximately half of all individuals to HHBs [24]. Consequently, the impact of measures of ACEs for England are relatively consistent

Bellis et al. BMC Medicine 2014, 12:72 Page 8 of 10
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Table 7 Modeled impact of preventing ACEs at sample and national population levels on health-harming behaviorsa
Sample Adjusted to national population
Table 6 AORs for health risk behaviors in ACE count groups Outcome Current Estimate % Number Current Estimate % Number
Outcome n ACE Count (reference category 0 ACEs) Demographic factors prevalence with 0 ACEs change saved prevalence with 0 ACEs change saved
P 1 P 2 to 3 P 4+ P Ethnicity Age Sex IMD % n % n % n % n
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Sexual behavior
Sexual behavior
Unintended teenage pregnancy (<18 years)a 3836 <0.001 1.95 (1.32 to 2.89) <0.01 2.72 (1.83 to 4.04) <0.001 5.86 (3.93 to 8.74) <0.001 <0.05 ns <0.001 <0.001 Unintended teenage pregnancy (<18 years) 5.4 211 3.0 117 −44.5 94 6.2 2199164 3.9 1372812 −37.6 826352
Early sexual initiation (<16 years) 3374 <0.001 1.93 (1.52 to 2.47) <0.001 2.39 (1.83 to 3.10) <0.001 4.77 (3.56 to 6.39) <0.001 <0.001 <0.001 <0.001 <0.001 Early sexual initiation (<16 years) 14.6 566 9.4 363 −35.9 203 16.4 5821047 10.9 3870314 −33.5 1950733
Substance use
Substance use
Smoking (current) 3885 <0.001 1.20 (0.98 to 1.47) ns 1.64 (1.32 to 2.04) <0.001 3.29 (2.54 to 4.27) <0.001 <0.001 <0.001 <0.001 <0.001
Binge drinking (current) 3885 <0.001 1.36 (1.05 to 1.75) <0.05 1.34 (1.00 to 1.80) <0.05 2.08 (1.47 to 2.94) <0.001 <0.001 <0.01 <0.001 <0.05 Smoking (current) 22.7 880 18.7 727 −17.4 153 22.7 8075185 18.9 6742668 −16.5 1332517
Cannabis use (lifetime) 3878 <0.001 1.80 (1.45 to 2.23) <0.001 2.53 (2.01 to 3.20) <0.001 6.20 (4.74 to 8.12) <0.001 <0.001 <0.001 <0.001 ns Binge drinking (current) 11.3 439 9.6 371 −15.5 68 11.9 4226450 10.1 3581091 −15.3 645359
Heroin or crack cocaine use (lifetime) 3882 <0.001 1.58 (0.77 to 3.26) ns 4.79 (2.55 to 8.97) <0.001 10.88 (5.86 to 20.18) <0.001 ns <0.001 <0.001 ns
Cannabis use (lifetime) 19.5 757 12.9 500 −33.9 257 20.8 7392259 13.9 4945099 −33.1 2447160
Violence and criminal justice
Violence victimization (past year) 3883 <0.001 1.60 (1.04 to 2.48) <0.05 4.42 (3.00 to 6.51) <0.001 7.48 (4.92 to 11.38) <0.001 ns <0.001 <0.001 ns Heroin or crack cocaine use (lifetime) 2.2 84 0.9 35 −58.3 49 2.4 861075 1.0 355251 −58.7 505823
Violence perpetration (past year) 3884 <0.001 1.71 (1.06 to 2.75) <0.05 4.30 (2.80 to 6.59) <0.001 7.71 (4.90 to 12.14) <0.001 ns <0.001 <0.001 ns Violence and criminal justice
Incarceration (lifetime) 3879 <0.001 2.63 (1.84 to 3.77) <0.001 3.65 (2.50 to 5.33) <0.001 11.34 (7.67 to 16.75) <0.001 <0.05 <0.05 <0.001 <0.001
Violence victimization (past year) 5.3 204 2.6 100 −51.0 104 5.8 2061912 2.9 1018287 −50.6 1043626
Diet, weight and exercise
Poor diet (current) 3879 <0.001 1.23 (0.99 to 1.54) ns 1.38 (1.08 to 1.77) <0.05 2.00 (1.49 to 2.67) <0.001 ns <0.01 <0.001 <0.001 Violence perpetration (past year) 4.4 170 2.1 81 −52.4 89 4.8 1708728 2.3 820709 −52.0 888019
Low physical exercise (current) 3881 ns <0.05 <0.001 <0.01 <0.01 Incarceration (lifetime) 7.1 276 3.3 126 −54.3 150 7.5 2683464 3.5 1259175 −53.1 1424289
Abbreviations: ACE adverse childhood experience; AOR adjusted odds ratios; IMD Index of Multiple Deprivation; NS not significant.
a
Accidentally got pregnant (females) or got someone else pregnant (males). Diet, weight, and exercise
Poor diet (current) 15.6 606 13.5 525 −13.4 81 16.1 5712524 13.9 4933592 −13.6 778932
Low physical exercise (current) 42.9 1667 NCb NCb
Abbreviations: ACE adverse childhood experience; NC not calculated.
a
See Methods section for details of modeling.
Page 7 of 10
b
Not calculated as model identified no independent impact of ACEs.
356 with this study. Thus, point estimates from national sur- support child development (for example, home visiting pro- 357
veys have suggested that 5.9% of children in England live grams, parenting programs, social development programs).
with an adult who is a dependent drinker, 2.8% with an Many of these interventions have been developed and
adult who is drug-dependent, and 7.8% with an adult with tested in North America, where they have reduced ACEs,
a mental health problem [29]. Our estimates for exposure increased child pro-social behavior, prevented HHBs,
to these ACEs at any stage in childhood were marginally and been identified as cost-effective [17,35-37]. The
higher, at 9.7% for alcohol abuse, 4.1% for drug abuse, and evidence base is also developing for their use in the UK and
12.0% for mental illness. Our sample size (n = 3,885) elsewhere in Europe [17]. Thus, the relationship between
and compliance (59.6% at the door and 53.5% including child adversity, HHBs, and poor health and social outcomes
households withdrawing at the letter stage) were also com- identified here provides a compelling case for investing
parable with other major national surveys (for example, at scale in parental well-being, parenting skills, and coor-
British Social Attitudes Survey 2012, n = 3,248, com- dinated health, education, and criminal justice services to
pliance 53% [30]; Adult Psychiatric Morbidity Survey prevent and identify child maltreatment. Moreover,
2007, n = 7,353, compliance 57% [31]). Finally, although measuring the benefits of such investments on such a
many individuals stated time constraints as their reason multi-disciplinary basis strengthens the economic case
for non-participation, we could not measure whether for investment, with total savings potentially exceeding
ACEs or HHBs were of a different prevalence or displayed program costs within a year [38]. Critically, investing in
different relationships in non-participants. parenting should be seen as a sustainable intervention that
In England and elsewhere, attempts to reduce financial has the potential to break cycles of adversity, with positive
and other inequities relating to NCDs have met with parenting practices likely to be passed down through gen-
limited success [32]. Equally, calls to limit the promotion erations once established.
and sale of alcohol, unhealthy foods, and to a lesser extent,
tobacco, are routinely blocked by industry [33]. However, Conclusions
resistance to commercial, cultural, and other environmental Emerging international literature is beginning to de-
pressures to adopt HHBs appears to be related to childhood scribe consistent impacts of ACEs on behavior and both
stressors, with nurturing, ACE-free childhoods increasing physical and mental health outcomes across a variety of
personal resilience [34]. There is a range of evidence-based nations [16,17,39]. However, empirical evidence on pre-
interventions already available to improve parenting and vention is more limited, largely to the USA [17]. A better

