Responding to Traumatic Incidents in Schools

1. Responding to Traumatic Incidents in Schools Nick Durbin Joint Programme Director Senior Educational Psychologist University of Nottingham Warrington BC Doctorate in Applied Educational Psychology

2. 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

3. Overview of the Session • Definitions and Impact of Trauma • Rationale for Support and Intervention • Levels of Response and Support • EP practice and Involvement

4. Educational Psychology:Levels of Involvement Community Organisation Group Ind’l

5. 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

6. 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 Case Study 1: A School Visit Bus Crash

7. 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)

8. Aims of the Critical Incident Support • Attempt to Minimise Impact • Ensure Appropriate Support • Co-ordinate Responses • Support Normal Processes

9. 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: A School Visit Bus Crash

10. Trauma: Some Considerations • Theory • definitions • signs and symptoms • Impact and Intervention • individual • groups • organisation and community • Evidence • research • practice

11. Traumatic Incidents: Impact and Intervention Community Organisation Group Individual

12. Common Reactions to Trauma • Feelings of denial • Distress • Guilt • Anger • Helplessness • Re-experiencing events • Avoidance • Arousal (high or low)

13. Common reactions (continued) • Flashbacks and intrusive memories • Headaches • Difficulty concentrating • Feeling guilty ‘it was my fault’ • Feeling detached from others

14. Common reactions (cont’d) • Numbness • Anxiety • Feeling on edge and Hyper-vigilant • Depression • Irritability and anger • Sleep disturbance, nightmares

15. Peoples’ Reactions and Needs • Reactions vary depend • Age • Experience • Personality • Nature of the incident • Degree of involvement

16. 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)

17. Post Traumatic Stress • And ……… • “The normal reactions of normal people to events which, for them, are unusual or abnormal” (Parkinson, 1993)

18. 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)

19. DSM IV Symptom Criteria

20. Trauma, PTS and PTSD • Dose = Symptoms • ‘ The vast majority of people exposed to serious traumatic events do not develop PTSD’ (McNally, 2003)

21. Normal Features of Grieving

22. Stages of Response and Recovery • Shock • Denial • Emotional Impact • Working Through • Acceptance • Normal reactions • Pre- trauma Stability • Post trauma Stability • Traumatic Incident 7 8 9 1 6 2 5 3 4 Adapted from Queensland Dept of Education

23. Some common needs • Information, • acknowledgement • opportunity to talk • formal and informal rituals • recognition • routines and normality • return and reintegration

24. 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)

25. 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)

26. 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)

27. Traumatic Incidents: Impact and Intervention Community Organisation Group Ind’l

28. 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? Case Study 2: Death in the Playground

29. Levels of Support (Hindmarch, 1999)

30. Impact of Traumatic Incident 1 2 3 4 5 1. Primary Victims 2. Secondary Victims 3, 4, 5.Tertiary Victims

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

32. 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)

33. 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

34. 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)

35. Psychological Debriefing • Introduction • Facts • Before, during and after • Thoughts • Feelings • Normalisation - psycho-education • Future • (Dyregrov, 2003)

36. Aims of Debriefing • Integrate cognitive and emotional memory • Connecting past - present - future • Psycho-education • Normalisation

37. Critical incident stress Debriefing Process Cognitive Introduction Re-entry Facts Teaching Thoughts Symptoms Reactions Emotional (Mitchell and Everly, 1996)

38. 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)

39. 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

40. 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)

41. 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

42. 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

43. 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)

44. 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)

45. 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? Case Study 3: Young Person Missing and Suspected Murder

46. Traumatic Incidents:Impact and Intervention Community Organisation Group Ind’l

47. 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’

48. 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

49. Impact of Trauma –School as an Organisation (Attneave, C cited in Hindmarch, C (1999)) 9 1 • Pre- trauma Context • Crisis • Retribalisation • Polarisation • Mobilisation • Depression • Breakthrough • Exhaustion/Elation • Post-trauma Context 2 3 4 8 5 7 6

50. 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)