The risk of misdiagnosing distress & three key questions that educators must ask – a reflection on Chapter 9 of ‘Boy Raised as a Dog’

This week at our ‘Boy Raised’ book club we met ‘James’, a six year old who was severely abused for almost all of his life by his adoptive mother. It transpired that she suffered from Munchausen syndrome by proxy, or Factitious Disorder Imposed on Another (FDIA), and all of her children were swiftly removed following Dr. Perry’s intervention.

The abuse – sustained, extreme, very near fatal – had been allowed to continue for so long in large part because the child’s distress had been explained through a diagnostic label, Reactive Attachment Disorder (RAD). Admittedly, James’s mother had done some ‘doctor-shopping’ to secure this, but Perry maintains that misdiagnosis is a common problem: “Fortunately, RAD is rare”, he observes. “Unfortunately, many parents and mental health workers have latched onto it as an explanation for a wide range of misbehaviour, especially in adopted and foster children.”

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We know that this medicalisation of distress in children extends way beyond RAD with the chapters of ‘Boy Raised’ punctuated by a bewildering array of diagnostic labels, stuck by well-intentioned professionals onto childhood trauma, effectively mis-explaining and masking it.

This article from a 2014 issue of The Atlantic focuses on the over-identification of attention deficit/hyperactivity disorder (ADHD). Dr. Nicole Brown was completing a residency at John Hopkins Hospital in Baltimore when she noticed that many of her low-income patients had been diagnosed with the heritable condition. They came from households where violence and relentless stress prevailed. Parents had found them hard to manage and teachers frequently described them as disruptive or inattentive.

When Brown looked closely, though, she saw something else. “Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by a stress response in overdrive.” Brown saw trauma.

Inattentive, hyperactive, and impulsive behavior may in fact mirror the effects of adversity, and many pediatricians, psychiatrists, and psychologists don’t know how—or don’t have the time—to tell the difference. (The Atlantic, 2014)

To test her hypothesis beyond Baltimore, she analysed the results of a national survey about the health and wellbeing of more than 65,000 children. This revealed that children with diagnosed ADHD also experienced significantly higher levels of poverty, divorce, violence, family substance misuse. Those who had experienced four or more ACEs were three times more likely to be medicated for ADHD.

“We need to think more carefully about screening for trauma and designing a more trauma-informed treatment plan,” Brown concluded.

This peer-reviewed study, published in the BMJ, confirms that diagnosis of ADHD has increased ‘substantially’ in the past decade, alongside a broadening of its definition in successive editions of the DSM-5. This is observed internationally, with a doubling of the rate in The Netherlands and the medication costs of inappropriately diagnosed ADHD estimated to run at between $320 and $500m in the US.

The need for clinicians and, much further upstream, families, childcare providers, SENCOs and others, to view dysregulated behaviour through a trauma-informed lens has never been more urgent than it is now, in the midst of a pandemic. What we can predict we can prevent.

It’s worth pausing for a moment to reflect on this graphical representation of the original ACES survey and to consider whether there is a single component that Lockdown will not have aggravated:

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For the avoidance of any doubt, and please do share this post with the complacent or the deluded, some really dire statistics are already making headlines:

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These headlines float on a sea of distress and we must expect a huge wave of diagnostic labels, EHCP plans, clinical referrals, Ritalin prescriptions to follow, if there is no change in the way that we respond to childhood adversity.

That’s if nothing changes. However, the trauma-informed movement that was slow to arrive here but which is gathering momentum, does represent a gleam of hope on the horizon. Moreover, it’s a democratising movement that educators can drive alongside mental health experts. Clearly, my reducing what can be done in schools down to ‘three questions that educators must ask’ was both a gross over-simplification and a flagrant attempt to encourage visitors to this post, but there are I think three lines of enquiry that we should prioritise through our pastoral work with children and families, in the fallout of this pandemic.

1. What are the symptoms, exactly?

This overview of the difference between ADHD and trauma symptoms is a really helpful reference point for conversations about problematic behaviour that are taking a medicalised turn.

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It’s taken from the NTCSN’s Guide for Clinicians, which repays reading in full. Clearly, introducing the concept of ‘trauma’ to parents can be problematic and we must tread respectfully and carefully, but equally we cannot protect the best interests of children if we are not curious about the roots of their distress and willing to talk about their life experiences, especially early ones which parents may not otherwise mention. Families should be advised that trauma is very common (I write as the mother of children with ACEs) and it should not be shaming to discuss its impact.

2. Who can help?

In addition, there is the problem of what Perry calls “child illiteracy” which we can address through gentle but well-informed conversations about the impact of stress on the developing brain. Such conversations also need to emphasise the great hope that is neural plasticity and, crucially,  the point that recovery is possible when children have access to a reliable supply of high quality relational support.

‘Behaviour meetings’ might be steered such that Mum agrees to have ten minutes after school talking about what went well today, understanding the importance of that; there might be a plan to visit Gran more, who is much-loved; to introduce a reliable routine for contact with Dad; to try scouts. School will also contribute to this web of therapeutic support. Children should be asked to identify trusted adults and accommodations agreed within the plan such that time is made for talking. A relational safety-net will need to be formulated for times of crisis or dysregulation. Who do I go to and how do I get there?

The day that a pastoral support plan looks like this, rather than an unattainable and  school-centric report card, is the day that trauma-informed practice has truly arrived in a setting. It is worth emphasising the importance of its reliability – few things are more damaging to the progress of a child who struggles to trust and to feel safe than wobbly plans that are not carried through, exactly as agreed. This involves ensuring they are understood and implemented by all staff.

3. Where is the crack in the problem?

This is Leonard Cohen’s phrase and it features in Dr. Geoff James’ great little solutions-focused workbook for educators How good are we at helping children and families find the exceptions, the crack in the problem, so that it can be mined for optimum light? How does the diagnostic route assist in this life-enhancing and hopeful process? Is there a risk that the label stops us even searching for the cracks, the light, because we have our genetically-rooted explanation and we must now just learn to live with the problem?

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Solutions-focused coaching guards against these risks. A simple but powerful process that involves asking children the right questions and really listening to their answers, it has much to offer the trauma-informed school and is, for me, a pastoral care essential. I see it as taking the relationship that heals and fitting it with super-boosters. As Geoff writes in his introduction:

We know that relationships are the heart of education. Be entering the solutions-focused conversation on hopes, resources and successes, strong relationships will develop, between the child and their best self and between them and the solutions-focused coach, the facilitator of their learning. This is solutions focused coaching.

Geoff’s guide (which Lincolnshire schools may request digital copies of at no cost) outlines the 7 simple elements of the approach with ‘exceptions finding’ at its heart:

  • When are the times that (the problem) doesn’t happen so much?
  • Tell me about a time when (the problem) happened but didn’t last as long?
  • When are the times when other people would notice you (e.g. behaving, working, being kind…) in a good way?
  • When are things a little bit better for you? What was different then?
  • Tell me about a time when (e.g. you stayed calm) in that difficult situation? 

(Workbook for Educators, p46)

Through simple scaling, the coach is able to re-imagine the traditional, behaviourist approach to target-setting  (which fails in the face of real difficulties), and harness instead the agency of the child, as expert in self:

  • On a scale of 1 to 10, with 10 being in control of yourself in a good way and 1 being not in control of yourself, where would you say you are right now?
  • So what are you doing that means you are not at (….a lower number)?
  • Where on the scale do you hope to get to over the next (e.g. week)? What will you be doing then that’s different?

(Workbook for Educators, p49)

To conclude, we know that we must ask children and families ‘What happened to you?’ rather than ‘What’s wrong with you?’ to avoid misdiagnosing trauma. We know too the importance of asking children who helps them and of building a relational plan. But we must never forget the fact that all children are resourceful and capable of change and that the most compelling line of enquiry of all centres around this question:

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School recovery through PACE and a plea to policy makers – inspired by chapter 8 of Boy who was Raised as a Dog

Chapter 8 illustrates the impact of toxic stress on an adolescent more vividly than anything most of us at book club last week had ever read.  The aim of this post is to use Amber’s story as a reference point against which to consider the lockdown-fuelled stressors bearing down on vulnerable children right now and then to look at how schools might mitigate some of that toxicity through a focus on Kim Golding’s attitude of PACE.

I’ll suggest some of the things that I think need to change in schools, especially in relation to behaviour policy and practice, for PACE approaches to stabilise those children whose stress response systems will be in need of consistent regulating experiences after lockdown.

The post concludes with a call on Westminster to flip the narrative around school recovery such that it focuses squarely on pupil wellbeing, following the example set by Welsh Minister for Education, Kirsty Williams. If ministerial guidance for English schools creates the kind of pressure cooker that stems from focusing narrowly (and counter-productively) on academic progress alone, then the most vulnerable will pay the heaviest  price.

That’s fact, not alarmism – it’s what we know from a plethora of research such as this about the impact of disasters on the most disadvantaged. We can expect, if we are not biologically-informed in the way that we meet vulnerability, a sharp increase in ‘conduct disorders,’ emotional disturbance and exclusion. Let’s use all of the very good evidence that we have at our disposal to avoid that.

Amber’s Story

Amber was found unconscious in her high school toilets. Her condition worsened in ER when her heart suddenly stopped beating and Dr. Perry arrived on the scene just as she was being revived and stabilised. He spoke to Jill, Amber’s distraught mother, whilst numerous tests were being undertaken to identify the cause of the problem.

Noticing evidence of recent self-harm, Dr. Perry asked Jill whether anything had happened to distress her daughter. It transpired that Amber had answered the phone to an ex boyfriend who called unexpectedly the night before. ‘Duane’ had been thrown out eight years previously, when Jill discovered him in bed with her then 9 year old daughter, whom he had sexually abused for several years.

Dr. Perry explains to the reader that many ‘cutters’ have a history of trauma, the self-mutilation inducing a dissociative state, similar to the adaptive response of escaping somewhere safe in the mind to survive the experience of the traumatic event itself. Such dissociative states, from dreamlike absences at one end of the spectrum to loss of consciousness at the other, are linked with the release of high levels of opioids, the brain’s natural heroin-like substance that kills pain and produces a calming sense of distance.

Whilst medics were extremely skeptical about this explanation for Amber’s condition, they agreed to try naloxone just as if she had overdosed on heroine, and the results were indeed rapid. She was conscious within 90 seconds of receiving the injection and Dr. Perry’s work with her, once he had gained some trust (using elements of PACE), could begin.

It is important to note that those who respond to extreme, prolonged or uncontrollable stress like Amber, through freeze or dissociation, might not be visible to us as educators, unlike others whose survival strategies tend towards flight or fight. This is one of the many reasons that trauma-informed practice is a matter of whole school culture and practice, not merely targeted intervention for individuals. It’s a community commitment. It’s a way of being with children, many of whom struggle silently.

