Therapeutic engagement with children & young people

1. Therapeutic engagement with children & young people Dr Robyn Miller Chief Executive Officer MacKillop Family Services

2. Understanding trauma The DSM-IV defines traumatic events as those which “… involve actual death or physical injury, or threat to the body integrity of oneself or other people.” The World Health Organisation’s health classification system, the ICD-10, describes these events as “…exceptionally threatening or catastrophic and likely to cause distress to almost anyone.”

4. The prevalence of trauma Research suggests that exposure to adverse, potentially traumatic events in childhood is not uncommon: The Adverse Childhood Experiences (ACE) study in the USA showed that of 17,337 respondents, 64% had experienced at least one adverse experience and approximately 12% had experienced four or more in the first 18 years of life (Anda et al., 2006). A 2015 suggested that childhood trauma affects an estimated five million Australian adults (Kezelman, Hossack, Stavropoulos, & Burley, 2015). A great deal of evidence associating traumatic experiences with a broad range of deleterious outcomes in childhood, adolescence and adulthood (e.g. Anda et al., 2006; Dube et al., 2001; Hahn Fox, Perez, Cass, Baglivio, & Epps, 2015; Johnson-Reid, Kohl, & Drake, 2012; Nurius, Green, Logan-Greene, & Borja, 2015). (Adapted from Wall, Higgins and Hunter, 2016)

5. Although the overall children population in Australia increased by just 9% between 2004-05 and 2013-14 the number of children in Out of Home Care across Australia increased by 82% over the past decade Royal Commission into Institutional Responses to Child Sexual Abuse, Consultation Paper, March 2016

6. International studies demonstrate that children with disability, particularly those with intellectual disability, communication impairments, behaviour difficulties, and sensory disability are at significantly increased risk of being maltreated including sexual abuse. L Jones et al, ‘Prevalence and risk of violence against children with disabilities: a systemic review and meta-analysis of observational studies’, The Lancet, 2012, vol 380, no 9845, p 905; P Sullivan & J Knutson, ‘Maltreatment and disabilities: a population-based epidemiological study’, Child Abuse & Neglect, 2000, vol 24, no 10, pp 1265 1266.

7. Children with disability are at a heightened risk of sexual assault by professionals, non parental figures and other children compared to children without a disability. S.F. Grossman & M Lundy, ‘Double jeopardy: a comparison of persons with and without disabilities who were victims of sexual abuse and/or sexual assault,’ Journal of Social Work in Disability and Rehabilitation, 2008, vol 7(1), pp 19–46.

8. Children with disability are around three times more at risk of sexual abuse than children in the overall population. P O’Leary, E Koh & A Dare, Grooming and child sexual abuse in institutional contexts, report prepared for the Royal Commission into Institutional Responses to Child Sexual Abuse, Sydney, 2017, pp 13–4.

9. Children with disability are also more likely than other children to have experienced repeated incidents of sexual abuse by the time they are 18 years old. R Wortley & S Smallbone, ‘Applying situational principles to sexual offenses against children’ in R Wortley & S Smallbone (eds), Situational prevention of child sexual abuse: Crime prevention studies (volume 19), Lynne Rienner Publishers, London, 2006, p 14. In a study by Smallbone and Wortley, 23 per cent of the sample were identified as persistent sexual offenders, including 5 per cent who had previous convictions for sexual offences only, and 18 per cent who had previous convictions for both sexual and non-sexual offences.

10. Of the 57 young people reviewed in MacKillop’s, Outcomes 100 process, almost half have a diagnosed disability or a learning disorder

11. Complexity Of Adaptation To Trauma Extreme arousal associated with trauma is accompanied by dissociation and the loss of capacity to put feelings into words (alexyithymia and somatisation) Adaptations to trauma can include problems with self efficacy, shame and self hatred and interpersonal conflicts

12. Affect dysregulation The lack or loss of self-regulation is possibly the most far reaching effect of trauma. ‘The most significant consequence of early relationship trauma is the lack of capacity for emotional self regulation and the loss of ability to regulate the intensity and duration of affects’ (Schore, 2002).

