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How to identify trauma in children and what you can do about it

Tips for general practice nurses, school nurses and health visitors on how to pick up on and alleviate emotional trauma in young people

Tips for general practice nurses, school nurses and health visitors on how to pick up on and alleviate emotional trauma in young people

  • Adverse childhood experiences include verbal, physical and sexual abuse, and neglect
  • Children may feel uncomfortable talking about trauma to their friends or teachers
  • Nurses in these roles need to make more of their own potential for tackling these issues
Boy drawing as part of therapy. School nurses, health visitors, and general practice nurses are often in a position to identify the damage due to trauma from adverse childhood experiences and the effect on children’s mental health.
Picture: iStock

School nurses, health visitors and general practice nurses are often in a position to identify the damage due to trauma from adverse childhood experiences and the effect on children’s mental health, says Queen’s Nurse and RCN fellow Ruth Oshikanlu.

‘Often, I’ve found that you just need to probe slightly and the whole surface bravado crumbles, so that you find that a child has been bullied or there is something going on in their home life,’ says Ms Oshikanlu.

A nurse, midwife and health visitor, she has been awarded a Churchill Fellowship for 2019 to research ways of supporting children who have had adverse childhood experiences. The findings from her project, for which she plans to visit Australia and the US, will contribute to work on supporting children through the trauma inflicted by those or similarly damaging experiences.

Peers may be perpetrators

Not all trauma is inflicted by domestic circumstances, or indeed by adults, says YoungMinds director of evidence and policy Marc Bush. ‘School nurses in particular need to remember that sometimes it’s peer-on-peer. And when it is, it is exceptionally likely that the other person has experienced a form of adversity or trauma themselves.’

Defining the problem and its effects

Adverse childhood experiences include:

  • Verbal, physical and/or sexual abuse
  • Physical and/or emotional neglect
  • Parental separation
  • Mental illness, domestic violence, drug abuse and/or alcohol abuse in the household
  • Having a household member in prison

A report by the young people’s mental health charities YoungMinds, the Anna Freud Centre and Body & Soul extends the definition to issues such as discrimination, household substance misuse and bereavement, while making the point that the term ‘trauma’ refers to the impact on mental health of adverse childhood experiences.

A significant proportion of the UK population has experienced adverse childhood experiences, often with long-lasting effects on physical and mental health.

The effects also become self-perpetuating. People who have had such experiences may find their own parenting affected, although this is not inevitable.

Lack of support for infants

Although the first 1,001 days of a child’s life are widely recognised as determining a great deal of their lifelong physical and mental health, there is little provision in the UK for supporting infants who are experiencing trauma.

The charity Parent Infant Partnership UK said in a recent report that it found only 27 specialised parent-infant teams across the entire UK, while most child and adolescent mental health service provision starts at the age of two.

The charity is campaigning to extend this provision, but in the meantime there is access to infant mental health skills training from specialised teams at charities such as Oxford Parent Infant Project (OXPIP), Warwick Medical School and the Solihull Approach.

 

Health visitors and school nurses best placed to spot children experiencing difficulties

RCN professional lead for children and young people’s nursing Fiona Smith says school nurses and health visitors are often best placed to identify those who may be experiencing difficulties. ‘They may not be always be comfortable speaking about it to their friends or even their teachers.’

Institute of Health Visiting director of policy and quality Alison Morton says adverse childhood experiences are not new for health visitors. ‘It’s more that this has brought a common language to our work. Health visitors are trained in recognising the signs of abuse and neglect.

‘It’s a matter of being aware of those and understanding how they play into adverse childhood experiences. We have two important roles: trying to prevent adverse childhood experiences in the first place, by supporting parents, as well as identifying and supporting a child who is experiencing trauma.’

Useful ways to think about trauma

Trauma manifests in different ways, depending on what has caused it, but there are some broadly useful ways to think about it.