Why we should be very concerned about toxic stress

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The ACE study should have been a public-health game-changer and will need to be now. This animation from Public Health Wales is a quick but powerful summary of its key messages and here is an excellent free, one hour and certificated e-module from Barnardos and partner organisations. Leaders might want to consider sharing these resources with staff before schools reopen, as essential CPD if they are to prepare for the professional challenges ahead, when children return from stress-filled households profoundly impacted by the pandemic.

There are ten types of childhood trauma measured in the ACE Study. Five are personal — physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members:

  • an alcoholic parent (read this in relation to the pandemic)
  • a mother who’s a victim of domestic violence (read this about our soaring rate of DV)
  • a family member in jail (lockdown currently distorting this data)
  • a family member diagnosed with a mental illness (alarming impact of Covid on mental health covered here)
  • the disappearance of a parent through divorce, death or abandonment (flagged in this research from the Lancet.)

Each type of trauma counts as one for the purpose of the ACE study. (Health warning – it’s a survey not an assessment and shouldn’t be used to ‘score’ pupils.) So a child who’s been physically abused, with one alcoholic parent, and a mother who has experienced DV has an ACE score of three. However, there are, of course, many other types of childhood traumas — racism, bullying, watching a sibling being abused, losing a caregiver (grandmother, mother, grandfather, etc.), homelessness, surviving and recovering from a serious accident, involvement with the juvenile justice system, and so on. Equally, the impact of one ACE might be just as devastating as the experience of ten, especially if it happened very early in life. However, the ACE study remains the most compelling data we have about the lifelong and indeed intergenerational impact of stressful events during childhood and it’s data that we cannot afford to ignore any longer.

We know then that ACEs are increasing at an exponential rate as this pandemic plays out. The graphic below, from Young Minds, refers to a population study undertaken in England before coronavirus. Even then, and linked with austerity, ACEs were very common.

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We know that, in the absence of buffering relationships, ACES lead to a multitude of illnesses in middle age and ultimately to premature death. The full report from Young Minds is worth reading.

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The pandemic is not only a current public health emergency, therefore, but one that will continue for generations to come if we don’t respond to it in an evidence-informed way. Schools are clearly key players, as communities that can wrap around and soothe children who return with toxic levels of stress coursing through the system. (Without getting bogged down in the neuroscience, and I am an educator, not a scientist, its cortisol that does the lasting damage) There is hope, therefore. There is an abundant supply of want children need to bounce-back – consistent and caring adults.  Research overwhelmingly shows that social buffering is the root of resilience. But this needs to be proactively created by leaders, because the young people who need us the most tend to push us away:

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PACE was developed as a way around this problem, within the therapeutic parenting field, but its potential for use in schools is, for me, enormous. I think the warmest, most nurturing school communities are already imbued with it and I’ve worked with some  individual teachers whose inclusive practice has been underpinned by an intuitive understanding of the need to regulate highly sensitised children through PACE. I think it can be traced in Mark Goodwin’s wonderful piece about school recovery here. So PACE principles are not revolutionary, necessarily, but they are paradigm shifting.

Playfulness, Acceptance, Curiosity, Empathy

Playfulness

This is described by the DDP Network (which I borrow heavily from in this section) as being about creating an atmosphere of lightness and interest when communicating with vulnerable children and young people. “It means learning how to use a light tone with your voice, rather than an irritated or lecturing tone. It’s about having fun, and expressing a sense of joy.”

It’s not suggesting that teachers need to become stand-up comedians, but rather that they should endeavour to adopt a playful stance. This can diffuse difficult situations and forge connections. In the pandemic age, with crushing worries, uncertainty and stressors so acutely felt at home by many, not to mention death and devastation on the news daily, children and young people will have felt the loss of those feel-good hormones that are released when we laugh. We know too that social bonds between humans are strengthened by social fun and laughter, so playfulness is a protective factor. It’s also highly rated by pupils: categorised as Fun and Funny in this YouGov poll from 2018, it’s topped only by Kindness, which is actually the essence of PACE.

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The strongest school communities make time for fun, inside and outside the classroom. Pudsey days, staff v pupil rounders, end of summer barbecues, trips to the panto, even the prom – they’re all about having fun together. Staff can relax, interact more informally with children, delight in them, forge bonds. The saddest thing in education is the barring of vulnerable pupils from such events as ‘consequences’  – thereby denying them the very experiences they need to thrive. This is the kind of medicine that kills the patient and it should be purged from the post-pandemic era. Consequences yes; vengeful, ostracising ones – no.

Acceptance

Unconditional acceptance is at the core of the child’s sense of safety. It is therefore also at the core of regulated behaviour – dysregulation being in essence a search for safety, driven by the brainstem and not the cortex which gives way when we feel threatened.

Creating acceptance within vulnerable children means actively communicating they we accept the wishes, feelings, thoughts, urges, motives and perceptions that are underneath any unwanted outward behaviour. It is about accepting, without judgment or evaluation, a person’s inner life. The child’s inner life simply is; it is not right or wrong.

(DDP Network)

Of course, the PACE-informed teacher may be very firm in limiting behaviour but will at the same time accept the motives for the behaviour. This way, the pupil learns that while behaviour may be criticised and limited, this is not the same as criticising the self and the relationship remains intact.

It is worth reflecting on behaviour policy at this point because some consequences deliver an intolerably heavy blow to a child’s sense of acceptance. A book club member reported that her school stopped issuing fixed term exclusions some years ago, when staff observed that it worsened children’s behaviour on return. This is entirely consistent with what we know about access to the regulating cortex when we feel threatened…and make no mistake, anything that pushes the human being out of the clan is registered by the ancient brain as a threat to life.

The repeated experience of fixed term exclusion, or isolation, is hugely detrimental to the wellbeing of children and young people with alternative strategies, around lowering demands such that the dysregulated pupil can build resilience over time, needed instead. In Lincolnshire, schools use a PSP in these situations with many more children and young people successfully included as a result of their solutions-focused flexibility.

Curiosity

Curiosity, without judgment, is how we help children become more aware of their inner life and able to reflect on the reasons for their behaviour. It is wondering about the meaning behind the behaviour, for the child. It links to a mantra within the trauma field, that we ask what happened to you, not what’s wrong with you.

In the school context, it is important to convey a sense of curiosity about what might have triggered an explosive incident, rather than just relationship-risking opprobrium. Kim Golding’s connection before correction is a superb step-by-step guide to this. Clearly, the approach requires the adult to be regulated. And it might feel clunky at first. Without doubt, it takes a few minutes longer than the swift direction to isolation that is the modus operandi of some secondary schools. But it is rooted in our understanding of the neurobiology of stress.

Connection* “Tyler, what I think happened there was that you felt really overwhelmed. I know there’s a lot going on at home at the moment – you’re worried about your mum and you’re arriving at school with your stress bucket pretty full. It doesn’t take much for it to spill over and I think that’s what we saw back then. Do you think that might be about right?”

Tyler might not reply, or he might think his teacher is completely wrong. But one thing is certain, he will have been soothed by these words because they communicate unconditional acceptance. More than that, they say to Tyler, here is an adult really trying to get me. Not condemning or judging me but curious, interested and seeking to understand.

*possible only when the child is out of crisis, with thinking brain online

Correction “But Tyler, it’s not ok for you to throw my books on the floor.”

And a consequence may then be needed, depending on the gravity of the incident, whether others were harmed. However, provided the experience is not shaming, a logical consequence will not overwhelm even the most highly-sensitised pupil if it is clear that the relationship remains intact and safe – stronger, even, for those moments of connection.

Empathy

Tyler, it must be really scary to feel out of control like that. Trust me, it’ll get better and I’m always here to help you, but right now it’s hard for you and I just want you to know that I’m really sorry about that.

With empathy, the teacher is demonstrating that he or she knows how difficult an experience is for the pupil and that comfort and support is available. Empathy is indistinguishable from kindness: the quality that pupils rate twice as highly as any other. (Oftsed makes reference to ‘fairness’ in its Handbook – assuming that children interpret this in the crudest possible way, as treating everyone exactly the same despite the scale of their personal challenges. I would posit that they don’t, having worked with thousands of them, but look anyway at how low fairness ranks, next to kindness.)

If children are to heal, then staff will need to be empathic and another training resource, just as important as the ACES material, is this brilliant animation about empathy as driver of human connection from the great Brene Brown. It has the added advantage of being wonderfully playful.

Plea to policy-makers

Clearly, pressurised or burnt-out teachers cannot interact with PACE – it requires huge reserves of compassion and regulation within the adult. If we are to protect the wellbeing of children and young people, then we must prioritise the wellbeing of their teachers and TAs. Strong leaders will do their best to ameliorate the full impact of the ‘catching-up’ agenda, but it would be better if this were replaced altogether with priorities more humane.

In practical terms, this means slimming down GCSE content for the current Y10. Speaking at a ResearchEd event recently, Dylan Wiliam used the word ‘immoral’ to describe the mountain of GCSE content that casts its shadow over KS4. (Story here) Having seen this volume crush one of my own daughters, I am inclined to agree with him. She’s Year 11 so it’s over now but when I asked her how she felt she would have coped as a Year 10 learner faced with the challenge of catching-up post-lockdown, I saw her blood run cold. (I must emphasise here, the school have been fantastic – there is nothing leaders can do about the exam system, apart from allow pupils to drop GCSEs when they sink – which we did.)

Ofqual has already mooted the idea of slimmed down exams for the current Y11 to sit during the autumn if they are disappointed with their grades this summer. These need to be used in the 2021 exam series too – so that teachers can ‘pace’ their work, in the fullest sense of that word. The Welsh minister for education has already advised that performance tables and national testing will be suspended. That should be the case on this side of the border too.

Those who assume that very, very few children will return to school traumatised (quoting leader of a flagship MAT last week) – and are therefore not preparing for this eventuality – would be well advised to read the ACES research and every one of the articles I linked in this post about the tsunami of adversity that is gathering and how that will effect children and young people. There is a clear need, exposed by a lets not assume children will be impacted attitude, for the DfE to launch a nationwide trauma-informed workforce development programme.

Edward Timpson recommended this very thing in his Review of School Exclusion of course – but then the department went on to launch its 10m behaviour hubs project, branding it a “crackdown on bad behaviour.” Just this week, a further 1.5m was found for a school leadership programme, aimed exclusively at those leaders with a strong record of traditional ‘behaviour management’. It’s almost as if Timpson wasted his time, and that of a great number of contributors.

