Responding to Traumatic Incidents in Schools

transcript

Nick DurbinJoint Programme Director Senior Educational PsychologistUniversity of Nottingham Warrington BCDoctorate in Applied Educational Psychology

Aims of Session

Develop awareness and knowledge of the psychosocial impact of traumatic incidents on children and schools

Examine current theory and the evidence base for practice

Explore what is known to support those affected by traumatic incidents in schools

Develop your understanding of how educational psychologists work as a part of a team to plan for, and support those affected by traumatic incidents

Overview of the Session

Definitions and Impact of Trauma

Rationale for Support and Intervention

Levels of Response and Support

EP practice and Involvement

Educational Psychology:Levels of Involvement

Community

Organisation

Ind’l

What is a Traumatic Incident? An incident charged with profound emotion

may involve serious injury or death Incident generating a high level of immediate

or delayed emotional reaction Incident involving serious threat or extremely

unusual circumstances Incident attracting unusual attention from the

community or media Surpassing an individual, group or

organisation’s normal coping mechanisms

Case Study 1: A School Visit Bus Crash

Issues?

Contacts?

Actions?

Bush crash close to school 70 Y6 pupils some with serious

injury Taken to 2 Hospitals 10 adult staff and helpers also

on trip some with injury 140 concerned parents 200 other pupils at school 20 staff and governors 3 emergency services Local authority managers

contact EPs ask them to respond

Rationale for Critical Incident Support Understand the Impact of Trauma

– Individuals– Organisations

Plan for Peoples’ Reactions and Needs Manage an Organisation and

Community Response ‘Wise before an Event’ rather than after

it (Yule and Gold, 1993)

Aims of the Critical Incident Support

Attempt to Minimise Impact

Ensure Appropriate Support

Co-ordinate Responses

Support Normal Processes

Case Study 1: A School Visit Bus Crash Bush crash close to school 70 Y6 pupils some with

serious injury Taken to 2 Hospitals 10 adult staff and helpers

also on trip some with injury 140 concerned parents 200 pupils at school 20 staff and governors 3 emergency services Local authority managers

and services

Trauma: Some Considerations Theory

• definitions

• signs and symptoms

Impact and Intervention• individual

• groups

• organisation and community

Evidence• research

• practice

Traumatic Incidents: Impact and Intervention

Community

Organisation

Individual

Common Reactions to Trauma

Feelings of denial Distress Guilt Anger Helplessness Re-experiencing events Avoidance Arousal (high or low)

Common reactions (continued)

Flashbacks and intrusive memories Headaches Difficulty concentrating Feeling guilty ‘it was my fault’ Feeling detached from others

Common reactions (cont’d)

Numbness Anxiety Feeling on edge and Hyper-vigilant Depression Irritability and anger Sleep disturbance, nightmares

Peoples’ Reactions and Needs

Reactions vary depend• Age• Experience• Personality• Nature of the incident • Degree of involvement

Definitions of Post Trauma Stress

“The development of certain characteristic symptoms following a psychologically distressing event which is outside the range of normal human experience” (APA, DSM 1987)

Post Traumatic Stress

And ………

“The normal reactions of normal people to events which, for them, are unusual or abnormal” (Parkinson, 1993)

Post traumatic Stress Disorder

Occurs when symptoms of PTS emerge later, persist or intensify long after the event. i.e. more than six weeks - and disrupt normal living

Involves three aspects:Re-experiencing, Avoidance and Arousal

(DSM IV, 1993)

DSM IV Symptom CriteriaRe-experiencing

(one required)

Avoidance

(three required)

Arousal

(two required)Distressing memories

Distressing images

Distressing thoughts

Distressing dreams

Feeling it is recurring

Illusions

Hallucinations

Flashbacks

Distress on exposure to trauma triggers

Physiological reactivity on exposure to trauma triggers

Thoughts

Feelings

Conversations

Activities

People

Places

Inability to recall aspects of the event

Reduced interest in usual activities

Feeling detached or estranged from others

Restricted range of affect

Sense of foreshortened future

Difficulty with sleeping

Irritability

Difficulty with concentrating

Hyper-vigilance

Exaggerated startle response

Trauma, PTS and PTSD

Dose = Symptoms

‘ The vast majority of people exposed to serious traumatic events do not develop PTSD’ (McNally, 2003)

