In focus: Trauma-informed care

Statistics tell us that 57–75% of Australians will experience a traumatic event at some point in their lives (Mills et al., 2001; Rosenman, 2002).

While many children grow up in safe and supportive environments, the insidious impacts of interpersonal trauma are still experienced by way too many.

Trauma can also be cumulative. Around 20% of Australian children are exposed to three or more adverse childhood experience (ACEs) (Olesen et al., 2010) – distressing situations they can’t control control (Burgermeister, 2007), like their parents’ financial or health problems, mental health struggles, marriage breakdown, or drug and alcohol issues.

So how does trauma effect children? And what can it mean for a child’s long-term mental health and wellbeing? Trauma has serious effects on the developing brain – impacts on comprehension, concentration and memory – and can lead to mental health difficulties, substance misuse, homelessness, unemployment … even things like increased rates of smoking, accidents and surgery (Australian Bureau of Statistics, 2019; Australian Institute of Family Studies, 2014; Blue Knot Foundation, 2021). It’s clear that left unchecked, the impacts of childhood trauma can last a lifetime.

For a generalist practitioner – often the first point of contact – a quick referral may seem the easiest way to deal with an anxious, aggressive, or uncommunicative child (or their parents). But with child psychologists’ waitlists ballooning out to three months and beyond, how can a practitioner help right now? And how can a practitioner, at any stage of the process, offer a child a sense of hope?

Taking a trauma-informed approach – building your engagement around curiosity, safety, trust, and transparency – is a good place to start.

Helping a child feel safe is the essence of a trauma-informed approach – because if a child doesn’t feel safe, there’s no way they’ll want to talk about what’s happened to them.

A curious, trauma-informed approach

Often, a child won’t mention a traumatic event: it might still be a secret, or too raw, recent or risky for them to bring it up. Children may fear for their safety, or the safety of loved ones. Sometimes these children can be withdrawn – or acting out – and the focus shifts towards responding to these obvious behaviours. Sometimes this helps, sometimes it doesn’t (Kezelman & Stavropolous, 2019) … but the underlying trauma usually come to the surface, further down the track.

Secrecy, fear and shame are common responses to trauma – powerful feelings that make it hard for practitioners to engage with children and start conversations that can lead to recovery. Taking a curious, trauma-informed approach can help practitioners understand a child’s daily experiences and the relationships that matter to them, and – eventually – can help a child talk about their concerns.

Curiosity – what you might call a ‘position of unknowing’ – is a real skill. Being curious asks you to step back from making quick assessments about a child – to keep an open mind, to watch, listen and wait.

Within a trauma-informed approach, curiosity isn’t about digging for answers or trying to get to the details of trauma, before the child is ready. It might mean that you never ask questions about the trauma – but that you recognise the signs, and open up opportunities for children to discuss their experiences without shame, or fear of being disbelieved.

A sensitive place to start can be to get to know a child by talking about some of the other things in their life: their school mates, their brothers and sisters, the things they’re good at, their football team, what they do on a Saturday morning … not just their behaviours. This gives you a look at the big picture – an understanding of the whole child, beyond just the trauma they’ve been dealing with. It can also help create the space, time and opportunity for the child to start to feel comfortable in their engagement with you.

When children are asked directly about trauma, they may breathe a sigh of relief: someone finally wants to talk about what’s happened to them! (Australian Child and Adolescent Trauma, Loss and Grief Network, 2017). But to reach this point can take time – a process that requires a strong relationship with the child, constructed around safety, trust and transparency.

In the following video (35 seconds), occupational therapist Ben Rogers talks about adopting a curious stance in practice.

Vimeo video: https://vimeo.com/560297722

Being curious asks you to step back from making quick assessments about a child – to keep an open mind, to watch, listen and wait.

Feeling safe enough to talk

Helping a child feel safe is the essence of a trauma-informed approach (Kezelman & Stavropolous, 2019) – because if a child doesn’t feel safe, there’s no way they’ll want to talk about what’s happened to them. Building a safe and supportive relationship is the key piece of the puzzle, helping to ‘defuse’ the things that have made them feel unsafe, physically or emotionally.

When you first meet with a child, take some time to watch their body language and facial expressions, to try and get a feel for where they’re at emotionally. As well as the more obvious ‘fight’ or ‘flight’ states – maybe swearing, aggression or turning away – a child could be in a ‘freeze’ state. They might be spaced-out, silent, or answering every question with a grunt or ‘I don’t know’ (Guy, 2020): they put up their defences and won’t let you in. To break through these barriers, try slowing things down and joining them in a quiet activity – maybe drawing or making something crafty.

Where a child feels threatened or unsafe, it’s also difficult for them to start talking: you’ll have to work harder to make them feel safe. This might mean using a physical activity – jumping up and down, doing some stretches or throwing a ball around – to try and burn off some of that ‘fight’ or ‘flight’ energy. Or maybe it means spending some time playing a game or doing a drawing with them until they’ve calmed down.

You should also check-in with your own emotions: think about your tone of voice, your body language and your facial expressions. It’s important that you’re sending out clear signals of safety to the child (Guy, 2020).