Whilst any expenditure of public money that will widen the disadvantage gap and drive exclusion (if it’s taken seriously) is a matter of deep regret, I want to conclude on a hopeful note. It’s that we are seeing a grassroots movement gather momentum as a result of this pandemic. Ideologically motivated DfE projects will come and go but I do believe that psychologically informed practice is here to stay.

Five ways to harness emotional contagion when schools reopen. (A reflection inspired by Chapter 7 of Boy who was Raised as a Dog)

Our book club arrived at Chapter 7 and with that a fascinating discussion about emotional contagion last week. This is clearly a topic of particular relevance in the context of Covid-19, with families confined to their homes and the impact of this on children largely dictated by the adults’ capacity to regulate their own emotional states. Some will be spreading their reassuring calm whilst the anxiety felt by others (remembering that disasters always impact the most disadvantaged families disproportionately) will be enormously detrimental to children’s wellbeing.

When schools reopen, emotional contagion will occur there too – and it will facilitate recovery or impede it, depending on the measures put in place and the extent to which these are enacted with authenticity and commitment by the whole school community. Clarity around the evidence-base for emotional contagion will be critical in this because culturally, it is way too easy for ‘Brits’ to dismiss important, psychologically informed practice as touchy-feely mumbo-jumbo. Our most vulnerable pupils in particular rely on us opening up to somewhat more enlightened thinking.

Suggested below, beneath a very brief summary of Chapter 7, are five components of what we might call an emotional contagion management strategy, but there will be many more. The underpinning principles relating to the primacy of connection and wellbeing are much more important than the nuts and bolts of the approaches suggested. First, though, a very brief glance at chapter 7.

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Chapter Summary 

I’m not going to attempt to tell the story of this chapter because it comprises multiple individual narratives and, as one of our book club members suggested, more than enough material for an entire Netflix series. Suffice to say, Dr. Perry describes the impact of very negative emotional contagion within a Texan community where it was believed that children were being ritually abused as victims of a Satanic cult. Testimony from them was coerced and many were removed from their families as a result. A judge eventually dropped all of the indictments, but many in Gilmer remained convinced, despite the lack of any evidence, that Satan worshippers had gathered there to abuse and kill children. Such is the danger of groupthink, a side effect of emotional contagion.

Defining emotional contagion

Emotional contagion is the phenomenon that individuals tend to express and feel emotions that are similar to those of others. If a friend tells us with a beaming smile that they passed an important test, we smile as well. If, on the other hand, we hear about a bereavement, we are saddened. Emotional contagion is the basis of empathy – where we ‘catch feelings’ from people around us, and its positive impact is to connect people. It is a form of social influence and, as such, a phenomenon of major relevance to school leaders; both a risk and an opportunity.

1. Prioritise staff well-being over performance tables

Literature on teacher contagion highlights the impact of increasing stress on teachers and the passing of this stress, or other emotions, onto pupils. Oberle and Schonert-Reichl (2016) measured salivary cortisol levels of pupils to assess the relationship between their stress and teacher burnout levels. Consistent with what we know about emotional contagion, pupils’ morning levels of cortisol were significantly higher if their teachers reported a higher level of burnout.

This underlines the importance of pacing the recovery phase of school reopening such that it is not experienced by teachers, and in turn their pupils, as stressful. Covid catch-up sessions, twilights, extra GCSE work  – all of these convey the message that children have fallen behind when in truth they are not behind anyone. They are all in the same place and anyway school is not supposed to be a race. The community will need to be reassured on this point, explicitly, as it is likely that some negative contagion around this thinking will already have set in.

Emotional contagion is transmitted through the links between individuals, nodes and ties, in the literature. Research shows that when the relationship is stronger, so is the contagion. It follows then that if teachers are given licence to work on their ties with pupils (or nodes), then they will be in a better position to generate positive emotional contagion; to share their calm, optimism, and hope. In so doing, they will help mitigate the stress that lockdown will have increased within some pupils and, in particular, the already disadvantaged.

There is an obvious link here with the key concept of social buffering. However, the bottom line is, adults can only provide this if their own wellbeing is protected. As Dr. Karen Treisman regularly observes, ‘Wellbeing leads to well-doing.’ Leaders will need to evaluate every element of their recovery planning in terms of its potential impact on staff wellbeing.

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2. Introduce a check-in strategy for staff

We learned from one member of our book club about a strategy their school introduced to facilitate virtual check-ins during lockdown. A simple wellbeing scale was recently added as part of this process which in turn identified a colleague who was really struggling. A sense of isolation the problem (a highly social species, we struggle on our own) he is now benefiting from additional relational support and a refreshed sense of belonging.

According to research from The Centre for Talent Innovation, employees are 3.5 times more likely to contribute to their fullest potential when they feel a sense of belonging. It makes every sense to actively promote this when schools reopen, therefore. We know that we must reach out to our most vulnerable learners so that they benefit from a sense of belonging as a protective factor, but again, the same principle applies to staff. Their wellbeing, and subsequently the emotional contagion that they transmit to pupils, will be enhanced if they feel a sense of the workplace as a second home.

This Harvard study suggests that the most powerful strategy to support staff wellbeing through a focus on belonging is simple and light-touch. Researchers found that the greatest sense of belonging was experienced by employees when their colleagues simply checked in with them, both personally and professionally. This was true across genders and age groups.

By reaching out and acknowledging their employees on a personal level, school leaders can significantly enhance the wellbeing of staff by making them feel valued and connected. Many, the best, already do this – but the process needs to be deliberate and strategic. In his YouTube series on trauma and Covid, Dr. Bruce Perry describes a relational tree whereby the leader routinely checks in with three ‘direct reports’ who do the same for three more each and so on.

Of course, the success of such a strategy will depend entirely upon the way it is implemented – a check-in doesn’t need to be long but it absolutely must be authentic. It would be worth sharing the evidence base with staff and then collaborating with volunteers on design and delivery, rather than imposing a poorly or only partially understood model for checking-in.

3. Introduce trauma-informed peer mentoring

Much of the research on emotional contagion within schools focuses on its negative manifestation in the form of detrimental peer influence. Studies of peer influence have identified a variety of negative adolescent behaviours, including smoking, drinking, and substance misuse (for a full review, see Brechwald & Prinstein, 2011). However, peer influence can be harnessed to spread positive behaviour and perhaps its potential in this regard is under-utilised. Research on peer mentoring (where peer leaders volunteer their time to help fellow pupils) demonstrates that structured peer interaction can have a huge impact on both sides of a peer partnership programme. (Tredinnick, Menzies, & Van Ryt, 2015).

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We are developing in Lincolnshire a specifically trauma-informed approach to this so that pupils learn through their training something about the brain and the way that it responds to prolonged, unpredictable or extreme stress; why emotional regulation is more difficult for some than others; the importance of safe relationships for recovery; grounding and regulating strategies; empathic listening and so on. All of this information is too important not to share with pupils, whether they are in need of regulating emotional support or providing it. And of course, if teachers are to act as role models for this important work, then they too must be trauma-informed and regulated.

4. Implement robust transition plans for the most vulnerable

“Growing up, I couldn’t have peace unless my mother was at peace,” writes Ariel Leve in ‘An Abbreviated Life’. “So, her peace was paramount.”

I had no choice but to exist in the sea that she swam in. It was a fragile ecosystem where the temperature changed without warning. My natural shape was dissolved and I became shapeless.

When somebody’s mood can shift quickly, you’re always on your toes and you’re always on guard, which means you can never really relax. And as a consequence, as an adult, I find that I absorb the mood and energy of other people very intensely, so I need a lot of time alone to decompress.

There will be children returning to school who will have been marinating in this kind of toxicity for months, without the respite normally provided by school and during a period of increased dysregulation and volatility at home. Their vulnerabilities will have been significantly increased through over-exposure to emotional contagion in its most destructive form. They will be highly sensitised, hyper-vigilant and settling to learn in anything but the safest classroom will be a huge ask; quite possibly not possible at all until safe, trusting relationships are re-established.

For children undergoing transitions, this will be harder still because the relationship will need to be built from scratch. Thought needs to be given to establishing these before schools reopen, as part of transition planning. The power of human connection over distance should never be under-estimated, as Lisa Barrett, Prof of Psychology, explains:

Humans are social animals. We are constantly regulating each other’s nervous systems. I can text someone halfway around the world. They don’t have to see my face or hear my voice, and I can affect their breathing, their heart rate, and the amount that they sweat. I can affect the functioning of their entire nervous system  and immune systems, for better or for worse, with a few words.

If we are able to reach out virtually to our most vulnerable children such that they feel  there are safe and open hands ready to greet them and hold them through transition, then they will be much more likely to navigate the challenge of new class or new school in a regulated way.  At least some of the negative emotional contagion experienced outside of school will be mitigated through access to a  consistent adult – or peer mentor – with this progress accelerated if the experience of school proper is therapeutic – that is, characterised by warm, unconditional and consistent relationships.

5. Understand that leaders are emotional contagion super-carriers

Because employees pay great attention to their leaders’ emotions, leaders can strongly influence the mood and thus performance of their staff through emotional contagion.

In this piece from Wharton Work, a case-study from Southwest Airlines is cited. Part of the company’s strategy was to attract positive people through ads such as ‘When we feel good, it’s contagious’ and by creating a culture of caring and compassion for employees. The business has seen profitable growth as a result, despite challenges facing the industry as a whole.

Leaders need to articulate the culture they seek to create and maintain as one in which positive emotions are not only allowed but encouraged. Making it clear that destructive negative emotions and the behaviors that come with them — such as bullying, back-stabbing, and incivility — will not be tolerated can help create an environment in which they are less likely to occur, take root, and spread. As school communities reassemble, there is a real opportunity to reassert the importance of these values and behaviours.

The Wharton piece serves as a useful reminder about the imortance of non-verbal behaviour, which leaders should heed:

As most emotional communication occurs through body language, facial expression, and tone (with less than 10% communicated through words), pay attention to your body language as you communicate your emotions. For example, you may be crossing your arms because you are cold, but the people observing you will likely believe you are defensive or angry, automatically mimic your arm crossing, and begin to feel that way.

This is also important information for teachers, every one of whom is of course a leader of children. Noting what has already been observed in relation to vulnerability and hyper-vigilance, there will be children in every classroom who are hyper-sensitised to non-verbal clues and who respond to tone of voice and body language before they hear verbal content.

For leaders at every level within the school community, the power of the meet and greet, the kind word or gesture, the regular check-in cannot be over-emphasised. Through such small acts, the ripple effect of positive emotional contagion will allow school communities to repair, in some cases stronger and more inclusive than they were before.

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The Problem of Child Illiteracy – a reflection on Chapter 6 of ‘The Boy who was Raised as a Dog’

Apart from the problem-focused ‘Scourge’ paragraph (mine), this is a guest post from friend and book study group member, Dr. Geoff James – ‘The Solutions Focused coach’.