understanding of the potential impact of integrated, large- writing. NL coordinated the study, formatted data, and contributed to data dysfunction to many of the leading causes of death in adults. The Adverse maternal life course and child abuse and neglect: fifteen-year follow-up
scale interventions is required in countries where universal analysis and manuscript editing. CP contributed to study coordination and Childhood Experiences (ACE) Study. Am J Prev Med 1998, 14:245–258. of a randomized trial. JAMA 1997, 278:637–643.
manuscript editing. HL supported study development and edited the 12. Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, 36. Menting ATA, de Catro BO, Matthys W: Effectiveness of the Incredible
health systems already support all parents and prospective manuscript. All authors read and approved the final manuscript. Giles WH: The enduring effects of abuse and related adverse experiences Years parent training to modify disruptive and prosocial child behavior:
parents. Thus, brief motivational parenting interventions in childhood: a convergence of evidence from neurobiology and a meta-analytic review. Clin Psychol Rev 2013, 33:901–913.
communicating the benefits of warm and consistent Acknowledgements epidemiology. Eur Arch Psychiatry Clin Neurosci 2006, 256:174–186. 37. Aos S, Miller M, Drake E: Evidence-Based Public Policy Options to Reduce
We thank Katie Hardcastle and Olivia Sharples for supporting study 13. Anda RF, Felitti VJ: Origins and essence of the study. ACE Reporter 2003, Future Prison Construction, Criminal Justice Costs and Crime Rates. Olympia,
parenting are largely untested, despite the success of such 1:2003. http://acestudy.org/yahoo_site_admin/assets/docs/ WA: Washington State Institute for Public Policy; 2006.
implementation. We are grateful to all the surveyors for their time and
approaches in other areas [40]. Neurobiological studies commitment to the project and to all the individuals who participated in ARV1N1.127150541.pdf. 38. Knapp M, McDaid D, Parsonage E: Mental Health Promotion and Mental
have already identified changes to the hippocampus and the study. 14. Dietz PM, Spitz AM, Anda RF, Williamson DF, McMahon PM, Santelli JS, Illness Prevention: The Economic Case. London: Department of Health; 2011.
Nordenberg DF, Felitti VJ, Kendrick JS: Unintended pregnancy among 39. Kessler RC, McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky
prefrontal cortex associated with ACEs, while epigenetic adult women exposed to abuse or household dysfunction during their AM, Aquilar-Gaxiola S, Alhamzawi AO, Alonso J, Angermeyer M, Benjet C,
Author details
studies are exposing gene-environment interactions with 1
Centre for Public Health, World Health Organization Collaborating Centre for childhood. JAMA 1999, 282:1359–1364. Bromet E, Chatterji S, de Girolamo G, Demyttenaere K, Fayyad J, Florescu S,
negative health consequences once exposed to stressors Violence Prevention, Liverpool John Moores University, 15-21 Webster Street, 15. Whitfield CL, Anda RF, Dube SR, Felitti VJ: Violent childhood experiences Gal G, Gureje O, Haro JM, Hu CY, Karam EG, Kawakami N, Lee S, Lepine JP,
Liverpool L3 2ET, UK. 2Public Health Wales, Hadyn Ellis Building, Maindy Road, and the risk of intimate partner violence in adults: assessment in a large Ormel J, Posada-Villa J, Sagar R, Tsang A, Ustun TB, et al: Childhood
[24]. Consequently, a joint research agenda between epi- health maintenance organization. J Interpers Violence 2003, 18:166–185. adversities and adult psychopathology in the WHO World Mental Health
Cardiff CF24 4HQ, UK. 3Department of Academic Neonatal Medicine, Chelsea
demiological and other sciences is required to identify and Westminster Campus, Imperial College London, Fulham Road, London 16. Bellis MA, Lowey H, Leckenby N, Hughes K, Harrison D: Adverse childhood Surveys. Br J Psychiatry 2010, 197:378–385.
the points in a child’s development at which interven- SW10 9NH, UK. 4Knowledge and Intelligence Team (North West), Public Health experiences: retrospective study to determine their impact on adult 40. Kaner EFS, Dickinson HO, Beyer F, Pienaar E, Schlesinger C, Campbell F,
England, 15-21 Webster Street, Liverpool L3 2ET, UK. 5Blackburn with Darwen health behaviours and health outcomes in a UK population. J Public Saunders JB, Burnand B, Heather N: The effectiveness of brief alcohol
tions to prevent ACEs are most important and when Health 2013. doi:10.1093/pubmed/fdt038. interventions in primary care settings: a systematic review. Drug Alcohol
Borough Council, Specialist Public Health Directorate, 6th floor, 10 Duke Street,
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policy perspective, child health is typically considered to Preventing Child Maltreatment. Copenhagen: World Health Organization 41. Crowne SS, Gonsalves K, Burrell L, McFarlane E, Duggan A: Relationship
Received: 20 March 2014 Accepted: 21 March 2014 Regional Office for Europe; 2013. between birth spacing, child maltreatment, and child behavior and
begin from conception. However, positive parenting 18. Centers for Disease Control and Prevention: Behavioural Risk Factor development outcomes among at-risk families. Matern Child Health J
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Annexes Annex B: Relationships between adverse childhood experiences and adult mental well-being:
results from an English national household survey
Hughes et al. BMC Public Health (2016) 16:222 Hughes et al. BMC Public Health (2016) 16:222 Page 2 of 11
DOI 10.1186/s12889-016-2906-3
psychosis and suicide attempt, along with overall psycho- measure including 38 indicators relating to economic,
RESEARCH ARTICLE Open Access pathology, psychotropic medication use and treatment for social and housing issues) [21]. Two LSOAs were then
mental disorders [2, 3, 7–11]. However the literature on randomly selected from each decile in each region
Relationships between adverse childhood the impact of ACEs on broader measures of mental health
and well-being is less extensive. While definitions vary
and for each LSOA between 40 and 120 addresses
were randomly selected for inclusion from the Post-
experiences and adult mental well-being: [12], mental well-being is widely recognised as being more
than just the absence of mental illness; incorporating
code Address File®. Sample sizes in each region were
proportionate to their population to provide a sample
results from an English national household

