Is childhood trauma a disability?

A landmark court ruling in the United States has found that children who experience trauma and multiple adversities could be considered to have a disability. Importantly, the judge in this case identified that not all children affected by trauma end up being disabled by their experiences of trauma, but that some children certainly do.

These findings have come out of a court case that has seen a class action taken by students of a high school, claiming that as the school was not trauma informed and trauma sensitive, their needs were not met and they were disadvantaged within this system. They claim that the school did not recognise that the behavioural, emotional and learning difficulties they were facing were caused by their exposure to trauma and adversity and that the school could have done more to meet their needs.

This is certainly an interesting development in the current response to children exposed to trauma and adversity. The research clearly indicates that for some children who experience repeated exposure to trauma and adversity early in life and are without opportunities for safety and adequate care, there are changes within the architecture of the brain that lead to learning difficulties and emotional health difficulties across the lifespan. This research has led to many services that work with children to become, at the least trauma informed, through to trauma sensitive and trauma focused. 

In thinking further about the long term impact of child trauma and adversity, we can turn to recent Australian research that has looked at the impact of physical abuse, sexual abuse, emotional abuse and neglect on adverse health outcomes across the lifespan: 

"Overall, an estimated 23.5% of self-harm, 20.9% of anxiety disorders and 15.7% of depressive disorders burden in males; and 33.0% of self-harm, 30.6% of anxiety disorders and 22.8% of depressive disorders burden in females was attributable to child maltreatment."

Long-term mental health conditions are often associated with disability, that is, with a long term impairment in several areas of functioning in the person's life. According to the UK government, a mental health condition is considered to be a disability if it has a long term effect on your normal day to day activity and in Australia mental health conditions are included under the National Disability Insurance Scheme. 

The pertinent question really is, would it be helpful for those who have experienced significant trauma and adversity as a child to be identified as having a disability? This is not a question that is easy to answer, though it is clear that if there was greater recognition of the impacts of these experiences, there may be greater access to funding and appropriate assistance. This may see some of the impacts, especially in the area of learning and emotional health, be addressed earlier on and more effectively, which would certainly be beneficial both in the short and the long term.

Through the Royal Commission into Institutional Responses to Child Sexual Abuse we have had a rare glimpse into the long term impacts that childhood trauma can have. As one courageous man Grahame Rundle has told the Commission:

"The truth is that we don't ever forget and get over it,

Once your childhood is taken from you, it's gone forever."

Skills in emotions: A key to children's success

Understanding emotions and learning how to manage them is a skill that children learn, it is not one that is inbuilt. From the time they are born, most kids will have a carer that is loving, warm and attuned to the baby's emotions. If you watch many parents of young children, you will see that they are consistently providing their child with feedback on how the child is travelling emotionally. They help them to navigate the ups and downs that their child feels. They may say "You look happy, you are enjoying that, that feels good" or "you seem angry, how can I help you calm down" or even " you are sad, I can give you a hug to help you feel better". 

Children need this consistent feedback on their emotional state to make sense of the big, overwhelming emotions that they are experiencing. Initially, this feedback helps them to be able to name their emotions and recognise when they feel angry, sad, happy etc. Then, they start to learn that other people can help them feel better. Eventually, they start to learn that they can calm themselves down, or that they can help themselves to feel better. 

By the time they get to school, most kids will be on the path to starting to understand and manage their emotions. We know from the research that this skill, of being able to understand and manage emotions, is central to building learning skills and developing and keeping friendships. 

But what about the kids who don't get this consistent feedback from a young age? 

Children who are exposed to lots of adversities or trauma from a young age are more likely to miss out on this development of understanding their emotions. The reasons that they miss out on this are complex, but some of the reasons that parents or carers may not be able to help their children develop this skill include: 

• multiple adversities that lead to family stress, with less attention to the baby or child's needs. 
• parents or carers who did not have this skill taught to them when they were a child. 
• parental mental health difficulties or substance abuse may mean that the parent or carer may not be attuned to the needs of the baby or child. 
• overly chaotic households where little or no rhythm or routine means less time for the baby or child. 

Children may also live in environments where they are overwhelmed by stress, uncertainty or fear, and without someone that can help them make sense of this. 

When children have not had the opportunities presented to them to develop this understanding and ability to manage their emotions, it can potentially lead to difficulties in several different areas of their life. This can include: 

• difficulties being settled and calm in the classroom, which can interrupt their learning or mean that they are unable to take in the information they need. 
• overwhelming emotions can lead to behaviours that may be disruptive. 
• difficulties in making and keeping friends. 
• behaviours at home that parents and carers may find tricky to deal with. 