The case-studies – Justin and Connor

This chapter carries the title of the book and tells us we’re entering a world of extreme trauma, maybe new to the reader and in language that goes beyond what we might expect from a measured medical professional. Dr. Perry explains in the introductory notes to the book, “… when we started, I didn’t really know what I was doing, at least as a writer. Unlike Maria, I had never written a book.” The two authors agreed to use the stories from Dr. Perry’s clinical practice to carry the narrative. They had to draw a fine balance. Dr. Perry ends his briefing with a warning that some readers could find the details distressing.

Bearing that in mind, this chapter tells the story of the upbringing of the Boy in the title, left at two months old by his fifteen year old mother, in the hands of her mother. Nine months later his loving grandmother died and he passed into the care of her boyfriend, a dog breeder. He was totally unprepared to cope with a baby and called social services who asked him to look after the Boy, Justin, until they found a permanent placement for him. The boyfriend, out of his depth, began keeping the baby as he did his dogs, in a cage, fed and watered, taken out for exercise but with little emotional care or social contact. This continued for five years.

At two years old Justin was taken to a clinic with pneumonia. There was no investigation so nothing known about his home life. He couldn’t walk or talk, and was diagnosed with severe, permanent brain damage. Subsequent clinical assessments and diagnoses confirmed the unlikelihood of any change. But what followed when Dr.Perry clinic became involved was a remarkable recovery.

The Boy received the concentrated support of physical, occupational and speech and language therapists and daily visits by Dr. Perry and a staff psychiatrist. The team started thinking in a novel way about the Boy’s limited but positive experiences, such as the “social stimulation and affection from the dogs he’d lived with; dogs are incredibly social animals and have a sophisticated social hierarchy ….. At times he responded to unfamiliar people like a scared dog….”

Given steady, multi-faceted support, within weeks Justin was out of hospital. Even with his history of trauma, the inherent plasticity of his brain together with his resources and strengths enabled him to capitalise on the stimuli offered through the recovery programme. In Dr. Perry’s words,

This was the most rapid recovery from severe neglect we had yet seen. It changed my perspective on the potential for change given early neglect. I became much more hopeful about the prognosis for neglected children.

In this chapter we also met Connor. From two weeks until eighteen months of age he was abandoned during the day by his childminder. She took a second job, leaving him alone in a crib and only returning briefly in her lunch-break to check him. When his mother discovered the neglect she left work and took over his full-time care, but the early trauma had long-lasting effects. As a teenager, Connor was barely able to function socially and emotionally.

Again, Dr. Perry’s clinic was able to offer a wide range of medical and therapeutic interventions, to aid Connor’s recovery from this profound trauma. Connor’s progress was, however, much slower and the contrasting case-studies underline the significance of the timing of childhood trauma:

The earlier it starts, the more difficult it is to treat and the greater the damage is likely to be. Justin had nearly a year of loving and nurturing care before he was put in the cage. That affection built the basis of so many important functions into his brain and, I believe, greatly aided his later recovery.

A foundational principle of Dr. Perry’s work is that neural systems organise and become functional in a sequential manner. If one system doesn’t get the stimulus is needs when it needs it, those that rely upon it may not function so well either, even if the stimuli for the later developing systems are provided appropriately. “The key to healthy development is getting the right experiences in the right amounts at the right time.” Connor’s painstaking therapy needed to focus on repair from the bottom of the brain up – the neurosequential approach – and moved from affectionate touch (massage) to music and movement to a carefully graduated socialization processes.

The Scourge of Child Illiteracy  

In reflecting on how these two children were failed for so long, Dr. Perry points out that public (state) education in the US includes no content on child development, caregiving, or the basics of brain development. Neither does this knowledge qualify as the ‘cultural capital’ that is important enough to be taught in English schools. “The result is a kind of child illiteracy.” This problem across both our cultures is aggravated by the fact that family units are smaller than they once were, more fragmented – reducing the infant’s opportunities for interaction with loving and responsive carers, beyond the primary.  In addition, strong anecdotal evidence suggests that the modern-day scourge of the screen reduces the number and quality of even this restricted range of relational experiences. 

Not only did Connor’s mother fail to recognise that the root of his difficulties lay in his year of near-daily neglect, but no-one in the school system, in special education, in occupational therapy, medicine, counselling or in any other field recognised the importance of exploring his history. Instead, presenting symptoms were matched with an alphabet soup of labels and disorders, such as psychotic disorder, ADHD and the strikingly descriptive ‘intermittent explosive disorder’…. a label that conveys a strong sense of Connor’s frustration and distress.

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Implications for practice 

A best hope for our reading group is to discover what insights the book could give us into our work with children who come to school with experiences ranging from the mildly distressful to the highly traumatic.

We had three main areas of discussion; the place for a focus on trauma awareness and practice in teacher standards; the relatively limited resources we have in schools in comparison with Dr. Perry’s clinic; in Initial Teacher Training (ITT), the need to raise awareness of the effects of trauma on children’s behaviour and engagement and to provide practical means to address and support children’s recovery and progress. All of these represent important opportunities to mitigate the problem of child illiteracy and to ensure that teachers are equipped with the knowledge and skills not simply to ‘manage’ behaviour, but to understand it.

The chapter gives a valuable insight into how to approach these issues from our educational, non-medical perspective. The antidote to relational trauma is not difficult to find:

Many of the truamatized children I’ve worked with who have made progress report having contact with at least one supportive adult: a teacher who took a special interest in them, a neighbour, an aunt, even a bus driver.

This means not leaving recovery to chance, but moving ahead of the most serious effects of trauma with predictable, respectful relationships:

From this nurturing ‘home-base’, maltreated children can begin to create a sense of competence and mastery. To recover they must feel safe and in control.

For myself I would sum this up as giving good grounds for the introduction of solutions focused coaching in ITT and in schools, promoting self-motivated learning through a child’s realisation of mastery, autonomy and purpose; Early Help for children’s mental  and wellbeing as a whole-school solutions focused approach.

 

Five ways to help children heal when schools reopen

We may not yet know when schools will reopen for all, but one thing is certain; they will need to be therapeutic. We are living a financial catastrophe; a public health emergency; a mass community trauma. And trauma always falls hardest on still-developing children. The notion that they are naturally resilient is supported by none of the research evidence. Such wishful thinking only hampers proactive attempts to promote healing and recovery. Being fit for purpose must now mean placing wellbeing front and centre and evaluating every element of school policy and practice through that lens.

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The good news is that the potential of schools to heal traumatised children, or to prevent an escalation of need, is huge. Moreover, it does not require the transformation of classrooms into CAMHS clinics or teachers into psychotherapists. The ‘treatment’ is the school community. If we can only harness its healing potential, through straightforward but in many ways paradigm-shifting measures, then a thing of value and strength will have been wrought from pandemic destruction. Adversarial growth will ensure that our schools are better than we were before; their communities more resilient. We will have made meaning.

In her letter to the chancellor, the children’s commissioner outlines a “cocktail of secondary risks” bearing down on vulnerable families, from poverty to homelessness to domestic violence. If closing the gaps means anything at all, it must now mean wrapping the right support around these children – really understanding how to support them – because they will not just bounce back. If the ACEs study  taught us anything, it taught us that.

The children most severely impacted by the pandemic will not find it easy to ‘settle to learn’ (Bomber, 2013) and we must expect their psychological distress to manifest in their behaviour. We know that chronic stress disrupts the nervous system. Many children will be jumpy, volatile, hyper-vigilant; still operating in survival mode and easily triggered into flight or fight reactions. Others may appear dazed or tuned-out. More likely to be girls, these will be the children whose survival strategy is to freeze or to dissociate – to retreat from a frightening and unpredictable outside world into one within the mind that feels more safe.

Never in the history of universal education has there been a more urgent need for our schools to contain and stabilise these children by becoming what Dr Karen Treisman calls the ‘brick parent, the secure base, the safe haven.’ And of course all children will benefit from immersion in the warmth of a relational culture after the deep rupture of Covid-19.

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So what might school leaders do to grow their settings as the brick parents our children need them to become? I’ve suggested five key elements of a wellbeing strategy below, but this is intended as a starting point for further reflection rather than an exhaustive list. Where these is a sense of mission about this work, a commitment to adversarial growth as the only possible way to draw meaning from chaos, then many more ideas will flow.

  1. Hold a formal act of remembrance as a community

We must tread carefully and children must not be re-traumatised, but there is actually a very strong argument for bringing a school community together for organised reflection.; for collective meaning-making. In this piece, Kalayjian writes:

Massive traumatic losses not only create a crisis in the community, they create opportunities for survivors to understand their obligations to one another …. it may well be a paradox that traumatic disasters which disrupt the way of life of a community may well lead to spiritual evolution as long as the community can learn from and find positive meaning in a communal crisis.

A remembrance event could take a wide range of forms. The whole school could clap for carers again and honour the NHS. Perhaps some of the things that pupils achieved when they were out of school could be shared and celebrated. Lots of these are coming through via schools’ social media accounts, but they could also be the basis for an assembly – a celebration of our resourcefulness as a community.

Some children will have lost family members. They might like to have their names read out, followed by a silence. We mustn’t allow bereavement to be a subject too difficult to talk about in school, a stigma, and the community must be given the opportunity to respect personal tragedies and to show compassionate solidarity with its members. We don’t generally invite parents and carers to secondary school assemblies but this might be a good opportunity to reach out to them, given that we have all been in this together. Alternatively, a Podcast of the event could be shared with families. 

        2. Place relationships front and centre and build social capital

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Teachers must be encouraged to be humans first in the wake of this crisis and to build positive relationships, especially with those children who struggle to form social bonds because of their experiences; their lack of trust in adults. These will be the children most in need of what Dr. Perry calls ‘social buffering’ and reaching out to them must be a deliberate strategy, not left to chance. In Dr. Karen Treisman’s memorable words, ‘Every interaction is an intervention.’

The more severely children are traumatised, the more repetition, the more positive relational experiences are needed for healing to occur. Dr. Perry’s calls this ‘therapeutic dosing’:

The good news is that anyone can help with this part of “therapy” – it merely requires being present in social setting and being, well, basically, kind….The more we can provide each other these moments of simple, human connection – even a brief nod or moment of eye-contact – the more we’ll be able to help heal those who have suffered traumatic experience. (From The Boy who was Raised as a Dog)

There will also be a need to deploy kind words and acts strategically, otherwise the Matthew Effect of sharing more of ourselves with children who are already relationally rich and less with the relationally poor will not be mitigated. Information sharing will be crucially important, so far as confidentially allows it. As teachers seeing over a hundred children and young people a day, we cannot target the resource that is our compassion at greatest need if we don’t know where we are needed most. Daily briefings will be key.