aspects of mental functioning, feelings and behaviours representative of the English population, with a total
and having been simply described as feeling good and of 16,000 households initially sampled to account for
functioning well [13]. Positive mental well-being has been ineligibility, non-response and non-compliance.
survey associated with better physical and mental health and with
reduced mortality in both healthy and ill populations
Sampled households were sent a letter prior to re-
searchers visiting providing information on the study
Karen Hughes1*, Helen Lowey2, Zara Quigg1 and Mark A. Bellis3,4 [14, 15]. Correspondingly, the promotion of mental and the opportunity to opt out; 771 (4.8 %) households
well-being has become a public and mental health priority opted out at this stage. Operating under the direction of
both globally and in countries such as the UK [16, 17]. the research team, a professional survey company visited
Abstract Understanding how different factors impede mental households on differing days/times (seven days a week,
well-being in adults is imperative to investing effectively 9:30 am to 8.30 pm) between April and July 2013. The
Background: Individuals’ childhood experiences can strongly influence their future health and well-being. Adverse and efficiently in its promotion. With little longitudinal protocol employed by the survey company was to re-
childhood experiences (ACEs) such as abuse and dysfunctional home environments show strong cumulative data available, considerable focus has been placed on move households after four attempted visits with no
relationships with physical and mental illness yet less is known about their effects on mental well-being in the the associations between current conditions (e.g. social contact. Where contact was made and more than one
general population. relationships, residential deprivation, physical exercise, household member met the inclusion criteria, the eli-
Methods: A nationally representative household survey of English adults (n = 3,885) measuring current mental well- health status) and mental well-being rather than longer- gible resident with the next birthday was selected for
being (Short Edinburgh-Warwick Mental Well-being Scale SWEMWBS) and life satisfaction and retrospective term drivers. However, a US study using the ACE frame- interview. Interviewers explained the purpose of the
exposure to nine ACEs. work found a cumulative relationship between childhood study, outlined its voluntary and anonymous nature and
Results: Almost half of participants (46.4 %) had suffered at least one ACE and 8.3 % had suffered four or more. adversity and markers of mental well-being in the general provided a second opportunity for individuals to opt
population, including mentally healthy days and life satis- out, with informed consent obtained verbally at the
360 Adjusted odds ratios (AORs) for low life satisfaction and low mental well-being increased with the number of ACEs.
AORs for low ratings of all individual SWEMWBS components also increased with ACE count, particularly never or faction [18]. In England, we conducted a pilot ACE study point of interview. Household visits ceased once the tar- 361
rarely feeling close to others. Of individual ACEs, growing up in a household affected by mental illness and in a local administrative area which found increased odds get sample size was achieved. Thus, 9,852 of the sampled
suffering sexual abuse had the most relationships with markers of mental well-being. of low life satisfaction and low mental well-being in adults households were visited of which 7,773 resulted in con-
with increased ACEs [19]. Following this pilot, we under- tact with a resident. Of these households, 2,719 (35.0 %)
Conclusions: Childhood adversity has a strong cumulative relationship with adult mental well-being. took a national ACE study of adults across England that opted out, 1,044 (13.4 %) were ineligible and 4,010 com-
Comprehensive mental health strategies should incorporate interventions to prevent ACEs and moderate their included validated measurements of mental well-being pleted a study questionnaire. Compliance was 59.6 %
impacts from the very earliest stages of life. and life satisfaction. Here we explore relationships be- across eligible occupied households visited and 53.5 %
Keywords: Adverse childhood experiences, Child maltreatment, Mental well-being, Life satisfaction, Prevention tween levels of exposure to adversity during childhood when including those opting out at the letter stage.
and current mental well-being in adults. Finally, we dis- The study used an established questionnaire covering
cuss the convergence between the roots of poor physical demographics, lifestyle behaviours, health status, mental
Background experiences of household dysfunction, such as witnessing health and poor mental well-being in early years and con- well-being, life satisfaction and exposure to ACEs before
Individuals’ childhood experiences are of paramount im- violence in the home, parental separation and growing up sequently, how poor mental well-being in one generation the age of 18 [19]. Participants were able to complete
portance in determining their future outcomes. Research in a household affected by substance misuse, mental may adversely impact well-being in the next. the questionnaire through a face-to-face interview using
exposing the harmful effects that childhood adversity illness or criminal behaviour. Studies show a dose- a hand held computer (with sensitive questions self-
has on adult physical and mental health has advanced responsive relationship between ACEs and poor out- Methods completed; n = 3,852), or to self-complete using paper
significantly over the past few decades. For instance, the comes, with the more ACEs a person suffers the greater A target sample size of 4,000 adult residents of England questionnaires (n = 158). Mental well-being was mea-
Adverse Childhood Experiences (ACE) framework has their risks of developing health harming behaviours was established based on the prevalence of ACEs identi- sured using the Short Warwick-Edinburgh Mental Well-
provided a mechanism for retrospectively measuring (e.g. substance misuse, risky sexual behaviour), suffer- fied in the pilot study [19]. Study inclusion criteria were: being Scale (SWEMWBS) [22], which asks individuals
childhood adversities and identifying their impact on ing poor adult health (e.g. obesity, cancer, heart disease) aged 18–69 years; resident in a selected LSOA; and cog- how often over the past two weeks they have been: feeling
health in later life [1]. ACEs include child maltreatment and ultimately premature mortality [1–6]. nitively able to participate in a face-to-face interview. optimistic about the future; feeling useful; feeling relaxed;
(e.g. physical, sexual and verbal abuse) and broader Much research on the long-term impacts of ACEs has Households were selected through random probability dealing with problems well; thinking clearly; feeling close to
focused on their relationships with mental illness. Thus, sampling stratified by English region (n = 10, with inner other people; able to make up their own mind about things.
* Correspondence: [email protected]
studies have found increasing numbers of ACEs to be and outer London treated as two regions) and then by Responses are scored from 1 (none of the time) to 5 (all of
1
Centre for Public health, Liverpool John Moores University, 15-21 Webster associated with increasing risks of conditions including small area deprivation using lower super output areas the time) and an overall mental well-being score is calcu-
Street, Liverpool L3 2ET, UK depression, anxiety, panic reactions, hallucinations, (LSOAs; geographic areas with a population mean of lated, ranging from 7 (lowest possible mental well-being)
Full list of author information is available at the end of the article
1,500) [20]. Within each region, LSOAs were categorised to 35 (highest possible mental well-being). Life satisfaction
© 2016 Hughes et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
into deciles of deprivation based on their ranking in the was measured on a scale of 1–10 using the standard ques-
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to 2010 Index of Multiple Deprivation (IMD; a composite tion: All things considered how satisfied are you with your
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Hughes et al. BMC Public Health (2016) 16:222 Page 3 of 11 Hughes et al. BMC Public Health (2016) 16:222 Page 4 of 11
life, with 1 being not at all satisfied and 10 very satisfied having low SWEMWBS scores (<23) and 11.6 % as having Table 1 Sample characteristics and prevalence of low mental well-being and life satisfaction
[23]. ACEs were measured using the Centers for Disease low life satisfaction (score <6; Table 1). % in the last two weeks that have never or rarely beena % with lowb
Control and Prevention short ACE tool [24] which com- Low SWEMWBS scores and LS were both associated All Feeling Feeling Feeling Dealing well Thinking Feeling close Able to make SWEMWBS LS
prises eleven questions covering nine ACE types: physical with age, being most prevalent in the 50–59 year age optimistic useful relaxed with problems clearly to others up own mind score
abuse; verbal abuse; sexual abuse (three questions); paren- group (Table 1). Significant relationships with age were n 3,885 3,876 3,882 3,882 3,879 3,883 3,879 3,883 3,868 3,884
tal separation; exposure to domestic violence; and growing also seen for all individual SWEMWBS components ex- All 12.9 8.4 14.5 6.2 3.5 5.3 2.5 13.0 11.6
up in a household with mental illness, alcohol abuse, drug cept feeling useful and dealing with problems. There Age group
abuse or incarceration (for further information see [4]). were no relationships between gender and LS or overall
18–29 21.0 9.7 8.7 13.7 6.5 2.5 4.4 3.1 11.2 8.3
Ethnicity was recorded using standard UK Census cat- SWEMWBS score, although among the individual
egories [25] and categorised as White, Asian and Other SWEMWBS components more females had low scores 30–39 19.9 8.4 7.6 16.7 6.0 3.1 4.3 2.1 11.3 8.3
due to small numbers within individual ethnic groups. Re- for feeling relaxed and more males for feeling close to 40–49 20.5 14.2 8.2 17.7 7.0 4.8 6.5 2.8 15.9 15.4
spondents were allocated an IMD 2010 quintile of others. There were no significant relationships between 50–59 18.0 19.5 10.0 16.2 6.4 4.7 7.3 4.0 17.1 16.6
deprivation based on their LSOA of residence. Ethical ap- ethnicity and either low SWEMWBS score or low LS. 60–69 20.7 13.2 7.7 8.7 5.1 2.5 4.0 0.9 10.0 9.8
proval for the study was obtained from Liverpool John However both outcomes increased with deprivation, as P <0.001 0.461 <0.001 0.579 0.015 0.008 0.002 <0.001 <0.001
Moores University’s Research Ethics Committee and the did low levels of all individual SWEMWBS components
Gender
study adhered to the Declaration of Helsinki. except feeling relaxed.
Analyses were undertaken using SPSS v20. Only indi- There were strong associations between ACE count Male 45.0 13.7 9.3 11.6 6.0 3.2 6.1 2.8 12.7 10.8
viduals with complete data relating to all ACEs, age, sex, and all markers of low mental well-being. Thus the Female 55.0 12.2 7.7 16.9 6.4 3.7 4.6 2.3 13.3 12.2
ethnicity, and IMD quintile were included in the ana- prevalence of low SWEMWBS score tripled from 9.5 % P 0.163 0.067 <0.001 0.549 0.397 0.041 0.318 0.604 0.156
lysis, resulting in a final sample size of 3,885. Bivariate in those with 0 ACEs to 30.7 % in those with 4+ ACEs, Ethnicity
analyses used chi-squared with backwards conditional while the prevalence of low LS more than tripled from White 86.3 12.7 8.5 14.6 6.0 3.5 5.2 2.5 12.9 11.4
logistic regression used to examine independent rela- 7.9 to 26.6 % respectively. These significant relationships
Asian 7.9 12.4 7.5 14.6 6.8 3.9 5.5 3.2 11.8 10.7
tionships between ACEs and adult mental well-being remained after controlling for confounders in logistic re-
and life satisfaction. Consistent with other work includ- gression analysis with adjusted odds ratios (AORs) for Other 5.7 16.1 9.0 13.5 9.0 3.1 5.4 1.3 16.6 14.4
ing previous ACE studies [1–3] and the World Mental low SWEMWBS score and low LS increasing with ACE P 0.321 0.794 0.896 0.178 0.887 0.973 0.384 0.226 0.363
Health Surveys [26–28], the number of ACEs partici- count and reaching 3.9 for both outcomes in those with
362 363
IMD Quintile
pants reported exposure to was summed into an ACE 4+ ACEs (compared with 0 ACEs; Table 2). Importantly, (least deprived)1 20.1 7.4 5.5 13.3 4.1 1.9 3.5 1.7 8.2 7.4
count (range 0 to 9) and here categorised into four while associations between both outcomes and age also 2 19.5 12.1 6.5 15.0 5.7 3.0 3.3 1.6 10.6 8.8
groups for analysis: 0 ACEs (n = 2,072), 1 ACE (n = 879), remained in LR, running separate models for each age
3 19.7 12.6 8.0 13.0 6.6 3.8 4.7 2.5 12.4 8.2
2–3 ACEs (n = 594) and 4 + ACEs (n = 322). We also ex- group showed the relationships between high ACE
plored relationships between outcome variables and in- count and low mental well-being to be consistent across 4 19.9 13.6 8.5 14.9 7.0 3.9 6.0 3.4 14.6 14.2
dividual ACEs, with analysis focusing on those with age groups. Thus, compared with individuals with no (most deprived) 5 20.7 18.5 13.4 16.4 7.7 4.7 8.7 3.5 19.1 18.8
highly significant relationships. The seven individual ACEs, AORs for low SWEBWBS scores in those with P <0.001 <0.001 0.291 0.033 0.034 <0.001 0.036 <0.001 <0.001
components of SWEMWBS were each dichotomised to 4+ ACEs ranged from 3.08 in both 18–29 year olds ACE count
indicate poor ratings (never or rarely in the last two (95 % CIs, 1.56–6.07) and 30–39 year olds (95 % CIs 0 53.6 10.7 6.5 10.9 4.8 2.5 3.3 2.0 9.5 7.9
weeks). Overall SWEMWBS scores and life satisfaction 1.66–5.72) to 5.34 (95 % CIs 2.10–13.57) in 60–69 year
1 22.7 12.9 6.9 14.1 5.7 3.5 4.9 2.4 12.1 11.7
(LS) ratings were dichotomised to indicate low scores as olds (all p < 0.001) and for low LS from 2.54 (95 % CIs
>1 standard deviation (SD) below the mean (SWEMWBS, 1.09–5.90, p = 0.030) in 18–29 year olds to 11.20 (95 % 2–3 15.4 15.3 11.7 20.1 8.2 4.2 8.6 3.5 17.2 16.1
mean 27.5, SD 4.4, low <23; LS, mean 7.7, SD 1.7, low <6). CIs 4.43–28.29, p < 0.001) in 60–69 year olds. 4+ 8.3 22.3 18.9 28.8 13.3 8.0 13.0 4.6 30.7 26.6
Figure 1 presents AORs for low scores for each com- P <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.012 <0.001 <0.001
Results ponent of SWEMWBS by increasing ACE count (all a
Variables represent the individual component questions in the SWEMWBS scale. bSWEMWBS (Short Warwick-Edinburgh Mental Well-being Scale) score <23; LS
The demographic breakdown of the sample is shown in ages). All relationships were significant and cumulative (life satisfaction) rating <6
Table 1. Compared with the English population the sam- with AORs for those with 4+ ACEs (compared with 0
ple overrepresented females (55.0 % v 50.3 % in England) ACEs) ranging from 2.23 (95 % CIs 1.22–4.10) for never
and individuals aged 60–69 years (20.7 % v 16.1 %) and or rarely being able to make up one’s own mind to 4.09 up about things. However parental separation or divorce the SWEMWBS component of feeling relaxed (Table 4).
underrepresented those aged 18–29 (21.0 % v 24.2 %). (2.70–6.20) for never or rarely feeling close to others. was only associated with two of the seven SWEMWBS Childhood sexual abuse was associated with all except the
There were no differences by deprivation quintile or eth- Table 3 shows the relationships between measures of components (feeling useful, feeling relaxed) and an over- SWEMWBS components of feeling useful and feeling
nicity. Just under half of participants reported having mental well-being and the nine individual ACEs exam- all low SWEMWBS score. For each marker of mental close to others. Emotional and physical abuse each had in-
suffered at least one ACE (46.4 %) with 15.4 % reporting ined. Physical, sexual and emotional abuse, witnessing well-being, a logistic regression model was run that dependent relationships with five of the nine measures
2–3 ACEs and 8.3 % 4+ ACEs. The proportion of partici- domestic violence, and living in a household affected by included individual ACE types significantly related to and household alcohol problems with four. Feeling close
pants with low measures (never or rarely in the last two mental illness or drug abuse were significantly associated the marker (in bivariate analysis, see Table 3) and demo- to others (the SWEMWBS component with the strongest
weeks) for the individual components of SWEMWBS with low levels of all mental well-being measures and graphic variables. Here, household mental illness was relationship with ACE count; Fig. 1), was independently
ranged from 2.5 % (able to make up own mind) to 14.5 % household alcohol misuse and incarceration with low found to have independent relationships with the most associated with household mental illness, emotional abuse
(feeling relaxed). Thirteen percent were categorised as levels of all except the ability to make one’s own mind mental well-being marker, being associated with all except and physical abuse.

