Responding to Traumatic Incidents in Schools
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
Group
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
Group
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
Panic
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
9
34
5
6
7 8
1
2
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)
Traumatic Incidents: Impact and Intervention
Community
Organisation
Group
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
Facts
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
Group
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
9
8
7 6
5
4321
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?
Traumatic Incidents: Impact and Intervention
Community
Organisation
Group
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
Group
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)
Responding to Traumatic Incidents in Schools
Questions
&
Comments
Responding to Traumatic Incidents in Schools
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