Trauma-training for all staff (non-teaching included) will be essential if they are to understand the difference they can make, through simple connection. Most staff will be encouraged by the knowledge that the small things they do and say have such healing potential. Pastoral leads in particular worry greatly about the finite supply of CAMHS therapists against the mountain of need that they see. Reassuring them that the most powerful therapy for trauma is actually in abundant supply all around them will allow them to manage their own anxiety in relation to not doing enough or not being up to the scale of the challenge. They just need the support of colleagues – everyone on the same page and playing their part.

      3. Identify and support children in most need of social buffering

If we value it, we measure it. A simple wellbeing rating scale completed by all pupils – 1 to 10 – and the question, ‘Name an adult in this school who you trust and can talk to’, will suffice. Some children will have expressed their need for additional support through their distressed behaviour. But if we rely on this feedback alone, then we may miss the dissociated children and those hiding through freeze who are equally distressed and in need of intervention.

Dr. Perry is clear that the need to process painful events by revisiting them is universal. In the aftermath of a distressing or traumatic event, we have intrusive thoughts. We keep thinking about what happened and we keep telling and retelling the event to trusted friends or loved ones. This is because our brains know what to do – rather than locking pain away unprocessed, we are driven to habituate it through the act of talking. The pain of loss then becomes tolerable, not toxic.

Teachers and other adults who listen with empathy  perform an important therapeutic function, without being therapists. Some children will be carrying enormous emotional burdens and school might be their only place for talking about these.  When this is the case, then the one-to-one with the trusted adult might be more important than form time, or a lesson, and flexibility will be required. If we don’t create these opportunities for children who need them, then blocked grief can drive self-destructive, dysregulated behaviours and mental illness. Flexibility is a major way of demonstrating that wellbeing is our first priority.

All pupils and families will benefit from being reassured that this is a listening school. As well as screenings, worry boxes (or inboxes), a morning check-in as part of the daily routine, circles, drop-ins, all of these strategies and more are worth introducing if they are not already available for children and families. The message from school needs to be that we do get this and if you are struggling, we want to know.

The virtual check-ins that have been established with vulnerable families during lockdown should be maintained. Paradoxically, social distancing measures have brought some schools closer to their most vulnerable children and families – a tremendously positive consequence of Covid-19 that mustn’t be jettisoned through a return to business as usual.

      4. Reaffirm boundaries, rules and routines as safety measures

Prioritising wellbeing and sweating the small stuff are mutually exclusive; a sure way of inducing rather than reducing stress by turning school into a pressure cooker of exacting, and sometimes from the pupil perspective, arbitrary standards. However, children do need clearly demarcated boundaries to feel psychologically as well as physically safe and the importance of these will need to be emphasised, in safety terms, on pupil’s return.

Rejoining a community will be frightening for those children who have internalised the message that people outside the home are a threat to life. If we can’t make children feel safe, they will not be able to learn. It’s a basic need that must be met so this messaging will be hugely important. Consistency will be critical – if we are allowed to shake hands again, then it is because it is safe to do that. Any member of staff suggesting otherwise undermines the sense of security that it must be our shared mission to re-establish.

Rules, some of which may well be Covid-related and new, should be stated in a positive way (ie. Do…as opposed to Don’t) in simple, limited language and kept to a small number that can easily be remembered and recalled by all pupils and staff. (Jarlath O’Brien, 2020).

Routines also serve to create a sense of safety because they are predictable, allowing hyper-vigilant children to lower their guard. Contributing greatly to an atmosphere of order and calm, it is going to be important to reteach routines when pupils return and to provide visual as well as verbal reminders. It will be helpful to think of all pupils as new starters, in need of clear and reassuring instruction.

      5. Re-evaluate and reaffirm core values, recognising all

Many of us have been reflecting on what really matters to us during this period of community trauma – we have reassessed our values and vowed to make changes in our lives, rather than just reverting back to the old ways. We might have resolved to appreciate simple pleasures more, our loved ones, to prize our personal connections over our possessions, and so on. We have reflected in a wide range of ways and in so doing, we have fashioned something of value from the wreckage of the virus. We have experienced adversarial growth.

Leaders should engage in the same process when schools reopen, collectively. This is an opportunity like no other to engage the whole school community in thinking about what really matters. Are we the same or have we changed? What matters most to us now and how do we live that?

Jarlath O’Brien writes about the way he approached this as a new Headteacher in Leading Better Behaviour (2020). Parents, governors, pupils and staff were asked, ‘What should our children be able to do when they leave here?’ Assimilating responses, he arrived at ‘When students leave, they should be ambitious, articulate, caring, determined, independent, resilient, respectful, responsible and successful’ (p13).

It was then important to embed and celebrate the values by recognising pupils demonstrating them on a day to day basis. A culture of recognition was created. It has been established already that children will need opportunities to talk through what has been difficult for them when they return to their schools, but it is also our duty as educators to fill them with a sense of hope and of their resourcefulness.

Transformation through trauma

A psychological phenomenon that enables individuals to look forward in life instead of being stuck in the past, adversarial growth is the hope. It enables people to emerge from highly challenging life experiences with increased emotional strength and resilience, a heightened sense of appreciation and improved personal relationships.  Some studies have shown that almost 90% of  victims report at least one aspect of post-traumatic growth after the stressful experience. (Tedeschi, 1990) That is a lot of personal growth to work with, in the wake of a mass trauma, and when our school leaders are able to harness it within a shared mission to help our children heal, then that could be transformational.

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SEMH Provision – who is it really for? A reflection on Chapter 5 of ‘Boy who was Raised as a Dog’

It was really lovely to see familiar faces as well as a new one (good to finally meet you Mark Goodwin!) during this period of social distancing. The pleasing symmetry of Dr. Perry’s book, about the importance of human connection, being the inspiration for our get-together was not lost on any of us. It’s fair to say that the relational rewards of gathering as a like-minded group, albeit virtually, were felt more strongly than usual this time, so we made the decision to move to weekly book club meetings. They’ll be every Wednesday, 6.30 to 8.00pm, if anybody else wants to zoom in. (Just @ me for how)

The discussion was, as ever, fascinating and we over-ran. I’m not going to attempt to capture all of it here but will rather focus on one element, which is whether the segregation of children with behavioural difficulties into specialist settings is the right way to help them. With perspectives from mainstream and special ed colleagues, there was rich debate about this.

Leon’s story, summarised below, does raise some difficult questions with the DfE’s stated aim, to ‘remove the bias towards inclusion’ (Gove, 2010), very relevant to this discussion. We have seen the proportion of secondary pupils with EHCPs educated in mainstream secondary schools drop by a third since 2010 to barely over a fifth in 2018 (O’Brien, 2020), with no sign of this particular curve flattening and high needs blocks across England struggling to fund the demand for special school places.

Now more than ever, as we confront the abyss of deep pandemic-driven recession, we must demand very good evidence for any political choice to invest public money in specialist provision, be that alternative provision or SEMH Special, without first adequately resourcing mainstream inclusion. It is fair to say that there has been no deliberate focus on the latter in recent years, at least not from the top (DfE) down, with official DfE guidance on behaviour the cause of real dismay within the SEMH community. Quite clearly, a department that is capable of translating the Timpson review of exclusions, which recommends trauma-informed practice, into a 10m ‘crackdown’ on behaviour, is one that has no vision for inclusion. That needs to change.

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Leon’s Story

This is the most troubling of all of the case-studies in Boy Raised; the only one that has nothing to say about survivorship and recovery but everything about how much damage parental neglect can inflict.

In an alcohol-fuelled rage, 15 year old Leon sadistically murdered and then raped the dead bodies of two barely pubescent girls. Dr. Perry was engaged by Leon’s defence lawyer to determine, pre-sentencing, whether there were any mitigating circumstances, such as a history of mental health or abuse. Initially taken aback by Leon’s lack of remorse, his ‘breathtaking’ coldness, the psychiatrist found an explanation for his emotional deadness upon exploring his formative years.

The boy’s mother, Maria, was mentally impaired and relied heavily on the unstinting support of a large family when her first child, Frank, was born. However, she was forced to move to a new and very deprived neighbourhood when her husband changed jobs. Leon was born soon after the move and Maria found herself quite unable to cope with the new baby single-handed. Her daily routine involved leaving the apartment early in the morning with her three year old and returning at night. ‘He stopped crying so much’, she said – indicating that she thought that this strategy of systematic neglect had worked.

When Maria had taken Frank for walks. Leon had wailed in his crib at first. But he soon learned that crying would bring no aid, so he stopped. He lay there, alone and uncared for, with no-one to talk to him and no one to praise him for learning to turn over or crawl (and not much room to explore anyway). For most of the day he heard no language, saw no new sights, and received no attention.

Deprived of critical stimuli throughout a critical period of development, Leon never developed the normal associations between human contact and pleasure. “What he learned was that the only person he could rely on was himself.” As he grew older, he was indifferent to his parents, whether he hurt them or pleased them, and avoided physical contact. He was bright and leaned to mimic socially appropriate behaviour and to use flattery and other forms of manipulation to get what he wanted. But if he didn’t get what he wanted, then he took it anyway.

Trouble at school inevitably followed and the worse Leon behaved, the more he confirmed to those around him that he was ‘bad’ and didn’t deserve their attention. This vicious cycle ensured that behaviours escalated from bullying into crime. By the fifth grade, he was a regular in the juvenile justice system.

Of course, severely neglected children do not inevitably become sociopaths and indeed Dr. Perry’s book is a celebration of neuroplasticity and recovery through nurturing relationships. There are virtuous cycles too and these can completely change the trajectory. However, many decisions and events conspired against Leon, including but not limited to his experience of education, which we turn to now.

Leon was first placed in specialist provision as a pre-schooler but exposure to a group of other disturbed children only worsened his condition. According to Dr. Perry:

Research has repeatedly found that surrounding a child with other troubled peers only tends to escalate bad behaviour.

Leon’s school career from thereon was spent within these special settings and Dr. Perry posits that this only amplified the harm. His impulsivity was reinforced by a negative peer group who modelled to one another that the best way to solve problems was through violence.

Implications for policy and practice

Now we have no way of knowing whether or not Leon was ever placed in what we would refer to in the UK as high quality SEMH provision. In recent years, we have seen within the sector (and beyond it) the introduction of trauma informed practice and this approach might well have enabled Leon to learn to trust and to form the social bonds that would have saved him (and his victims). We also know that high quality SEMH settings are not characterised by violence, bullying and disorder. On the contrary, they are singularly calm, therapeutic places often much loved by families.