Table 2 Adjusted odds ratios for low mental well-being and life satisfaction
Lowa
SWEMWBS score Life satisfaction
AOR 95 % CIs P AOR 95 % CIs P
Age 18–29 (Ref) *** ***
30–39 1.049 0.763–1.444 ns 1.057 0.734–1.521 ns
40–49 1.609 1.196–2.165 ** 2.227 1.612–3.076 ***
50–59 1.893 1.398–2.562 *** 2.683 1.992–3.774 ***
60–69 1.100 0.795–1.523 ns 1.572 1.108–2.229 *
Deprivation quintile 1 (least deprived; Ref) *** ***
2 1.244 0.877–1.765 ns 1.135 0.783–1.647 ns
3 1.517 1.081–2.130 * 1.073 0.736–1.564 ns
4 1.770 1.270–2.465 ** 1.992 1.414–2.808 ***
5 (most deprived) 2.382 1.734–3.273 *** 2.714 1.952–3.774 ***
ACE count 0 (Ref) *** ***
1 1.350 1.048–1.739 * 1.636 1.256–2.132 ***
2–3 1.946 1.497–2.529 *** 2.235 1.696–2.947 ***
4+ 3.856 2.896–5.134 *** 3.893 2.867–5.286 ***
a
SWEMWBS (Short Warwick-Edinburgh Mental Well-being Scale) score <23; Life satisfaction rating <6. AOR adjusted odds ratio; 95 % CIs 95 % confidence intervals;
Ref reference category; *P < 0.05, **P < 0.01, ***P < 0.001, ns not significant. Analyses used backward conditional logistic regression. Gender and ethnicity were also
entered into the model but were not significantly related to low SWEMWBS score or low life satisfaction (data not shown)
Discussion relationship between childhood adversities and two