Normal Features of GrievingPhase Symptom Tasks Methods

1.Denial Shock, disbelief, Sense of unreality

Accept reality of loss

Facing loss by e.g. ritual, talking about it

2. Pain

Distress

Anger, guilt, worthlessness searching

Key task to experience pain of grief

Weeping, raging, talking about loss

3 Realisation

Depression, apathy, fantasy ‘if only

Adjust to life without deceased

Resolving practical issues

Making sense

4. Resolution

Hindmarch (1999)

Readiness to engage in new activities relationships

Re-invest emotional energy in new relationships

Looking to new activities and people exploring new options

Stages of Response and Recovery

1. Shock2. Denial3. Emotional Impact4. Working Through5. Acceptance6. Normal reactions7. Pre- trauma Stability8. Post trauma Stability9. Traumatic Incident

Adapted from Queensland Dept of Education

Some common needs

Information, acknowledgement opportunity to talk formal and informal rituals recognition routines and normality return and reintegration

Evidence based treatment for Individuals with PTSD NICE (2006) guidance suggests the

importance– Psychological first aid – Watchful waiting– Trauma focused CBT – Eye Movement Desensitisation Reprocessing

(Shapiro,1993)– CBT has slightly better evidence base in children

than EMDR (Wolpert,M et al, 2006)

Psychological treatments for adults Interventions need to be focused on trauma

and structured:– Trauma focused CBT

– Helps confront traumatic memories with less fear– Modify misinterpretations which overestimate threat– Develop skills to cope with stress.

– Eye movement desensitisation and reprocessing– PTSD sufferer is asked to recall an important aspect of the

traumatic event– Wilst following repetitive side to side movements, sounds or

taps as the image is being focused on » (NICE, 2005 PTSD guidance)

In children and young people

Diagnosis is the same as adults Symptoms may differ in younger children may

include re-enacting, repetitive play, emotional and behavioural difficulties.

Intervention of choice is currently trauma focused CBT

Need for better evidence base and audit of all interventions

» (NICE PTSD guidance 2005)

Community

Organisation

Ind’l

Case Study 2: Death in the Playground 12 noon Pupil aged 7

years Suddenly falls and hits

head in the playground Pupils alert staff who

give first aid Ambulance is called Parent informed Ambulance arrives but

pupil has died before arrival at hospital

Issues?

Contacts?

Actions?

Levels of Support (Hindmarch, 1999)Level 1 Someone

thereFirst Hours

Level 2 A Listening Ear

First Days

Level 3 Structured Group Support

First weeks

Level 4 Counselling or Therapy

First Months

Impact of Traumatic Incident

1 2 3 4 5

1. Primary Victims

2. Secondary Victims

3, 4, 5.Tertiary Victims

Group Reactions and Needs

Reactions can vary depend• Previous Experience • Group Dynamics• Nature of the incident • Degree of involvement• Closeness to incident

Critical Incident Debriefing A structured group process that aims to

reduce the impact of PTS and enhance coping mechanisms

Confidential and supportive service offered staff, parents and pupils affected by an an incident

In which group shares experiences, thoughts and feelings about an incident

Usually takes 2-3 hours ( but can vary depending on size of the group)

Critical Incident Debriefing (continued) For Adults and Children Initial session with follow up Between 3-14 days after incident Two trained facilitators (lead and support) Priority given to those who witnessed or were

closely involved in some other way Children groups need informed parental

consent

Definition

‘ a group meeting or discussion, employing both crisis intervention and educational processes, targeted towards mitigating or resolving psychological distress associated with a critical or traumatic event’

(Mitchell and Everly, 1996)

Psychological Debriefing

Introduction Facts

– Before, during and after Thoughts Feelings Normalisation - psycho-education Future

