By Dr Sheena Webb
Children with adverse experiences
Most children involved with the Family Drug and Alcohol Court (FDAC) have experienced a long period of instability and adversity prior to entering the service. Returning to a safer home environment, with parents who are no longer using substances, is clearly beneficial but the psychological legacy of the child’s experience remains.
Children exposed to neglect and maltreatment carry a ‘latent vulnerability’ which may not express itself until later in their life. Many of these vulnerabilities do not manifest in a way that fits within the diagnostic frameworks used to access child mental health interventions. As such, they often constitute a ‘hidden harm’ that has a pervasive and negative impact on the child’s developmental trajectory. By adulthood this may lead to irreversible and entrenched psychosocial problems.
We know from the Adverse Childhood Experiences (ACE) study (Felitti et al., 1998) that the impact of suffering adversities in childhood leads to increased risk of serious physical and mental health conditions in adulthood. For instance, a male child with an ACE score of six or more is 46 times more likely to become an intravenous drug user in adulthood than a child who has not experienced adversity.
Children who have gone through proceedings, even those who have returned to safe homes, are at increased risk of difficulties during their development into adulthood. The support systems (for example, mental health services for young people or CAMHS) are not set up to recognise these latent vulnerabilities, nor to intervene early. Intervention tends to only be initiated once problems have become ‘clinically significant’.
Providing aftercare to children who return home
We believe that we have an opportunity to intervene earlier with this group of children to alter their trajectory and mitigate the effects of their earlier exposure to adversity. We want to trial aftercare support for FDAC children who remain with or return home to their birth families.
Currently, it is unlikely that a child will access treatment beyond the end of proceedings due to the barriers they will face in accessing appropriate services. The barriers include:
- referrals (from FDAC) to treatment services are often rejected by agencies because the child’s needs are deemed ‘sub-threshold’
- many areas do not have types of services that the child needs
- the under-resourcing of CAMHS and consequent gate-keeping of treatment services for children with a diagnosable mental health condition. FDAC children are likely to present atypically and the classification for a mental disorder (DSM-5) does not have a diagnostic framework that adequately describes the impact of cumulative and complex trauma across the developmental period.
We believe that a trauma-informed approach to helping these children would work. Trauma-informed approaches are gaining recognition as a way of providing a context for the healing of people affected by complex trauma. The approach recognises that the cognitive and emotional vulnerabilities of individuals can often be misunderstood. It also aids accurate diagnosis so that children receive the most effective treatment.
There are six core areas in the recovery from complex trauma (Spinalozza et al., 2007). FDAC bases most of its intervention on the first area of recovery – safety. Many of the other areas can be achieved outside of a clinical room, for example in education. Trauma therapy is only one part of the picture and experts recommend that this work should only occur once there is a good foundation of safety, relationships and coping skills.
FDAC want to provide a range of interventions designed to promote healing and resilience in children remaining with birth families after proceedings. We want to develop and deliver a new, individually tailored approach for the needs of the child. Our interventions would include:
- a consultation with practitioners working with the child (for example family support workers) about the likely impact of complex trauma for the child
- a consultation with parents to help them understand how complex trauma might manifest within the home and how to respond
- sessions with the parent and child together to open a conversation around repair and recovery post-proceedings
- sessions with the child around emotional management skills
- sessions with the child using a form of narrative exposure therapy to help them process their experiences
- Art and music therapy sessions with the child to help them to self regulate and develop an emotional vocabulary.
The London FDAC team is a partnership between the Tavistock and Portman NHS Trust and Coram. The FDAC team works with 60 families every year across ten local authorities and three family courts. FDAC is a problem-solving court approach to improving outcomes for children and families involved in care proceedings. Research has shown that FDAC children’s outcomes are dramatically better than ordinary care proceedings. More about FDAC can be found here: www.coram.org.uk/supporting-parents/family-drug-and-alcohol-court
Dr Sheena Webb
Sheena has 14 years’ experience as a clinical psychologist working with children and families. She specialises in therapeutic, trauma-informed family court assessments and is the London FDAC team manager. Previously, Sheena worked in a local authority court assessment team. Sheena’s work is focused on complex family risk and capacity for change. Sheena delivers training nationwide about trauma-informed approaches.
Felitti, Vincent J.; Anda, Robert F.; Nordenberg, Dale; Williamson, David F.; Spitz, Alison M.; Edwards, Valerie; Koss, Mary P.; Marks, James S. (1998). Adverse Childhood Experiences. American Journal of Preventive Medicine. 14 (4): 245–258
Spinazzola, J, Cook, A., Ford, J., Lanktree, C., Blaustein, M., Sprague, C., Cloitre, M., DeRosa, R., Hubbard, R., Kagan, R., Liatuad, J., Mallah, K., Olafson, Erna & van der Kolk, B. (2007) Complex Trauma in Children and Adolescents. Focal Point, 4-8
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