Promoting mental well-being has become a major public widely used measures of mental well-being. The more Fig. 1 Relationship between adverse childhood experience count and components of poor adult mental well-being (adjusted odds ratios and
364 health priority as recognition of the links between well- ACEs participants reported having suffered during their
95 % confidence intervals). Variables represent the individual component questions in the SWEMWBS scale. Adjusted odds ratios were calculated
using logistic regression analysis. Additional independent variables included in the logistic regression were age, gender, deprivation and ethnicity.
365
being and broader health and social outcomes has grown. childhood the more likely they were to report low All relationships are significant with poor mental well-being components positively related to increasing ACE count (p < 0.001, except ‘ability to
This has contributed to the emergence of broader policy SWEMWBS scores and low life satisfaction (Table 1). make up own mind where p < 0.05). Ref = reference category
approaches to mental health, both globally and nationally, These relationships remained after controlling for demo-
that incorporate population-level prevention and promo- graphics, with odds of poor outcomes for both measures
tion activity alongside traditional therapeutic responses to being elevated in those with even a single ACE and al- also face a range of risk factors for poor mental well- all except parental separation/divorce with low life satis-
mental illness [16, 17]. In England, motivation for in- most four times higher in those with four or more ACEs being in adulthood, such as poor health, low employ- faction and most individual SWEMWBS components. In
creased investment in mental well-being promotion (compared with those with no ACEs; Table 2). We also ment and social deprivation [2, 4, 36]. These effects multivariate analyses, however, the ACEs with the most
has centred around the notion that interventions to found ACE count to be independently related to each of can contribute to cycles of adversity and poor mental independent relationships with markers of low mental
improve mental well-being at a population level could the seven individual components of SWEMWBS; indi- well-being whereby individuals that grew up in adverse well-being were growing up in a household with some-
produce greater benefits than those to prevent mental viduals with higher ACE counts were more likely to re- conditions are less able to provide optimum childhood en- one affected by mental illness and suffering childhood
illness in at-risk populations [29, 30]. However, the port never or rarely (in the last two weeks) feeling vironments for their own offspring [37]. Here, and consist- sexual abuse.
evidence base on which such approaches are based is optimistic, useful, relaxed or close to others, dealing ent with previous work [38], the SWEMWBS component The links between growing up in a household affected
being questioned as broader measurements and studies of with problems well, thinking clearly and being able to with the strongest relationship with ACE count was by mental illness in childhood and low mental well-
mental well-being emerge [12]. Thus, existing studies have make up one’s own mind (Fig. 1). never or rarely feeling close to others. Children whose being in adulthood may in part reflect genetic risk fac-
largely associated mental well-being in adults with A variety of mechanisms link ACEs to poor adult men- parents show poor relationships with them are at greater tors that make the offspring of individuals with mental
factors linked to their current circumstances, such as tal well-being. Critically, maltreatment and other risks of ACEs [39], thus individuals who cannot feel disorders susceptible to poor mental health themselves
employment, residential deprivation, social participa- stressors in childhood can affect brain development and close to others as a result of their own ACE history [40]; although genetic explanations for the transmission
tion, physical exercise, relationship satisfaction and have harmful, lasting effects on emotional functioning may subsequently be more likely to expose their own of mental disorders are disputed [41]. Thus, parental
health status [31]. Correspondingly, interventions have [2, 34]. Children who are maltreated can develop attach- children to ACEs. These relationships may also have mental illness can have broader impacts on children’s so-
often focused on promoting individual behavioural ment difficulties, including poor emotional regulation, implications for the implementation and effectiveness cial and emotional development when parenting prac-
change through, for example, increasing social con- lack of trust and fear of getting close to other people. of interventions to improve mental well-being through tices are affected by factors such as low emotional
nectedness and physical activity [32, 33]. A life course They can also form negative self-images, lack self-worth social connectedness. warmth, reduced responsiveness, impaired attention and
perspective that incorporates the longer-term impact and suffer feelings of incompetence, all of which can be While analysis based on ACE count highlights the cu- unpredictable behavioural patterns [42]. An extensive
of childhood adversity has largely been absent from retained into adulthood [2, 34, 35]. The relationships be- mulative impact of childhood adversity on mental well- body of research provides evidence that exposure to
discussions on mental well-being. tween ACEs and factors including poor educational at- being, it is also useful to explore which ACEs may have childhood adversity such as parental stress, disrupted
Using a randomly selected national household sample tainment and the development of health-damaging particular effects. All ACE types showed significant bi- care patterns and abuse increases risks of mental illness
of English adults, our study found a strong cumulative behaviours mean that individuals who suffer ACEs can variate relationships with low SWEMWEBS scores, and [43], while studies are increasingly identifying how