However, despite the nurturing and expert support that is available within such provision, it is highly unusual for children to make enough socio-emotional progress to ever return to mainstream. It is important to ask why this is the case, when the miraculous promise that is neuroplasticity should facilitate healing and recovery, at least for a good proportion. Is it because Dr. Perry remains right and that even the best, most trauma-informed specialists can never quite counteract the influence that troubled peers have on one another? Could the stigma associated with the special setting constitute another barrier? What impact does it have on self-esteem and how is that communicated through children’s behaviour?

Our SEMH book-club members acknowledged all of these challenges, citing the environment that young people are immersed in outside the school as another. If Dr. Perry’s book teaches us anything, it is just how sensitive to the environment the child’s developing brain is; how it is literally sculpted and shaped through interaction with the outside world. Which returns us to the central question. What is the optimal environment, from a schooling perspective, for growth and recovery? Is that to be found within special or mainstream sectors?

The answer is of course both simple – it depends – and complex – it depends on a multitude of interplaying factors, from how inclusive the mainstream setting to how complex the needs of the child. Ultimately, it has to be right that parents, as experts in their children, make the decision. It is not right, however, when such decisions are made with deep regret. For example, a child should not have to be educated in a special school to be protected from the ravages of undifferentiated  ‘behaviour management’ or because consistency means rigid inflexibility in their local school.

Of course, the choice between special and mainstream need not be binary. Resource-base provision within mainstream can be a very positive option when staff are appropriately trained (Mike Armiger’s regulation framework provides an excellent model) and pupils are also included within the wider school community, accessing those lessons they can manage – the range of which increases as social and emotional skills are learnt. We know that children impacted by trauma recover in the context of unconditional, nurturing relationships and resource base staff can offer those. In large secondary settings, where children are not generally so well known as they were in primary (and the movement out into special school accelerates) the resource base is a solution.

However, the conditions for their growth don’t currently exist with the haemorrhage of vulnerable children out of mainstream continuing unabated. Two things need to change for us to level this curve. First, cash-strapped schools need more funding for enhanced pastoral care and the recruitment of specialist staff, such as OTs. Second, the accountability framework needs to be reformed such that a headteacher’s moral purpose and a commitment to every child is no longer career-threatening but rather richly rewarded.

Until these things happen, then it seems to me that SEMH provision is not actually for vulnerable children at all, though it may serve them well. Segregated provision is much more about the maintenance of a narrowly defined mainstream sector that is simply not designed to tolerate diversity or to include all children.

 

Professional Hugs – A reflection on Chapter 4 of Boy Raised as a Dog

Those following this blog will know about our book-study group; a number of us meet monthly to discuss a chapter from Dr. Perry’s iconoclastic The Boy Raised as a Dog and I try to convey a sense of the chapter and our discussion afterwards.

Our most recent get-together focused mainly on the issue of physical contact with pupils. There wasn’t a single mention of coronavirus, that’s how rapidly the crisis has escalated here. But was it ever a good idea for teachers to hug children, even in those carefree pre-Covid days?

Clearly, there is a risk that touch makes teachers vulnerable to allegations, should their actions be misconstrued. And there are children who definitely don’t want to be touched, for a range of very good reasons. But when a warm hug is quite obviously what a child needs, especially a young child, a no-touch policy can feel counter-intuitive, inhuman even.

In the fourth chapter of The Boy who was Raised as a Dog, Dr. Perry underlines the importance of physical contact through Laura’s story. I summarise the chapter below and then go onto consider some of the implications for practice. I’ve linked a school policy which leaders grappling with this tricky area of work may well find useful.

We do of course have access to departmental guidance on physical contact in the form of Use of Reasonable Force in Schools but nothing, somewhat sadly in my view, to steer us in the use of kind, emotionally regulating touch. Model policies are therefore helpful. The example shared (from an Outstanding school, for what it’s worth) usefully frames the approach taken in child-development and trauma-informed terms.

Laura’s Story

When Dr. Perry first met Laura as a four year old, she weighed just twenty-six pounds and was being fed a high-calorie diet via a tube. Since birth, she had puzzled medics with no-one able to explain her inability to gain weight. The theory at the point of Dr. Perry’s intervention was that Laura had a rare case of ‘infantile anorexia.’

Beginning with a focus on family history, Dr. Perry found that Virginia – Laura’s single mother – was a child of the foster care system at a time when it was common to move children to new foster carers every six months. The rationale for this was that it would prevent them from becoming too attached to one particular carer.

Consequently, as an adult, Virginia had no idea what to do with her baby. “Having had her own early attachments abruptly and brutally terminated, she didn’t have what some might call ‘maternal instinct” (p94). The result was that whilst Laura’s physical needs were met – Virginia had been taught and understood from foster carers the importance of personal responsibility – her emotional needs were neglected.

‘Failure to thrive’ is a condition that has been documented for centuries. Dr. Perry draws our attention to the suffering of children in orphanages and other institutions where there is not enough attention to go around. For Laura, the lack of nurturing interaction with her mother had been devastating. Her body responded with a hormonal dysregulation that impeded natural growth, despite any amount of nutrition. Dr. Perry’s prescription for Laura, and her mother, was therefore human touch.

This came in the form of a confident, highly experienced foster carer known as ‘Mama P’. The first time Dr. Perry met her, she was caring for ‘Robert’ – a boy who had lived in six foster homes, three shelters and who carried a dozen diagnostic labels, from ADHD and ODD, to bipolar, to schizoaffective disorder.

Robert presented in clinic because his episodic rages were causing problems at school and Mama P was refusing medication: “No doctor is going to drug up my baby.” Asked how she managed Robert’s rages at home, Mama P advised Dr. Perry:

I just hold him and rock him. I just love him…..I just put everything down and hold him and rock in the chair. Doesn’t take too long, poor thing. (p102)

Mama P knew long before the medical world that many young victims of abuse and neglect need physical stimulation, like being rocked and gently held. She understood intuitively that our interactions with children must be based on what they need, not on their age. (“Robert has been a baby for seven years.”) Dr. Perry observes that all of the children sent to her had “a tremendous need to be held and touched.”

They had never received the repeated, patterned, physical nurturing needed to develop a well-regulated and responsive stress response system. They had never learned that they were loved and safe; they didn’t have the internal security needed to safely explore the world and grow without fear. They were starving for touch – and Mama P gave it to them. (p103)

The doctor’s prescription, then, was for Laura and her mother to move in with Mama P and there they remained for about a year. Both benefited immeasurably – Virginia got some of the mothering she had missed, as well as learning how to parent by following Mama P’s cues. Laura gained ten pounds in the first month of her stay and her growth continued, both emotionally and physically. She went onto college and both of her own children did well in school. Virginia had a second child who suffered no growth problems. The three remain tight friends.

Implications for Practice

At Ashleigh Primary School and Nursery, we have adopted an informed, evidence based decision to allow safe touch as a developmentally appropriate intervention that will aid healthy growth and learning.

Clearly, there is much to be said for policies like the one cited above, from Ashleigh Primary School. It can read in full here.

The document makes reference to the neurobiological research evidence for physical contact before outlining the range of forms that touch may take within school, namely:

  • Casual/informal/incidental touch
  • General reparative touch
  • Contact play
  • Interactive play
  • Positive handling/restrictive intervention

The practice wisely enshrined within this policy is perhaps more commonly found within special schools. Indeed, one of our book-club members described a beautiful example of physical contact that she had deployed to ground and regulate a distressed pupil in her MLD setting that very day.

Many Lincolnshire have accessed the LA’s (free) two-hour introduction to trauma-informed practice. This includes some thinking about Dan Siegel’s  window of tolerance and the strategies we might use to co-regulate dysregulated children back into their thinking brains. We’ve found that special school colleagues are generally quick to share a range of strategies at this point in the training. Many of these are tactile, and all well established within everyday practice.

If we are to respond in an evidence-informed way to the exponential increase in the number of young children now being identified as having SEMH needs within mainstream, maybe this is special school practice that needs mainstreaming. Without doubt, as increasing numbers of children arrive in our schools with significant social and emotional gaps, responding to their stage and not their age has become imperative.

That said, there are many schools that have accepted this challenge already and trauma-informed practice is growing as a grassroots movement. Because it’s about human connection, providing psychological safety through authentic relationship, it’s exacting emotional work though. Much easier to deliver the academic curriculum.

It seems appropriate to end by acknowledging the many teachers and pastoral staff who engage in this emotional labour. Especially now, in the context of coronavirus lockdown, when they will be worried about all of those in their care who aren’t hugged enough at home, or who weren’t at a critical stage of development. The Lauras.

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What secondary schools can learn from primary about changing behaviour: a reflection on chapter 3 of ‘Boy Raised as a Dog’

This is the third in a series of what will be ten posts inspired by Dr. Perry’s case-studies. It was a small (but perfectly formed) group that met for Chapter 3 and this post captures an element of the discussion that has haunted me since, as a secondary teacher and SENCo reflecting on what I could have done better.

Beginning with a brief outline of the case-study, Chapter 3 focuses on Dr. Perry’s work with the child victims of the Waco siege of 1993, when a 51 day stand-off between US federal agents and the Davidian cult ended with the destruction by fire of the cult’s compound and 80 fatalities.

Dr Perry’s ‘rapid response’ trauma assessment team was brought in to support the children through this crisis. He had formed the team in part to research why children are impacted by traumatic events in such a wide range of ways – some seemingly unscathed while others develop serious mental illnesses and behaviour problems:

No one knew where the devastating symptoms of conditions like post-traumatic stress came from, and why some children would develop, say, primarily dissociative symptoms, while others would be mainly hyper-vigilant. (p61)

To explore this, it was necessary to work with children immediately after a traumatic event rather than years later, which tended to be when children were brought to him. There was indeed rich learning: “The seeds of a new way of working with traumatised children were sown in the ashes of Waco.” (p85)

The Davidian children had experienced severe abuse at the hands of their mercurial cult leader, David Koresh. He believed that the will of children needed to be broken with strict physical discipline if they were to stay ‘in the light.’ Maintaining an iron grip, he separated husband from wife, child from parent, friend from friend – undermining any relationship that could challenge his rule of terror. Children lived in constant fear of the physical attack and public humiliation that could result from the tiniest error, “like spilling milk.” (p60). Children were starved, beaten with a wooden paddle and for the girls there was the sure knowledge that many would be groomed to become ‘Brides of David’, as young as ten.

On top of this appalling context, the children were facing the real and present terror of the siege itself when Dr Perry met them. They had witnessed a deadly raid on their home, been driven away from their parents in tank-like vehicles, interrogated by FBI and Texas Rangers, often for hours, and placed temporarily in a strange children’s home, their future destination unknown. The children did not feel like they had just been liberated. They felt like hostages.