13. Childhood abuse as trauma: Schore (2001) in comprehensive research on right brain development and relational trauma, also suggests that chronic and cumulative emotional abuse by an attachment figure is the underlying foundation of childhood trauma. ‘The most pernicious trauma is that trauma inflicted in a relationship where the traumatised individual is dependent… (Allen, 1995)’.

14. The Pattern of Trauma

15. The Pattern of Trauma

16. Some practice implications following acute trauma: The need to ensure the trauma is over The need to provide meaningful and lasting supports as soon as possible The need for routine and consistency as soon as possible The need to assess over time if the child is still stuck in the trauma experience. If the trauma is not over in their mind, regardless of the reality – then more specific therapeutic intervention is required (in addition to – not instead of their support systems) We need to reduce or remove the possibility of secondary trauma where our own actions can increase the experience of being overwhelmed for the child

17. Organisational Change Change from the old paradigm that sees organisations as machines… to seeing the organisation as a living system. Dr Sandra Bloom

18. RELATE creates a culture of safety, inclusion and wellbeing for optimal learning and growth across the whole school.

19. Shared Understanding Trauma Theory Neuroscience Therapeutic Crisis Intervention Attachment Theory Systems Theory Education Theory Promotes shared knowledge

20. Trauma Re-Enactment

21. Shared Knowledge Informs Culture ‘What has happened to you?’ - Not ‘What is wrong with you?’ (Dr Sandra Bloom) “Students do well if they can” (Dr. Ross Greene) Unconditional Positive Regard (Dr. Carl Rogers)

22. Promotes a shared language Dr. Sandra Bloom, 2013

24. DE-ESCALATION Reading the Level of Stress Martha Holden, 2012, Therapeutic Crisis Intervention for Schools

25. DE-ESCALATION Responding Appropriately to the Level of Stress - Agitation Managing the environment Prompting Caring gestures Hurdle help Redirection and distraction Proximity Directive statements Martha Holden, 2012, Therapeutic Crisis Intervention for Schools

26. Safety Plan

27. Safety Plan

28. Challenging Behaviours: Flight, Fright, Freeze Dr. Dan Siegel

29. Co-Regulation to Support Self-Regulation Dr. Dan Siegel

30. Enhanced Outcomes Attendance Figure 1.1 MacKillop School Student Attendance, as of Term 3 2018

31. Enhanced Outcomes SAFETY

32. Best Interests Case Practice Model:

33. How do we deal with very normal errors in individual reasoning? Confirmation bias: once we have formed an opinion, we are slow to revise it; we are more likely to notice evidence that supports it and overlook or interpret ambiguous evidence in a way that confirms rather than challenges our opinion. Representativeness heuristic: assessing people or objects based on their similarity to the standard for that category. Most people working in children’s services are caring and well motivated in their actions towards children. The default position is to think well of a new colleague. Hindsight error: Once we know what happened, we over‐estimate how obvious it was (or should have been) to those involved at the time.*

34. Critical Reflection is Crucial ‘Workers should be searching for the truth with an open mind, testing the conclusions they reach……Unlike barristers, defending one particular point of view…. “The single most pervasive bias in human reasoning is that people like to hold onto their beliefs.” (Munro, 2002) Are we overly optimistic or overly pathologising? What else should/could we be doing?

35. Trauma-informed model of care The available literature suggests that there is a continuum from being trauma aware (seeking information out about trauma and its implications for organisations) to being trauma-informed (a cultural shift at the systemic level). One useful resource sets out the progression in four stages: trauma aware: seek information out about trauma; trauma sensitive: operationalise concepts of trauma within the organisation's work practice; trauma responsive: respond differently, making changes in behaviour; trauma informed: entire culture has shifted to reflect a trauma approach in all work practices and settings. (adapted by Quadara from Mieseler & Myers (2013)

36. Trauma-informed model of care Responds by fully integrating knowledge about trauma into policies, procedures and practices and seeks to actively resist retraumatisation (SAMHSA, 2014, p. 9) Clients ‘bad’ behaviour acknowledged as being adaptive behaviours to trauma that have become maladaptive over time (Hopper, Bassuk, & Olivet, 2010; Markoff, Fallot, Reed, & Elliot, 2005).