Table 3 Bivariate relationships between mental well-being measures and individual adverse childhood experience types Table 4 Adjusted odds ratios for low ratings on SWEMWBS components, low overall SWEMWBS scores and low LS in those
ACE All In the last two weeks, % never or rarelya: % with lowb: reporting individual adverse childhood experience types
Feeling Feeling Feeling Dealing well Thinking Feeling close Able to make SWEMWBS LS ACE In the last two weeks, never or rarelya Lowb
optimistic useful relaxed with problems clearly to others up own mind score Feeling Feeling Feeling Dealing well Thinking Feeling close Able to make SWEMWBS LS
Physical abuse optimistic useful relaxed with problems clearly to others up own mind score
No 85.7 11.6 7.2 13.0 5.6 3.0 4.2 2.3 11.1 9.6 Physical abuse AOR 1.50 1.53 1.39 1.55 1.49
Yes 14.3 20.5 15.6 23.9 10.1 6.5 11.9 3.9 24.2 23.2 95 % CIs 1.16–1.94 1.11–2.13 1.06–1.83 1.05–2.28 1.11–2.00
P <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.020 <0.001 <0.001 P ** * * ns ns * ns ns **
Emotional abuse Emotional abuse AOR 1.46 1.47 2.12 1.73 1.54
No 82.7 11.9 7.1 12.6 5.5 3.0 3.9 2.2 10.7 9.3 95 % CIs 1.06–2.00 1.13–1.89 1.46–3.08 1.36–2.20 1.16–2.05
Yes 17.3 17.6 14.7 24.0 9.8 5.8 11.9 4.0 24.0 22.2 P ns * ** ns ns *** ns *** **
P <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.007 <0.001 <0.001 Sexual abuse AOR 1.55 1.52 1.82 2.68 2.5 2.30 1.79
Sexual abuse 95 % CIs 1.10–2.20 1.08–2.12 1.19–2.79 1.64–4.38 1.40–4.49 1.67–3.18 1.27–2.54
No 93.8 12.2 7.9 13.6 5.7 3.0 4.8 2.3 11.7 10.4 P * ns * ** *** ns ** *** **
Yes 6.2 23.4 16.7 28.9 14.2 10.9 13.0 6.7 33.2 28.9 Parental separation AOR na na na na na na
P <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 95 % CIs
Parental separation P - ns ns ns
No 77.4 12.9 7.8 13.2 6.1 3.5 5.2 2.5 12.4 11.1 Domestic violence AOR
Yes 22.6 12.8 10.5 19.2 6.7 3.3 5.4 2.7 15.1 13.2 95 % CIs
P 0.906 0.013 <0.001 0.486 0.744 0.880 0.657 0.040 0.084 P ns ns ns ns ns ns ns ns ns
Domestic violence Mental illness AOR 1.43 1.44 1.78 1.79 2.04 1.85 1.97 1.47
No 87.9 12.2 8.0 13.3 5.6 3.2 4.7 2.3 11.8 10.7 95 % CIs 1.09–1.88 1.04–2.00 1.25–2.53 1.15–2.78 1.42–2.94 1.12–3.07 1.52–2.55 1.09–1.97
P * * ns ** * *** * *** *
366 367
Yes 12.1 18.1 11.7 23.2 10.4 5.7 9.2 4.0 21.6 17.9
P <0.001 0.006 <0.001 <0.001 0.004 <0.001 0.025 <0.001 <0.001 Alcohol problem AOR 1.46 1.41 1.56 na 1.52
Mental illness 95 % CIs 1.02–2.07 1.06–1.89 1.04–2.34 1.11–2.08
No 87.9 12.0 7.6 13.3 5.4 3.0 4.3 2.2 11.2 10.2 P ns * * * ns ns ns *
Yes 12.1 19.1 14.7 23.4 12.4 7.2 12.0 4.9 25.9 21.5 Drug misuse AOR 1.76 2.45
P <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 95 % CIs 1.06–2.93 1.34–4.46
Alcohol misuse P ns ns ns * ** ns ns ns ns
No 90.9 12.3 7.7 13.4 5.5 3.2 4.8 2.4 11.9 10.3 Incarceration AOR 1.53 na
Yes 9.1 19.0 16.1 25.8 13.0 6.5 9.9 4.0 24.4 23.8 95 % CIs 1.03–2.26
P <0.001 <0.001 <0.001 <0.001 0.001 <0.001 0.070 <0.001 <0.001 P ns ns * ns ns ns ns ns