We immediately recognised that we had a group of children that had essentially been marinated in fear. The only way we could get them the help they needed was to apply our understanding of how fear affects the brain and then consequently changes behaviour. (p67)

Perry reminds us that the brain evolved from the inside out and that it develops in much the same order. The brainstem completes much of its development in utero and in early infancy. The midbrain and limbic systems develop next and the frontal lobes of the cortex, which regulate planning, self-control, and abstract thought do not complete their development until late adolescence.

This sequential development explains why very young children are at great risk of suffering lasting effects of trauma: their brains are still developing.

The same miraculous plasticity that allows young brains to quickly learn love and language, unfortunately, also makes them highly susceptible to negative experiences as well. (p68)

Fear, our most primal emotion, arises from the brainstem and shuts down the highest cortical regions first. We subsequently lose the capacity to think, plan, even sometimes to speak. We just react. With prolonged fear, there can be chronic or near permanent changes in the brain. Terror, especially early in life, may cause an enduring shift to a more impulsive, more aggressive, less thoughtful and compassionate way of responding to the world. This is because the brain is use-dependent. The more a system like the stress response system is fired, the more it changes and the greater the risk of altered functioning. Similarly, the less the cortical regions are used, the smaller and weaker they become:

Exposing a person to chronic fear and stress is like weakening the breaking power of a car while adding a more powerful engine: you’re altering the safety mechanisms that keep the ‘machine’ from going dangerously out of control. (p69)

Dr. Perry explains how understanding the importance of use-dependent development was vital to his work in treating the traumatized children of Waco.

He found that they needed the opportunity to process what had happened at their own pace and in their own ways. They didn’t need traditional ‘therapy’ from a stranger. The children were able to control when, with whom and how they interacted with the nurturing adults around them. Soothing connections were made according to compatible personality types and a powerful therapeutic web was observed to develop around the children. Staff meetings charted these interactions and it emerged that therapeutic experiences were taking place in short, minutes-long interactions.

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To experience the psychological safety essential for recovery and growth, the children also needed predictable routines and clearly demarcated boundaries, enforced through an empathic, relational approach to discipline. Staff were fully aware that the children’s permanently aroused, fearful state would make them prone to mistakes – impulsive or aggressive behaviour. It was important not to punish them for these natural responses but to redirect their behaviour until they calmed down and were able to reflect. It was vital that discipline did not undermine relationships, because:

Relationships matter: the currency for systemic change was trust, and trust comes from forming healthy working relationships. People, not programmes, change people. (p85)

Longer term, outcomes varied enormously. Some of the Davidian children went on to study at college, have families and careers. Others led profoundly troubled and chaotic lives. Dr. Perry is clear about what made the difference:

The children who did the best after the Davidian apocalypse were not those who experienced the least stress or those who participated most enthusiastically with us at the cottage. They were the ones who were released afterwards into the healthiest and most loving worlds. In fact, the research on the most effective treatments to help child trauma victims might be accurately summed up in this way: what works best is anything that increases the quality and number of relationships in the child’s life.

We can only speculate about the extent to which experience of school impacted on outcomes for these children, but the evidence would suggest substantially – because school is potentially a huge contributor of high quality relationships. It is one of the most important protective factors that children can access. A teacher making a connection with a child can change a life. We know this. Not only do neuroscientists like Dr. Perry tell us it is so, but we have the powerful personal testimony of survivors like Ian Wright and Jaz Ampaw-Farr. (If you haven’t watched her “Power of Everyday Heroes’ on YouTube, you really must).

But the experience of school can also be harmful; stress and fear inducing rather than reducing. We have seen that children impacted by trauma are often hyper-vigilant and volatile – they will make mistakes. If we are not trauma-informed in the way that we respond to these, then we can expect distress and with that dysregulation to intensify. We are in effect fuelling the brainstream and at the same time restricting cortical growth when ‘consequences’ are all we’ve got; when we are doggedly ‘consistent’ in the administration of these.

Two questions of critical importance then:

1. Do we know our children and young people well enough to ensure we ‘First, do no harm’ when we respond to their distressed behaviour?

2. Do our systems allow us to respond in flexible and helpful ways?

The case-study below illustrates that we can and do, as educators, change lives when the answer to these questions is yes. The work described below is beautiful, but I think relatively uncommon in secondary schools – including all of those that I have worked at. That’s why the anecdote haunts me. I think many of us, as we immerse ourselves in the world of trauma-informed practice, would respond differently to some of our most ‘challenging’ young people if we could only go back. We can all, I’m certain, bring a ‘Sam’ to mind.

A Case Study

‘Sam’ began at a new school as a Year 5 (?) pupil having been permanently excluded from another setting for ‘persistent disruptive behaviour’. Professionals counted nine adverse childhood experiences (ACES) from scrutiny of his social care file and discussions with his very young single mum on admission. Domestic violence, arson, prison, pedophilia, bereavement and mental illness all featured in his troubled and complex history.

It was anticipated that he would need a high level of support, at least through transition, and a key adult was assigned this role. As she approached the Y5 class with him,  his fear and anxiety increased visibly and by time they reached the door he was punching and kicking her.

Recognising this as the survival behaviour of an extremely anxious boy, the key adult resolved to get to know him away from the classroom. The next week, a table was provided for him outside the class and they worked there. Later, another pupil joined Sam to work outside the classroom and gradually a small group was formed. Whilst class 5 were in assembly, Sam and his key adult would thoroughly explore the classroom.

Eventually, he felt safe enough to join the classroom to learn alongside his peers. Progress continued such that, as a Y6 child, all he needed from his key adult was a daily check-in and the chance to talk about home. She was by now working with another highly vulnerable new starter and Sam was proud to have been asked to mentor him. He was able to offer the assurance that things do get better, people are kind and school is safe.

Sam’s behavior deteriorated towards the end of Y6 as he became anxious about transition into a large high school. As it turned out, with good reason. He appeared back at his primary school one cold afternoon with the news, “I’ve been kicked out.” He never returned to mainstream.

 

 

 

 

 

 

 

 

“Give me someone I can talk to” Reflecting on Chapter 2 of Boy who was Raised as a Dog

Last week our Think2Speak based book-study group met for the second time to discuss Chapter 2 of Dr. Perry’s ‘The Boy who was Raised as a Dog’. It was lovely to welcome new participants and it’s worth reiterating that people are free to join our conversation at any stage – either by coming along to Gainsborough or virtually, via a Zoom link. The purpose of this blog is to reflect some of the discussion and to share it with a wider audience of educators, many of Dr. Perry’s insights having such relevance to the way we do schooling and in particular ‘behaviour’. (The Chapter One reflection can be found here.)

Introducing Sandy – Chapter 2

Like all of the children featured, ‘Sandy’s’ is a heartbreaking story. She witnessed the rape and murder of her mother as a three-year-old and was left for dead after having her own throat cut.  A protection programme meant that her history wasn’t shared with the series of foster carers that she was subsequently passed between or the many teachers she encountered.

Sandy’s therapy, when it was eventually provided, involved enabling her to re-enact elements of the traumatic experience, a process that she initiated and controlled throughout her many sessions with the psychiatrist. Dr. Perry’s role was essentially that of Sandy’s prop.

He explains the purpose of this approach: “To restore its equilibrium, the brain tries to quiet our sensitised, trauma-related memories by pushing us to have repetitive, small doses of recall. It seeks to make a sensitised system develop tolerance.” Sandy’s brain was providing the ‘dosing’ it needed to tolerate the events of that night.

Her progress was slow but steady. Over time she became less prone to fight, flight and freeze behaviours, less triggered, more self-regulated and she was able to cope with school.  Indeed, we learn at the end of the chapter that she went on to achieve good grades and now lives a fulfilling life as a notably kind person.

One of the most uplifting features of this book is its joyous illustration of neural plasticity: with the right care, all children can recover from developmental trauma to thrive. That’s what makes the case for trauma-informed practice as standard in schools such a compelling one. The stakes are enormous.

Implications for educators

Whilst Sandy’s story is extreme, Dr. Perry is clear that the need to process painful events by revisiting them is universal. In the aftermath of a distressing or traumatic event, we have intrusive thoughts, he explains. We keep thinking about what happened and we keep telling and retelling the event to trusted friends or loved ones.

The vast majority of readers will know the truth of this. When my mum died, some fourteen years ago now, I talked and talked and talked to family members, especially the brother who was with me ‘at the scene’. I returned to work too early, with hindsight, and ran out of petrol on the A17 because of the daze that I was in. I remember knocking on the door of a very kind stranger and telling her my story too (as well as asking for petrol!). She gave me the longest hug and that helped. My boss, on the other hand, never checked in with me and I always thought less of her for that. A lot less, actually.

People who listen with empathy  perform an important therapeutic function, without being therapists. We know that many children experience bereavement and loss, they carry enormous emotional burdens, but do we create opportunities for them to talk about these in school? They don’t benefit from the option of compassionate leave – they are expected, by and large, to go with the programme despite the fractious divorce or whatever it may be that plays out at home. How easy do we make this for them, really? Do we encourage them to share their worries and ensure that each has access to a trusted adult?  Belonging to a form group simply doesn’t tick that box – especially in settings where the form tutor role has been reduced to checking uniform and equipment.

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We have a wealth of scientific research that says ‘social buffering’ (having someone at the time of the painful life experience, to listen, empathise and understand) can prevent painful experiences transitioning into toxic stress, or trauma. This buffering is something that needs to be planned as part of a school’s mental health provision. Dr. Perry repeats time and again that the most accurate predictor of positive mental health outcomes is the number and quality of a child’s relationships. ‘Relational poverty’ greatly increases risk, therefore. Resilience is not created within the child but is cultivated in the web of relationships around the child. Something the DfE completely fails to understand in its ill-informed framing of ‘character education’, of course.

I was privileged to speak to two CAMHS peer support workers recently – young people, that is, who have accessed the service in the past and now support new entrants. I asked the boy whether school could have done anything more to meet his emotional needs early. His reply was instant. “Yes, they could have given me someone I could talk to.” The girl remarked that there was a TA in school that she did trust enough to talk to – in fact, he was the single reason she didn’t school-refuse, so important to her was access to this empathic adult. However, their discussion was limited to 5 minutes at the start of the day, because it wasn’t possible to be excused from form-time. Stories like this highlight an inflexibility and lack of understanding that we need to address if young people are to access the psychological support they need within school. The answer is rarely as simply as a referral out into services and the strong message from these young people was that this was not what they wanted.