Head and shoulders picture of Ruth Oshikanlu, a Queen’s nurse and RCN Fellow whose project will contribute to work on supporting children through trauma.
Ruth Oshikanlu Picture: David Gee

Ms Oshikanlu says: ‘A child who wants to hide trauma will hide it well, but we always talk about professional curiosity. The beauty of being a general practice nurse is that we also have family histories. If you know that there are adverse childhood experiences in the family, and that the child has experienced those things, be more curious. Above all, it’s essential to establish communication.’

YoungMinds director of evidence and policy Marc Bush says: ‘The most common behaviour sets are those relating to acting out – seeming very angry, becoming very confused and disoriented and so on – but there’s also acting in, where a child might be trying to please or really bond with you, invading your boundaries very fast.’

‘If it seems that a child is very distant, or you have a sense they don’t trust you –  or seemingly they have no boundaries and don’t seem to be able to distinguish you from their own parent, or anyone else – that may be an indication too.

‘What is most important is remembering that across all the age range, even if they are interacting with you in a way that seems that they like you, they may in fact perceive you as a threat and be adjusting their behaviour accordingly.’

Karen Bateson of the charity Parent Infant Partnership UK (PIPUK), stresses the importance of communication between parent and child. ‘Because we know that trauma has an impact on the nervous system, the main way babies will communicate that is through manifestations of dysregulation.

Some of the most common manifestations of trauma

Anxiety Children can become anxious after certain events, and experiencing adversity and trauma can heighten these feelings of insecurity and lack of control

Avoidance Active attempts to avoid anything that could be connected to the traumatic experiences

Depression and low self-esteem Children may start to withdraw, and become increasingly isolated

Dissociation Reaction to events with what seems the opposite to hyperarousal by blocking off thoughts, feelings or memories

Hyperarousal Trauma can leave children with the belief that they are vulnerable or powerless, and that other people are potential threats

Intrusive Memories of traumatic events that are volatile and vivid, and are easily triggered

 

‘Their ability to regulate themselves is either over or under-reactive – they may be unusually difficult to soothe or will sleep a lot of the time. They may be actively avoiding face-to-face contact, because they have already learned that seeking comfort from the adult doesn’t lead to feeling regulated again.

‘All babies cry, and all parents have moments of exasperation, but what you are looking for is whether over time the baby and the parent-carer can get into tune with each other.’

Nurses need to make more of their own potential for tackling adverse childhood experiences

Once identified, it’s an issue of referring on. ‘Look for services that are specifically dedicated to young people, which cover issues like sexual health and well-being,’ suggests Ms Oshikanlu.

‘We need to seize the opportunities to influence the agenda – because this work is so important’

Ruth Oshikanlu

Nurses in these roles need to make more of their own potential for tackling adverse childhood experiences, and maximise their own position. ‘General practice nurses need to think about how to start those conversations with patients, how they can use this opportunity genuinely to make that contact count – and how they can influence the GPs they work with.

‘School nurses could go directly to the commissioning services to explain the significance of what they do. We don’t always influence as much as we should. But it’s not enough simply to move on to another service if your own is cut.

‘We should be speaking to clinical commissioners, and to whoever has the purchasing power, and if possible write a business case for our work. We need to seize the opportunities to influence the agenda – because this work is so important.’

The physical legacy of childhood trauma

A meta-analysis in 2015 of 25 studies featuring over 16,000 people found that childhood trauma can affect the immune function, leading to increased levels of inflammation in the system.

This may be one major factor in why people who have experienced childhood trauma are more prone to physical and mental health problems in later life, since high levels of inflammation are associated with psychiatric disorders and conditions such as type 2 diabetes and cardiovascular disease.

The researchers also found that different types of trauma were associated with different biomarkers in the blood – physical and sexual abuse were associated with one specific factor, while parental absence during early childhood was associated with another.


Radhika HolmstromRadhika Holmström is a health writer

 

 

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