The ARC (Attachment, Self - Regulation, Competency) framework for intervention features emotional skill development as one of the core features of working with children who have experienced trauma and multiple adversity. If offers a theoretically based way of working directly with children, with parents and carers, and within systems to build skills for children in emotion recognition, modulation and expression. Here, at the Australian Child & Adolescent Trauma, Loss & Grief Network (ACATLGN) we are using the ARC framework for our trauma sensitive schools project, TRUST in Schools. 

What can be done? 

All children need to be helped to develop the skills to recognise, understand and manage their emotions. It will make a real difference to how they travel through life. Adults involved in the lives of children can do this by talking about: 

• their own emotions, including the difficult emotions. 
• ways to manage emotions and modelling positive ways to manage emotions. 
• how emotions get bigger and smaller and change over time. 

and also by: 

• helping children to label their emotions. You can say "you seem sad", or "you are yelling a lot, I think you are feeling angry". You don't have to get this right every time - the child will let you know if your guess is not correct! 
• suggesting ways that the child can manage their emotions: "Maybe if you talk to me about what is going on, you will feel better"; "Sometimes running and jumping around can help people feel better when they are angry". 
• making a real attempt to try to understand what is happening for the child and communicating to them that you care about them and how they are feeling. 
• not punishing children for some of the difficult behaviours that may arise out of their overwhelming emotions. 

Kidsmatter also have some great resources on helping kids with emotions. 

Social and emotional learning programs implemented at a school wide level and incorporated into the curriculum are also a great way to help all children to understand and manage their emotions, but these programs are additionally beneficial for children who have experienced adversity and trauma. 

Whether you are a parent or carer, a therapist, an educator, or someone else who works with children, we can all spend more time thinking about how to help kids build the skills they need to understand and manage their emotions. 

Domestic violence and children

We have heard so much in the media recently about the lasting and damaging impacts of domestic violence. Domestic violence is a long under acknowledged problem in all of our communities. It is mostly women who experience the dangerous, abusive and violent behaviours that is domestic violence. The Australian Bureau of Statistics has reported that almost 1.5 million women have experienced physical or sexual violence by a partner. When we look at these figures we know that this means that there are also many, many, many children who have witnessed this violence. 

Children do not need to directly experience physical or sexual abuse to be impacted by it. Being a witness to violence, living in a house that is permeated by fear, is enough to have a significant impact on the wellbeing of children. Children experience domestic violence in many ways. They may be a witness to violence, either by seeing what is happening or by hearing it. For many children, hearing the safety of their parent or carer threatened, especially when this occurs over and over again, will be a terrifying experience that stays with them forever. 

We know from so much research that has come out in recent years, that witnessing domestic violence potentially threatens children's physical and psychological wellbeing, as well as their social functioning, and their ability to engage at school and learn. Of course, all children are affected differently, and some children may be more resilient or have protective factors that mean that they will not be as greatly impacted. 

The potential impacts

Exposure to violence in the family has similar impacts on many children that are common to other experiences of adversity or trauma. We generally see these impacts in the area of a child's emotional functioning, mental health, relationships, development and learning. In fact, we know that some of these impacts may last past childhood and adolescence and into adulthood. 

Children exposed to domestic violence can live in a state of fear and heightened arousal. They may be overly anxious and sometimes see threat or danger outside of the home when there is none. These children may be easily startled or may become easily defensive and ready to protect themselves. They can frequently be very sensitive to the verbal and non-verbal cues that others express and may relate these back to their own experience. For example, at school, when a teacher raises their voice to gain the attention of the whole class, this may be perceived as a threatening situation and the response to this may be to try to escape the situation, to try to defend themselves or to withdraw and try not to be noticed. 

Children who live in environments where domestic violence is prevalent can also experience difficulties in their attachments and relationships. When children are on alert, they may misread the signals of non-threatening others, as described above, and this can get in the way of forming friendships and other relationships with significant adults, such as teachers.

We also know that children who are affected by domestic violence may have difficulties at school with learning. When children live in situations where stress is ongoing, it can flood their brains with stress hormones, such as cortisol, that can interfere with memory, concentration and executive functioning. This can mean that children may find it more difficult to concentrate, more difficult to remember instructions and what they have already been taught and more difficult to use skills such as problem solving in the classroom. All of this can interfere with a child's ability to learn and can possibly mean that they may miss bits of learning or start to slip behind their peers. 

Where to from here? 