» (Dyregrov, 2003)

Aims of Debriefing

Integrate cognitive and emotional memory

Connecting past - present - future Psycho-education Normalisation

Critical incident stress Debriefing Process

(Mitchell and Everly, 1996)

Introduction

Thoughts

Reactions

Cognitive

Emotional

Re-entry

Symptoms

Teaching

Objectives of CISD Ventilation of impressions, reactions and feelings Promotion of clear understanding of precipitating

events and subsequent reactions Decrease in individual and group tension and the

sense abnormality Mobilisation of coping resources Preparation for future symptoms and

identification of avenues for further assistance (Hodgkinson and Stewart, 1993)

Issues of debriefing with Children (Wraith, 2000) Involvement of parents Developmental issues in child Role of peer group Modalities of expression and conversation Level of engagement Self disclosure, confidentiality, coping skills Secondary traumatisation/retraumisation Importance of trained leadership,

psychological first aid linked to debriefing

Issues of debriefing

In a comparative study of adolescents Stallard and Law (1993) conclude

‘psychological debriefings can be very effective in reducing intrusive thoughts, possibly by validating the person’s experience of trauma, allowing re-interpretation of their attribution and providing a forum in which emotions can be discharged’ (p.663)

Debriefing Questions have been raised as to efficacy of

single session debriefing in preventing PTSD in individuals

Needs to be part of group and overall management response and package of care

Careful consideration of elements of debriefing• Purpose• Timing and Duration• Group membership• Training of facilitators• Follow up

Criticisms of CISD and its impact on PTSD Evidence base for CISD and other interventions are

inconclusive– A meta analysis by Van Emmerick et al (2002) adult CISD

studies found no evidence of prevention of PTSD– But some evidence of perceived helpfulness and satisfaction

But CISD has other purposes too – contributing to psychological first aid and part of a planned

response– reduction of distress and psycho-education

Ethical and research issues – Normalising rather than pathologising– Research with bereaved and traumatised groups notoriously

difficult

Methodological criticisms of the critics of debriefing Analyse single session debriefing Use self selection and groups not adequately

matched Actual debriefing used not defined Timing of intervention variable Intervention insufficient Training of facilitators not clear Not part of Critical Incident Stress

Management (Dyregrov, 2003)

Context for debriefing

Needs to be part of overall crisis intervention or plan

Not given too early Or without follow-up Assessment of group and individuals Trained personnel Focus cognitive and education Not too long or too short

(Hodgkinson and Stewart, 1993)

Case Study 3: Young Person Missing and Suspected Murder Young Person Aged 17

missing Concerned friends tell

teacher who reports this to police

Frequent news stories and bulletins over months

Body found and confirmed it is the young person

Suspected Murder Family members arrested

then released

Issues?

Impact?

Actions?

Traumatic Incidents:Impact and Intervention

Community

Organisation

Ind’l

Impact on Organisations Incidents can directly or indirectly affect a school and

organisation Can be an onsite, offsite or multi-site May directly/indirectly affect school staff including

senior managers May generate a lot of media interest May generate reaction in parents May generate over zealous helping, callers and

visitors Plans and responses need to be flexible and ‘Wise

before the event’

Impact of trauma in Organisations

Brings out the ‘Best and Worst’ in people

Magnify difficulties or strengthens existing relationships

Close ranks ‘in group versus out group’ Competing pressure to stop or carry on Opportunity to share and support

Impact of Trauma –School as an Organisation (Attneave, C cited in Hindmarch, C (1999))

1) Pre- trauma Context

2) Crisis

3) Retribalisation

4) Polarisation

5) Mobilisation

6) Depression

7) Breakthrough

8) Exhaustion/Elation

9) Post-trauma Context

Managing an incident in school

Action within Hours– Obtain and Collate Information– Convene Critical Incident Management team– Create Incident room and phone line– Contact Families affected– Make arrangements for informing other parents– Inform school staff– Inform Pupils– Inform Local Authority and Communications