a
Variables represent the individual component questions in the SWEMWBS scale. bSWEMWBS (Short Warwick-Edinburgh Mental Well-being Scale) score <23; LS
Drug misuse
(life satisfaction) rating <6. Analysis used backward conditional logistic regression. Separate models were run for each SWEMWBS component, low SWEMWBS score
No 96.1 12.5 8.2 14.2 5.8 3.2 5.0 2.4 12.6 11.2 and low LS. Models included ACE types significantly related to each outcome in bivariate analysis along with age, gender, IMD quintile of deprivation and ethnicity.
na not applicable; variable not included in the model due to lack of relationship in bivariate analyses. For each ACE, the reference group is those that did not report the
Yes 3.9 20.9 15.0 22.9 16.3 11.1 11.2 5.2 23.7 19.6 ACE. *P < 0.05, **P < 0.01, ***P < 0.001, ns not significant
P 0.002 0.003 0.003 <0.001 <0.001 0.001 0.030 <0.001 0.001
Incarceration
and adult mental illness [11]. For example, in England sex- [17]. Interventions that seek to reduce ACEs, develop
ual abuse in childhood has been attributed to 11 % of all parenting skills and promote resilience in children
No 95.9 12.5 8.1 13.9 5.9 3.3 5.0 2.5 12.5 11.1
common mental disorders, along with 7 % of alcohol de- should thus be considered essential elements in com-
Yes 4.1 21.5 17.1 28.5 13.9 7.0 12.0 2.5 24.7 22.2 pendence disorders, 10 % of drug dependence disorders, prehensive mental health strategies. Starting at the
P 0.001 <0.001 <0.001 <0.001 0.015 <0.001 0.995 <0.001 <0.001 15 % of eating disorders and 17 % of post-traumatic stress very earliest stages of life, these can include measures
a
Variables represent the individual component questions in the SWEMWBS scale. bSWEMWBS (Short Warwick-Edinburgh Mental Well-being Scale) score <23; LS disorders [47]. to train midwives, health visitors and other early years
(life satisfaction) rating <6
The WHO Mental Health Action Plan 2013–2020 in- professionals to enquire about parental mental well-being
corporates the promotion of mental well-being as part of and identify and treat post-natal depression and other
exposure to such adversity can trigger epigenetic modi- emotional development, having been linked to feelings of its overarching goal: highlighting the need for a life course mental health concerns [48]. The ante- and post-natal pe-
fications to gene expressions, altering brain structure, shame and self-blame, powerlessness, inappropriate sexual approach that intervenes early to prevent mental health riods also offer the opportunity to identify and address a
stress reactivity and consequently vulnerability to both beliefs and difficulties forming and maintaining intimate difficulties; recognising the importance of reducing broader range of ACEs including parental substance use
mental and physical ill health [44]. Childhood sexual abuse relationships [45, 46]. Correspondingly research has identi- violence; and emphasising the importance of services and domestic violence as well as to increase parenting
can have particularly damaging effects on individuals’ fied strong relationships between childhood sexual abuse being responsive to the needs of survivors of violence skills and knowledge. Effective interventions include home