Domestic violence is a serious issue that needs more attention in our society. We have outlined only some of the potential impacts of domestic violence on children above, there are certainly other impacts that we have not included here. The impact of domestic violence does not just end when the victims are safe and away from the perpetrator. The impacts can last through childhood, adolescence and on to adulthood. This makes it an even more crucial issue to be addressed. Reducing domestic violence also means reducing the incidence of mental health difficulties and learning difficulties that result for many children who are exposed. And the benefits of this can last a lifetime. 

For more information on the impact of domestic violence, and other adversities, on children, please visit our websites: 

For families - www.tgn.anu.edu.au

For people working with children - www.earlytraumagrief.anu.edu.au

Supporting children in response to the Sydney siege

The siege that we are seeing unfold in Sydney today will be having, and will continue to have a significant impact on many people around Australia. There has been building anxiety  that there will be deliberate harm done to people in public and the threat that this siege poses will touch on the fears of individuals, families and children. 

The nature of events, such as this siege, is that they are seemingly random, unexpected and take place in places where people go about their daily business with the belief that they are safe. And this is one of the factors that makes an event such as this trigger our fear. It threatens one of our core beliefs that we are essentially safe. 

Media coverage at times like this is important in providing people who are affected with news and information about loved ones, about where to go and when it is safe. Reading and watching the media coverage and following what is happening on social media leads to feelings of worry, anxiety and distress for most of us. It is normal to feel anxiety and sadness for those who are involved, their loved ones and others that are affected. We know, though, that for some people, this ongoing media coverage has the potential to lead to some more significant feelings of anxiety, worry and sadness. This can be especially true of children, who do not always have a good understanding of what they are reading about or witnessing in the media, and to some extent need to be protected from some of this ongoing coverage. 

When distressing events, such as this siege, are shown on TV, or covered on the radio or internet, parents need to be mindful of how much exposure their child has to this. The media can tend to focus on some of the more frightening aspects and images. Seeing this type of media coverage can cause distress or worry for children and young people. Children may also discuss these events amongst themselves, so even though children may not see images on TV, they may still be exposed through their conversations with others. 

Some of the ways this sort of media coverage can affect children and young people includes: 

• It can lead to children and young people thinking a lot about the event, which can impact on their sleep and can also impact on their concentration when they are at school. 
• It can cause worry and anxiety that the same thing may happen to them or their family. 
• It can lead them to feel generally unsafe and worried and that some other bad event may happen to them or their family. 

Families can help to support children at this time by: 

• Restricting the amount of media coverage children see of the event. 
• Watching media coverage with your child so that you are there to answer any questions they may have. 
• Helping to remind your child that they are safe and that you are there to answer any questions for them if they feel unsafe. 
• Giving support to your child if they are upset and comforting them. 

Many children may feel worried or anxious over the days to come, but for most this will settle. If your child has worries or sadness about this event that continues over the days and weeks, then it is good to speak with a health professional about how your child is going. 

The Trauma & Grief Network: Supporting Families website has lots of helpful information for families on helping children with the impact of trauma. Some helpful resources include: 

Disasters, the media and your child

Signs of possible trauma in children and adolescents

The strengths of children and families

The Australian Child & Adolescent Trauma, Loss & Grief Network website also has an extensive range of resources on the impact of trauma for people working with children. 

Trauma and the impact on children's education

There is a movement in the United States at the moment towards creating what are called Trauma Sensitive Schools. It is of course no surprise that when children experience trauma, many of them experiences difficulties at school. For some kids these difficulties will be short lived, but for others the difficulties will persist over time and significantly impact on their ability to learn, as well as their relationships at school. This is especially true for those children who live in environments where there is constant stress or ongoing abuse. 

Just some of the difficulties that these children may face at school include: 

• problems with concentration and attention
  
• difficulties with short term memory
• decreased ability to follow instructions in the classroom
• difficulties transitioning between activities and between teachers
• difficulties in managing their emotions
• problems trusting adults and teacher

For more extensive information on the difficulties that children may face in schools click here. 

In Washington State in the US, there has been an ongoing study looking at just how trauma and adversity impacts on children at school. Researchers worked with teachers to find out which children had experienced trauma at home. They asked teachers to identify children who had: 

• parents divorced / separated
• residential instability
• witnessed domestic violence
• been involved with child protection
• a family member in prison
• a family member with a substance abuse problem
• basic needs not met
• a family member with a mental health difficulty
• a family member with a physical disability
• been exposed to community violence
• a parent or caregiver who had died. 

They then looked at key areas in the child's schooling including whether the child was meeting grade expectations at school, attendance problems, behaviour problems and poor health. Not surprisingly they found that trauma and adversity in a child's life was strongly related to how the child was functioning at school. 