In the next video (45 seconds), child psychologist Lisa Johnson talks about constructing a sense safety for a child in the practice setting.

Vimeo video: https://vimeo.com/560298286

Building trust

When a child has had their trust betrayed by someone they know and love, they’re going to have a hard time trusting you – it’s a fair response, and a child’s safety may depend on their wariness. To help rebuild their trust, try to place the child at the centre of your engagement. This is an essential part of a trauma-informed approach – a deliberate decision to focus on what the child needs most from you, and from your sessions together. As the adult in the room, this means stepping back from controlling everything and allowing yourself to be guided by the child – who is, after all, the most important person involved.

Children are also probably going to be anxious about meeting with you (Bernard, 2016). In these situations, helping a child understand the ‘intent and purpose’ of your work together is important. Without having a handle on this stuff, a child might think that you’ll try to ‘fix’ them, tell them off, get their parents into trouble, or ship them off to yet another counsellor. But once they know why they’re meeting with you, and have some idea about the rules of engagement, they’ll be more likely to trust you and begin to open-up about what’s happened to them.

Building trust also means being crystal clear about the boundaries around privacy, confidentiality, and mandatory reporting. If you can explain your position on these to a child using language they can easily understand, you’ll be setting up a clear, open pathway for your conversations.

In the following podcast excerpt (36 seconds), speech pathologist Kate Headley talks about building trust when engaging with children.

Kate Headley, Speech Pathologist

Around 20% of Australian children are exposed to three or more adverse childhood experience (ACEs) – distressing situations they can’t control control.

Being transparent

Children often have very little power or control in traumatic situations. Some forms of childhood trauma, like physical or sexual abuse, actively exploit this helplessness and lack of control.

An effective way to re-empower children and create a fair and equal relationship is to be transparent in your engagements. If a child has been referred to you, this can mean letting the child know what you know – sharing the details of the referral, and shining a light on whether the child’s version of events matches up with the one that’s been described to you.

Being open and transparent like this recognises the child’s right to be heard, and part of making decisions about things that affect them. Giving children a choice in the way conversations happen – what gets talked about, when, and for how long – is a great way of restoring their sense of control (Guy, 2020), so that they can start to feel comfortable about sharing their story.

In the next short video (23 seconds), child psychologist Jessica Warren discusses being transparent with children in practice.

Vimeo video: https://vimeo.com/560299247

Trauma-informed care involves having an understanding of the profound psychological, social and physical effects that trauma and adversity can have. It asks you to think about a child’s whole environment and their experiences, and how their behaviours might be seen as responses to trauma, rather than pathologies (Herman, 1992).

At the very least, taking a trauma-informed approach is a good way of working respectfully with a child who’s already in distress. And when your conversations are built around a ‘curious’ standpoint – with the emphasis on safety, trust and transparency – trauma-informed care can help a child move past fear and hopelessness, and feel safe enough to talk about what’s happened to them.

Trauma-informed care involves having an understanding of the profound psychological, social and physical effects that trauma and adversity can have.

Resources

Emerging Minds has a range of resources – including e-learning courses, podcasts, webinars and practice papers – specifically addressing trauma-informed care, including the following:

References

Australian Bureau of Statistics. (2019). Personal safety, Australia, 2016: Characteristics and outcomes of childhood abuse. Cat. 4906.0. Canberra: ABS. Available here.

Australian Child and Adolescent Trauma, Loss and Grief Network. (2017). Talking to children and young people about trauma. Canberra: Australian National University. Available here.

Australian Institute of Family Studies. (2014). Effects of child abuse and neglect for children and adolescents. Melbourne: AIFS. Available here.

Bernard, M. (2016). How does childhood trauma affect trust? Practical Psychoanalysis: PsychCentral.

Blue Knot Foundation. (2021). Impacts: What are the impacts of child abuse and childhood trauma? Sydney: Blue Knot Foundation. Available here.

Burgermeister, D. (2007). Childhood adversity: A review of measurement instruments. Journal of Nursing Measurement, 15(3), 163–176.

Guy, S. (2020). Making use of practitioners’ skills to support a child who has been sexually abused. Adelaide: Emerging Minds. Available here.

Herman, J. (1992). Trauma and recovery: From domestic abuse to political terror. London: Pandora.

Kezelman, C.A. & Stavropolous, P.A. (2019). Practice guidelines for clinical treatment of complex trauma. Sydney: Blue Knot Foundation. Available here.

Mills, K.L., McFarlane, A.C., Slade, T., Creamer, M., Silove, D., Teesson, M. & Bryant, R. (2011). Assessing the prevalence of trauma exposure in epidemiological surveys. Australian and New Zealand Journal of Psychiatry, 45(5), 407–415.

Olesen, S.C., McDonald, E., Raphael, B., & Butterworth, P. (2010). Children’s exposure to parental and family adversities: Findings from a population survey of Australians. Family Matters, 84, 43–52.

Rosenman, S. (2002). Trauma and posttraumatic stress disorder in Australia: Findings in the population sample of the Australian National Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry, 36(4), 515–520.

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