37. Poor institutional culture Can prevent abuse from being disclosed Children who complained were punished, disbelieved or accused of lying, and no further action was taken. A failure to enforce and educate staff on existing child protection policies Not accepting that there were systemic failures to protect children in the institution through recruitment and staff training Leaders actively denied responsibility for the abuse that occurred and working to insulate the institution from outside threats (Royal Commission into Institutional responses to Child Sexual Abuse, 2017a: 149)

39. Defining a child safe institution Child safe institutions create cultures, adopt strategies and take action to prevent harm to children, including child sexual abuse. We have adopted a definition of a child safe institution given by the Royal Commission, as one that: consciously and systematically creates conditions that reduce the likelihood of harm to children creates conditions that increase the likelihood of identifying and reporting harm and responds appropriately to disclosures, allegations or suspicions of harm.

40. Child Safe Standards The Royal Commission published 10 Child Safe Standards to protect children Adapted by National Catholic Safeguarding Standards to be implemented into Church entities in Australia

41. The 10 standards that would make institutions safer for children: Child safety is embedded in institutional leadership, governance and culture Children participate in decisions affecting them and are taken seriously Families and communities are informed and involved Equity is upheld and diverse needs are taken into account People working with children are suitable and supported Processes to respond to complaints of child sexual abuse are child focused Staff are equipped with the knowledge, skills and awareness to keep children safe through continual education and training Physical and online environments minimise the opportunity for abuse to occur Implementation of the Child Safe Standards is continuously reviewed and improved Policies and procedures document how the institution is child safe. (Royal Commission into Institutional responses to Child Sexual Abuse, 2017a: 12)

42. Focusing on Culture (Standard 1) From the Australian Royal Commission into Institutional responses to Child Sexual Abuse : “An institutional culture where the desire to protect an institution’s reputation was stronger than the desire to protect the interests of children has been frequently illustrated in our case studies” (Royal Commission into Institutional responses to Child Sexual Abuse, 2017a: 149)

43. The Seven C’s of Reform Leadership (Miller, R, PhD Thesis 2014)

44. Action Research – Respecting Sexual Safety Partnership between MacKillop Family Services and University of Melbourne Three prevention strategies: Whole-of house respectful relationships & sexual education Missing from home strategy Sexual safety response Trialling these strategies in four MacKillop residential homes & 20 foster care families Generating and sharing evidence about what works, when & for whom Philanthropic funding ongoing for next 3 years

45. ‘If in ten years’ time, you have every policy and procedure in place, and you meet every mandatory standard, but you do not have a genuine culture of safety then you will fail. What we have seen over the decades is that bad culture breeds bad conduct’. We must all take responsibility for developing and sustaining healthy cultures where our values are lived and walked each day, and celebrate the people who are champions of excellence.’ Fitzgerald, R (21 March 2018)

46. The Sanctuary Model – establishing a culture of safety The Sanctuary Model is an organisational change model that integrates trauma theory with the creation of therapeutic communities to promote safety for service users, volunteers and staff

47. The Sanctuary Model – establishing a culture of safety S.E.L.F. Framework Seven Commitments Trauma Theory Sanctuary Tools

48. The Sanctuary Model – establishing a culture of safety The Seven Sanctuary Commitments: Social Responsibility Nonviolence Emotional Intelligence Democracy Social Learning Growth and Change Open Communication

49. Keep me away from the wisdom which does not cry, the philosophy which does not laugh and the greatness which does not bow before children

50. We listen to the voice of children and the language of their behaviours.