Department» (Managing the response to critical incidents in schools

(Cheshire CC Guidance, 1995)

Managing an Incident in School Develop a plan for handling the feelings and

reactions of people Prepare a more detailed media statement in

association with Communications Dept Prepare further information for parents, pupils and

staff Contact Critical Incident Support Team (CIST) Consider and arrange where appropriate

debriefing for staff, parents and the pupils involved » (Managing the response to critical incidents in

schools( Cheshire CC Guidance, 1995)

Case Study 4: Child found in a swimming pool Child aged 6 with learning

difficulties Enters swimming through an

unlocked door and pool is unsupervised

Staff supervising other children getting changed

Child found face down in pool but is resuscitated by school nurse

Sent to hospital but is discharged later that day

Issues?

Impact?

Actions?

Community

Organisation

Ind’l

Core Components of Critical Incident Stress Management Pre-incident education/mental prepardness On scene crisis intervention support Demobilization Defusing Critical Incident Stress Debriefing Additional support for families and children Follow up services and appropriate

» (adapted from Mitchell & Everly, 2000)

Case study 5: Meningitis Death

Suspected meningitis death of Child aged 5

A member of school staff ill also with suspected meningitis

Community and parents very upset and concerned

Parents keeping children away from school despite advice to the contrary

Issues?

Impact?

Actions?

EP involvement in Strategic Development

Involvement in development and revision of policy, procedures and guidance for schools

Training and development activities provided for Staff in LA, Schools and other settings to ensure they are aware of issues related to bereavement and loss, psychological impact of trauma and effective management

Coordination and Liaison with other agencies e.g. Health Protection Agency

Authority and Community Wide Involvement and Support Emergency Planning Team Development and Co-ordination Simulation and practice Links and Liaison with other services Training and Development Support and Response

» (See Pousada, 2006 for example)

Crisis Support to Schools

Crisis support to schools is still valid and needed

Psychological debriefing useful aid to cognitive restructuring and normalisation

Group work and coaching can lead to self help and dispel misunderstandings

Work on planning and response is highly valued by schools

(adapted from McCaffrey, 2004)

Critical Incident Support: Three Teams with Links and Roles

Immediate Aftermath - Local Authority Managers and Officers

Short-term – Multi-Disciplinary Critical Incident Support Team

Medium-termOther Specialist Support Services including Occupational Health, CAMHS and bereavement

services

Long-termCritical Incident promotion, planning and preparing

Local authority and other services

EP involvement in Multi-Agency CIST working

Involvement in responding and supportingCo-ordinated Multi-Agency Critical Incident Support Team

involving Including educational psychologists, Child health and

social care professionalsTrained and developed for role

Involvement in Coordination, Training, Planning and Working with Emergency Planning Officer Health Protection Agency (HPA)Public Relations and Communications TeamsChildren and Social servicesEmergency services

(see Pousada, 2006, for example)

EP Position in the Chain of Command

Emergency Planning Officer

Emergency Plan

Small Team Established

Critical Incident Support Team

Longer Term Follow-up

Team Visit

School Visit

Educational Psychologist

Critical Incident Co-ordinator

Phone Support / Contact

Phone Support to Headteacher

Local Authority Co-ordinator

School

Press Office

Other agencies

Incident

Case Study 1: A School Visit Bus Crash

Issues

Impact?

Actions?

Bush crash close to school 70 Y6 pupils some with

serious injury Taken to 2 Hospitals 10 adult staff and helpers

also on trip some with injury 140 concerned parents 200 pupils at school 20 staff and governors 3 emergency services Local authority managers

and services

Case Study 1: The Incident

The Incident The Hours following The rest of the day/night The next day The day after that The rest of the week

Case Study 1: The Response

Information and support for• Pupils• Family• Parents Group• Staff• Media• Others (inc Governors, LEA etc)

Case Study 1: Team and EP Response The Call The Reactions The Response Issues, Actions and Contacts Evaluation and Learning points