visiting and parenting programmes that promote adults who suffered ACEs are widely recognised, data Received: 21 August 2015 Accepted: 22 February 2016 22. Stewart-Brown S, Tennant A, Tennant R, Platt S, Parkinson J, Weich S.
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KH supported study development and implementation, analysed the data
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2008;70:741–56. genome-wide analysis. Lancet. 2013;381:1371–9.
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Such limitations aside our analyses did include multiple final manuscript.
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transparency, discussion has focused on highly significant We thank Nicola Leckenby for coordinating the study and preparing data for 18. Nurius PS, Logan-Greene P, Green S. Adverse Childhood Experiences (ACE) 44. Vaiserman AM. Epigenetic programming by early-life stress: evidence from
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“It is the experiences we find hardest to talk about in our society that have a lasting
impact on the mental health and wellbeing of children and young people. Be it bereavement,
domestic violence, caring for a parent, or sexual abuse, we must ensure that all services
are better able to identify childhood adversity and help to resolve the trauma related to it.”
Sarah Brennan OBE Chief Executive of YoungMinds
With 1 in 3 adult mental health conditions related directly to adverse childhood

experiences, it is vital that we understand the impact that adversity and trauma
can have on the mental health and wellbeing of young people, and how we can
strengthen resilience and support recovery.
Addressing Adversity presents evidence, insight, direction and case studies for
commissioners, providers and practitioners in order to stimulate further growth
in adversity and trauma-informed care, and spark innovation and good practice
across England.
Section 1: Understanding adversity, trauma and resilience includes evidence and

analysis of the impact that adverse childhood experiences and trauma have on
children and young people’s mental health and wider outcomes across the lifecourse.
Section 2: Addressing childhood adversity and trauma includes insights from
the NHS in England, organisations and clinicians working with children and young
people who have experienced forms of adversity and trauma.
Section 3: Emerging good practice includes insight, case studies and working
examples of adversity and trauma-informed service models being developed across
England.
The collection ends with an agenda for change, calling on all Directors of Public
Health, commissioners and providers to make adversity and trauma-informed
care a priority in their locality.
ISBN: 978-1-5272-1946-5 You can download the Addressing Adversity ebook at

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Prioritising adversity and trauma-informed care

Edited by Dr Marc Bush

The publication of this collection was funded by Health Education England

Print ISBN 978-1-5272-1946-5

4 Creating trauma-informed mental healthcare in the UK – extract from ‘Trauma-informed mental

Addressing Adversity youngminds.org.uk

and ultimately have a profound impact on their social, psychological and

Matilda Allen is a Public Health Consultant Trainee. She previously worked at

Associate Professor Mario Alvarez-Jimenez is Head of e-health at Orygen,

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Addressing Adversity youngminds.org.uk

Addressing Adversity youngminds.org.uk

Addressing Adversity youngminds.org.uk

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Dr Graham Simpson-Adkins is a clinical psychologist in a specialist community

Dr Angela Sweeney (MA Hons (Cantab) PhD) is a trauma survivor and

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13. Straight Jacket: the mental health consequences of LGBT+ prejudice

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Addressing Adversity youngminds.org.uk

Addressing childhood adversity and trauma HOW COMMON ARE ACES?

WHAT IS ADVERSITY? Around half of all adults

Adaptations are children and young people’s attempts to:

Maltreatment Violence & coercion Adjustment Prejudice

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WHAT PROTECTS YOUNG Flexible “Shape your support around me”

or safeguarding b syste -infor

Early intervention from

involves young people in decisions about

Making childhood Creating a common Investing

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Navigation boxes For more on:

The term Adverse Childhood Experiences was popularised through US studies

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Adverse Childhood Experiences

Adult responsibilities: including being the primary carer

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Source: adapted from the CDC-Kaiser ACE Study [1998]

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For more on the impact of childhood adversity across the lifecourse

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environment63. This is associated with problems with sleeping64 as the child

Experiencing psychological trauma can also create a hypervigilance, in which

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• adopting culturally sensitive trauma-informed models of care

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48 on health-harming behaviours in the Welsh adult population: http://www.cph.org.uk/wp-con-

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111 UNICEF (2006) Op. cit.

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2. Adverse Childhood Experiences,