Children who experienced just one adversity were two times more likely to have attendance problems and 2.5 times more likely to have behaviour difficulties at school than those children who had not experienced any trauma or adversity. When they considered children who had three or more adversities present, the results were significant. These children were three times more likely to have academic failure; five times more likely to have attendance problems; six times more likely to have behaviour difficulties; and four times more likely to have poor health. Unless these difficulties are addressed within the school, children fall behind and some disengage from schooling altogether.

These findings have led to the implementation of programs to create schools that are trauma sensitive. A school that is trauma sensitive is one that builds meaningful relationships with students and parents or carers; create an environment of safety and predictability for all students; promote skill development for all students; help to build reasoning and problem solving; and add targeted supports where necessary. In order to do this, they start by building social emotional learning into universal practice across schools. All school staff are provided with professional development on social emotional learning and trauma informed practice. This assists teachers to look at new ways to address classroom management and to recognise and reduce triggers for trauma responses amongst students. 

The results of these trauma sensitive schools have been positive. There have been fewer behaviour difficulties in children and less suspensions and an increase in teachers satisfaction and self efficacy. This New York Times article provides a good overview of some of the interventions and the successes of the program. 

Of course, changing the way any system works takes time, knowledge, resources and a willingness for change. But it can be done. And considering that the long term benefits of children completing schooling include better physical and mental health, improved ability to participate in family life and more opportunities for employment and financial security, it seems crucial that we start to take steps to make schools a safe and engaging place for everyone. 

A cost effective way to help children after trauma

There is an increasing shift in community health to looking at more cost effective models to treat children and young people who have a range of mental health difficulties, including anxiety, depression and more recently post-traumatic stress. One of the models that is currently being trialled is a stepped care model. You can read more about the latest research on this here. 

Stepped care models provide treatments that are designed to minimise the use of therapist hours as well as costs, time and inconvenience to those participating in the therapy. Therapists provide treatment in steps according to the needs of the individual they are treating. Step 1 involves few therapist sessions, with clients working through material at home and accessing support as needed. Clients are monitored and assessed to determine if they then need more intensive treatment following Step 1, and if they do, they proceed to Step 2, involving an increase in one on one sessions with therapists. 

This is a particularly useful model to consider in the treatment of young children who have experienced trauma. There is often limited access to therapists who are well trained in treating symptoms of trauma in young children, and the services that they typically present to - community and public health systems - are often limited in terms of providing cost intensive treatments. Step 1 of the stepped care model for treating trauma, also puts the parent in the role of providing some of the treatment, an element which has been strongly supported in therapy with younger children. A potential barrier to treatment for parents of young children seeking or completing treatment is the parents desire to solve the problem related to the child on their own. With both parents and children both actively involved in therapy it is likely that it will be more successful. Some of the components of the intervention that has been trialled include: 

• 3 sessions with a therapist
• workbooks for both the parents and the child to work through at home that incorporates exposure tasks and relaxation exercises
• phone calls to therapist for support
• access to psychoeducation through online resources 

This is a promising development in the area of treating children affected by trauma, with the potential to allow greater access to children earlier in life. For more information on the latest research and news coming out in this area, subscribe to the Australian Child & Adolescent Trauma, Loss & Grief Network and visit our Journals section. 

A link between ADHD and trauma

A recent study by the American Academy of Pediatrics has found that children who have a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) are more likely to experience more adverse life events than those children without ADHD. The researchers involved in the study analysed data from the National Survey of Children's Health in the United States. They found: 

• 17% of children with ADHD experienced 4 or more adverse events compared to 6% of children without ADHD. 
• These children with 4 or more adverse events were more likely to be using medication to treat the ADHD. 
• The parents of these children with ADHD and 4 or more adverse events were more likely to rate their child's ADHD as moderate to severe. 

The adversities that were measured as part of the study included divorce; death of a parent or guardian; discrimination; domestic violence; mental health difficulties in the family; incarceration of a family member; neighbourhood violence; living in poverty; and substance abuse in the family. 

The results of this study are interesting for many reasons, especially given the ongoing public concern that there is an over diagnosis of ADHD in the community. 

Many of the symptoms that a child displays when they have been negatively impacted by an adverse or potentially traumatic event, are very similar to symptoms that children who are diagnosed with ADHD present with. These include symptoms such as difficulties in concentration and attention, difficulties in organisation, difficulties in relating to others and difficulties in behaviour. 

The study highlights the need that those working with children and young people need to be trauma aware and trauma informed. Unfortunately, there are some cases where children do get misdiagnosed and treating a child for ADHD when they are presenting with behaviours and symptoms of trauma is not meeting the needs of the child.