Support Needs

Support needs – In The Immediate Aftermath– The Short Term ( up to 4weeks)– The Medium Term ( 1 month to year)– The Long Term ( 1year on and beyond)

Some feedback

‘The Critical Incident Team were a tower of strength to us all. They handled the whole incident in a very supportive and caring way without being intrusive. I feel that they were excellent in very way and do not lack in any area’

Educational Psychology:Levels of Involvement

Community

Organisation

Ind’l

Aims of the Session (Revisited) Develop your awareness and knowledge of

the psychosocial impact of traumatic incidents on children and schools

Examine current theory and the evidence base for practice

Explore what is known to help support those affected by traumatic incidents in schools

Develop your understanding of how Educational Psychologists work with other professionals to support those affected by traumatic incidents

Remember ………..

‘The normal reactions of normal people to events which, for them, are unusual and abnormal’ (Parkinson, 1993)

Questions

Comments

I hope that you now feel “Wise before the Event

(or is it Exam!)”Good Luck!!

References American Psychiatric Association (1993) Diagnostic and

Statistical Manual of Mental Disorders Washington: APA Carroll,D., Frew, D., Futcher,A., Ladkin,M., Morey,Y., price,T.’ & Smith, A. (1997) The educational psychology crisis intervention service. Educational Psychology in Practice, 13, 2, 112-114

Dyregrov, A. (2003) Psychological Debriefing: A leader’s guide for small group crisis intervention USA: Chevron Publishing

Everly, G.S., & Mitchell, J.T. (1999) Critical incident stress management(CISM): A new era and standard of care in crisis intervention.

References (Continued) Hindmarch, C (1999) On the Death of a Child. Hodgkinson, P.E. and Stewart, M(1998) Coping

with Catastrophe. London: Routledge O’Hara, D.M., Taylor, R., & Simpson, K.,(1994)

Critical incident stress debriefing: bereavement support in schools - developing a role for an LEA educational psychology service. Educational Psychology in Practice, 10, 1, 27-34

Mallon, F.,& Best, C., (1995) Trauma in School: A psychological service response Educational Psychology in Practice, 10, 4, 231-237

References (continued) Mitchell, J.T., and Everly, G.S. (2000)Critical Incident

Stress management and critical Incident stress debriefings: evolutions, effects and outcomes. In Raphael, B., and Wilson, J.P.(2000) (Eds) Psychological Debriefing: Cambridge: Cambridge University Press

National Institute of Clinical Excellence (2005) Post-Traumatic Stress Disorder Guidance

Parkinson, F. (1993) Post trauma stress. London: Sheldon Press

Parkinson, F (1997) Critical incident stress debriefing. London: Sheldon press

Resnick, P.A. (2001) Stress and Trauma East Sussex: Psychology Press

References (Continued) McCaffrey, T (2004) Responding to Crises in Schools:

A consultancy model for supporting schools in Crisis: educational and child psychology 2004, 21, 3, 109 -120

McNally., R.J., Bryant, R.A., & Ehlers, A. (2003) Does early psychological intervention promote recovery from post traumatic stress? Psychological science in the Public interest 4, 2, 45-96

Pousada, S.(2006) Applying Psychology in Local Authority Emergency Planning Processes Educational Psychology in Practice, 22, 3, 199-214

Shapiro, F. (2001) Eye movement Desensensitization and Reprocessinig. New York: Guilford Press

References (continued)

Van Emmerik, A.P.A., Kamphuis, K.H., Hulsbosch, A.M. & Emmelkamp, P.M.G.(2002) Single session debriefing after psychological trauma: a meta-analysis Lancet, 360, 766-771

Wolpert, M., et al (2006) Drawing on the Evidence London: EBPU

Wraith, R. (2000) Children and debriefing: theory, interventions and outcomes. In Raphael, B., and Wilson, J.P.(2000) (Eds) Psychological Debriefing: Cambridge: Cambridge University Press

Yule, W.,and Gold, A.(1993) Wise before the event. London: Calouste Gulbenkian Foundation

Responding to Traumatic Incidents in Schools

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