There is, of course, much really good practice too. For example, key worker schemes through which all adults in a school are utilised – from receptionist to site manager to headteacher – to offer an empathic ear.  I operated such a system at my last school and can verify that an option to self-refer did not open the floodgates. The provision was used responsibly by pupils and much loved by our local CAMHS team, who provided a level of supervision. The coaching circle model developed at Carr Manor (website strap-line – ‘we know our children well’) in Leeds is very exciting. Here, pupils don’t meet as large form groups but rather split into small vertical coaching circles three times a week. Pupils are very well known, cared about and talk to any one of them and they will confirm that their coaching circle feels like family. Worry boxes, I wish my teacher knew schemes – all of these enable young people to feel safe in the knowledge that school is a place that understands and that there are people ready to listen when needed.

Our next book study discussion is on January 22nd 2020, 6.30 – 8.00pm, Think2Speak, Marshall’s Yard, Gainsborough.

We’ll be discussing Chapter 3. Join us if you can!

 

 

Chapter 1 of ‘The Boy who was Raised as a Dog’ & key messages for educators

Our book-study group

I read ‘The Boy who was Raised as a Dog’ (TBWWRAAD) on a family holiday this year and I found that I really wanted to talk about it. Strangely though, apart from one animated discussion about the fact that people will always speak English with a foriegn accent if they learn it after puberty, I was unable to generate much enthusiasm for Dr Perry’s insights.

I can understand a reluctance to talk about childhood adversity and trauma whilst unwinding on holiday, of course, but this isn’t a depressing read. (I also refute the charge that it was ‘a work book’.) It is actually about the extraordinary courage, the survivorship and ultimately the recovery of traumatised children, when they are held by attuned adults.

TBWWRAAD urges readers to reach out to vulnerable children in the sure knowledge that small acts of kindness make a difference. It’s about relationships over referrals, love over diagnostic labels.  The key message is a galvanizing, a democratizing one because it is essentially that we can all help children recover from trauma, through simple human connection and kindness. The implications of this are massive – for schools, for service design and delivery, for families. It’s something all of those who come into contact with children need to be talking about.

Undeterred by the family fail, I therefore tweeted that it would be great to start a conversation with interested readers and from that our book-study group was born.   We met for the first time last week at the HQ of Think2Speak in Gainsborough. A social enterprise that aims to enable helpful conversations, this provided the perfect context and it’s where the group will continue to meet monthly.

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Mostly, we wanted to get to know each other a bit and talk about ‘Tina’ (Chapter One) but we also needed to agree how best to share any implications for practice: Dr. Perry is clear that school has the potential not only to heal but also to further harm traumatised children. There is a strong moral imperative, therefore, to share the knowledge. Especially as we are in the realm of biological fact here.

We agreed that we would blog about each of Perry’s patients (this is the first attempt), produce an info-graphic of the key messages (good luck with that one Mel) and design a model PSP for each school-aged child. The PSP will be co-constructed each time we meet; a way of sharing best inclusive practice between us and also of translating some of Dr Perry’s insight into a practical resource for educators.  Future posts will follow the format below and there will be ten of these, one for each of Dr. Perry’s subjects. The aim of the posts is not to cover each chapter comprehensively but to pull out those elements that have clear implications for school policy and practice.

Introducing Tina – Chapter One

Just seven years old when he started working with her, ‘Tina’ was Dr. Perry’s first child patient and he describes the panic of feeling inexperienced and out of his depth on their first encounter.  Tina had been sexually abused by a babysitter over a two year period. A year later, she was presenting in school as disruptive, aggressive and inappropriately sexualised and had been referred to the clinic by her mother, Sara.

Dr. Perry worked with Tina for a period of three years, beginning by simply lying next to her on the floor and colouring with her. Through the child-directed games that they played in the weekly sessions that followed, Tina learned new concepts, like waiting, taking turns and thinking before deciding what to do next.

Dr.Perry was delighted by her apparent progress: over time, reports of inappropriate behaviour at school stopped, she was no longer fighting with other children, her speech and language improved, she developed impulse control and was able to pay attention for sustained periods. However, after the therapy ended, Dr. Perry received the devastating news that Tina, now ten, had been discovered performing fellatio on an older boy at school.

He concluded from this that whilst he had helped Tina learn appropriate behaviours to avoid getting into trouble, he had not succeeded in addressing the trauma that was at the root of her difficulties. His examination of the neuroscience of developmental trauma, through which he developed better tools than he had at his disposal for Tina, is in essence the subject of TBWWRAAG.

Take-aways for Educators

  • School punishments can be harmful

It is fitting that one of our group is Callum Wetherill because he leads the Lose the Booths  campaign. Tina’s story and tens of thousands like it raise grave concerns about the undifferentiated use of punishment, or ‘consequences,’ in our schools. It doesn’t need a child psychologist to work out that punishment – the use of power to do something unpleasant to another human being – can re-traumatise survivors of abuse.  Tina avoided this as a primary aged pupil but we will never know how many older victims, acting out their distress and their profound mistrust of adults in secondary schools, spend hours in isolation booths. We do know that sexual abuse is very common and mostly never reported. We must hold in mind then that behavioural difficulties (I prefer ‘distress’) are a reason to be curious and compassionate, not judgemental and punitive.

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  • Children need to be taught self-regulation, not ‘managed’

The book is in many ways a celebration of neural plasticity. The brain fires and wires throughout the lifespan but the rate of change during childhood is little short of miraculous. That’s why, with the right stimulus from Dr. Perry, Tina very quickly developed skills that were lagging as a result of her developmental trauma. (The impact of trauma on executive functioning will be covered later, as one of the book’s key themes.)

However, too often, when the response to distressed behaviour is rigidly behaviourist, children are not given the necessary stimulus for new neural connections to be made. Rather, pressure is applied in the form of rewards and sanctions aimed at encouraging ‘better choices’. This futile, stress-inducing manipulation only results in school discipline becoming a traumatic experience for children who need help to grow skills, not sanctions for lacking them.

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  • Diagnostic labels can get in the way of recovery

Dr. Perry describes two very different experiences of supervision in this chapter. ‘Dr. Stine was a complacent traditionalist and his advice about Tina went as follows: “She is inattentive, a discipline problem, impulsive, non-compliant, defiant, oppositional, and has problems with her peers. She meets diagnostic criteria for Attention Deficit Disorder and oppositional defiance disorder.” Dr. Perry wondered how a Ritalin prescription could possibly solve Tina’s problems and left feeling confused and disappointed. In his other supervisor of that time, however, he found a liberating mentor; one who encouraged him to challenge traditional disorder-thinking and to ask what had happened inside Tina’s rapidly developing toddler brain during the period of horrific sexual abuse. Dr. Dyrud’s focus was never on medicalising ‘symptoms’ but on identifying their roots.

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SENCOs and families might be inclined to believe that referrals to paediatricians for diagnostic assessment are in the best interests of children, but this is clearly not always the case. As one of our book-study members has witnessed on many occasions,  accompanying families for assessment, diagnosis never takes into account environmental factors, it is undertaken by a stranger to child and family, and it is very quick. Substantial evidence about the widespread misdiagnosis of trauma as psychiatric disorder is now available. It represents a therapeutic catastrophe for children because it locates the problems ‘within child’ and the solution in drugs. No amount of medication is going to heal trauma. Only relationships can do that.

  • Relationships are the best therapy

As already suggested, the great theme of this book is relationships. Every chapter can be viewed as a take on this biologically incontrovertible conclusion:

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Schools are huge sources of what Dr. Perry refers to as ‘relational wealth’ – and therefore huge sources of healing, when that potential is harnessed. Clearly, in his early work with Tina, he hadn’t made this  breakthrough in understanding and invested too much hope in one-to-one clinical intervention. Whilst Tina gained much from the sessions, there was certainly growth, they were not up to the task of freeing her from the powerful grip of early trauma.

Only in retrospect did Dr. Perry understand the essential role of ‘therapeutic dosing’ in recovery. Here is how he explains that phenomenon:

Just as a traumatic experience can alter a life in an instant, so too can a therapeutic encounter. Unfortunately, in order for positive ‘doses’ of interaction to lead to long term change, much more repetition is needed. Consequently, the pattern and spacing required to ensure long term maintenance of any therapeutic change is going to require a density of therapeutic interactions that our current mental health model of fifty minutes once a week cannot provide. For children like Tina to truly benefit from therapy, it needs to be embedded in a context of safe and positive interactions.

The good news is that anyone can help with this part of “therapy” – it merely requires being present in social setting and being, well, basically, kind….For people who have been sexually abused, like Tina, just being acknowledged in a supportive, respectful and non-threatening way aids healing. The more we can provide each other these moments of simple, human connection – even a brief nod or moment of eye-contact – the more we’ll be able to help heal those who have suffered traumatic experience.

The implications of this for school policy and practice are enormous. A population study found that half of children in England have experienced one childhood trauma and one in ten have suffered four or more. These are our ‘high risk’ children – high risk of permanent exclusion, of poor mental and physical health in later life, of addiction, of suicide, of stunted lives. (For an excellent public health animation about the impact of trauma on outcomes, see here.) Sometimes as educators we are aware of children’s adverse experiences out of school but often we are not.  So we need to ensure that our schools develop as caring communities in which all children can flourish. We should be prepared to target support when we can – for me, reminders that Pupil X is in need of compassion are entirely appropriate – as a classroom teacher, I know that I would have gone out of my way to offer my own form of ‘therapeutic dosing’. Some pupils may need additional time with a key-adult, a daily meet and greet, more relational opportunity than is generally available during a busy school day, without adjustments. But kindness needs to be standard, so that no child slips through the compassion net simply because their struggle is hidden. This needs modelling by SLT and pupils themselves also need to be taught about the transformative impact they can have on one another. (For ideas about how to create social capital, there is no better source than Paul Dix’ When the Adults Change. )

Consequences may be necessary because of course boundaries must be enforced to keep everyone safe. But when these consequences are arbitrary and puntive rather than logical – when they take away the very stuff that children need to bounce back  from adversity – then they become unethical. We need to move in closer to distressed children  – not marginalise them through exclusion or through the withdrawal of relational experiences, such as playing for the school team, going on the trip, attending the prom. We must at all costs avoid the Matthew Effect of sharing more of ourselves with children who are already relationally rich and shunning the relationally poor because they seem hostile, having not yet learned to trust adults. Tenacity is required, perseverance, deliberate effort – and love, never forgetting that ‘the children who need the most love ask for it in the most unloving ways’.

Next book-study meeting

November 13th 2019, Think2Speak, Marshall’s Yard, Gainsborough. 6.30pm to 8.00pm.

All welcome – either virtually, via a Zoom link, or in person. We will be discussing Chapter Two.

Those attending the inaugural gathering (and thank you so much for doing that) please do use Comments below to note anything that I may have missed from our discussion. I know I haven’t covered it all!