Written evidence submitted by WAVE Trust (CYP0027)
- This submission will focus primarily on how children and young peoples’ mental health can be best supported through preventing trauma from occurring during the early years and supporting those who have experienced it via trauma-informed practice and communities.
- Adverse childhood experiences (ACEs), and the trauma they can cause, are one of the most prevalent and impactful root causes of mental health issues, alongside many other personal and social problems.
- The earliest years of a child’s life are highly important for brain development, laying the foundation for a person’s cognitive, mental and emotional abilities. Both the damaging impact of ACEs and the beneficial impact of best childrearing practices that build resilience are most profound when they occur during this period.
- Correlations between ACEs during any point of childhood and suicide attempts, both for children and adults, are particularly strong.
- Research tells us how we can prevent trauma from occurring during the early years, and ensure optimum brain development for as many children as possible during this time. We know what approaches and programmes can be implemented to great effect, including in particular the clinical-based programme Parent-Child Psychological Support (PCPS).
- Trauma-informed practice has been shown to achieve a range of positive outcomes across multiple sectors. We have a substantial and growing evidence base showing that it is particularly effective at providing a ‘therapeutic’ environment for all children, with positive side effects including reductions in exclusions.
- UK-based case studies also show how trauma-informed practice (and similar) can be very effective as part of a wider approach at reducing the use of physical restraints in mental health services.
- Trauma-informed practice at individual services works most effectively when they are part of a wider Trauma-informed Community, whereby not only do all services use this approach, but the information is also disseminated among the wider population.
Recommendations for actions
- Government strategies aimed at improving the mental health of children and young people should prioritise attention and resources on the first 1,001 days of life.
- The Government should fund at least one pilot of the clinical-based programme Parent-Child Psychological Support (PCPS) in a UK-based locality.
- Trauma-informed practice should play a key role in the Department for Education and Department for Health’s strategies to support the mental health of children and young people.
- The Government should fund at least one pilot of a Trauma-informed Community project based on Washington State’s successful and cost-saving Self-Healing Communities model.
- Government’s strategies aimed at reducing rates of suicide attempts should take into account the significant correlations between them and ACEs.
WAVE Trust – who we are and what we do
- WAVE Trust has 24 years’ experience of researching and working in the field of trauma. It has delivered training and workshops on Adverse Childhood Experiences (ACEs) and trauma in England, Northern Ireland, Scotland and Wales. The charity is a member of the World Health Organisation’s (WHO) Violence Prevention Alliance and has advised the UK Cabinet Office, Home Office and Departments of Education and Health, the Scottish, Welsh and Northern Irish Governments and the Metropolitan Police. It is the UK co-ordinator for the WHO European Trauma Informed Prevention of Adverse Childhood Experiences Network.
- George Hosking OBE, CEO and Research Director: George is a trained Clinical Criminologist with experience of working with victims of trauma both in prison and in the community, and has an Advanced Diploma in the Management of Psychological Trauma and degrees in Economics and Psychology. He has decades of experience delivering presentations and workshops including over two decades on infant mental health, brain development and the early years of children’s lives.
- Aidan Phillips, Trauma-informed Communities Project Manager: Aidan oversees WAVE’s Self-healing Trauma-informed Communities (STiC) project, supporting community-led and statutory projects across the UK. He was the principal researcher in our 3-year study of severe disadvantage which identified the key role of adverse childhood experiences (ACEs) on the pathway to homelessness, unemployment, school exclusion, mental health problems and the criminal justice system; and in a recent project which involved interviewing more than 70 practitioners with experience of implementing trauma-informed practice across education, health, housing and policing UK-wide.
Our reason for submitting evidence
- Despite decades of compelling research in this field, the significantly positive impact we could have on the mental health of children and young people (and adults) if we prevented trauma from occurring, particularly during the early years, continues to be largely unexploited by the Government. In addition to this, the evidence base for trauma-informed practice and communities as means of effectively mitigating the impact of trauma where it has occurred is becoming increasingly compelling over time, with a growing number of UK-based projects showing promising results. We believe that both of areas need to play a far greater role in the Government’s mental health strategy than they currently do.
- We will begin by detailing the psychological basis to our arguments throughout this submission. We will then detail our recommendations and how they relate to items in your call for evidence (https://bit.ly/2ZqK8eW).
Why trauma, particularly during the early years, is the key to improving mental health
Adverse Childhood Experiences (ACEs) and trauma
- Studies into ACEs often categorise adversity as abuse (physical, sexual, emotional); neglect (physical, emotional); or household dysfunction (witnessing domestic violence, parental substance abuse, parental mental illness, parental incarceration, parental separation). There are other possible options, including parental death and experience of community violence.
- These experiences are by no means rare: studies from England and Wales between 2013 and 2018 have shown that 46-50% of people experience at least 1 type of ACE, whereas 8-14% experience 4 or more types (referred to as an ‘ACE score’ of 4).[i]
- What is most important is whether each incident has the potential to create “toxic stress”. “Toxic stress” is where a person experiences natural stress responses (fight, flight or freeze), but in a manner which is more prolonged, severe or unpredictable than usual. When this is coupled with a lack of support by caring adults, the brain is left unprotected from the increased levels of cortisol and development is disrupted. For instance, it is the difference between boxing in a gym, but returning home to a stable household; and being punched by your father, creating an unsafe home environment. If a child experiences toxic stress, especially during its earliest years, it can result in the child’s brain to believe it’s in permanent danger and/ or over-react to actual threats.
- Numerous studies have demonstrated strong correlations between ACEs and later life mental health issues. For example, a meta-analysis of ACE studies (Hughes et al., 2017) found that mental ill health had a ‘strong’ association with ACEs, as categorised by having an odds ratio of between 3 to 6. This included anxiety (3.70 OR), low life satisfaction (4.36 OR) and depression (4.40 OR). Conclusions from other reputable sources include:
- “Experiencing or witnessing violence and abuse or severe neglect has a major impact on the growing child and on long term chronic problems into adulthood. Many mental health service users of all ages have problems directly attributable to severe neglect and/or trauma in the early years.” (WHO, 2013)
- “Maltreatment may cause stress that affects children’s brain development, especially in the early years but also into adolescence. This can lead to cognitive impairment and the development of health-risk behaviours, harming mental and physical health.” (NHS, 2012)
- “Childhood maltreatment strongly predicts poor psychiatric and physical health outcomes in adulthood … individuals who suffer abuse, neglect, or serious family dysfunction as children are more likely to be depressed, to experience other types of psychiatric illness, to have more physical symptoms (both medically explained and unexplained), and to engage in more health-risk behaviors than their nonabused counterparts.” (Bremneet al., 2006)
- “Disorders emerge earlier in maltreated individuals, with greater severity, more comorbidity, and show a less favorable response to treatment.” (Teicher and Samson, 2013)
Table 1. Mental health problems that have been linked to ACEs
- Such damage when it occurs is rarely untreatable, as the effects can often at least be mitigated. But the older a person gets, the harder it becomes to change the architecture of their brain, requiring more time, effort and, in terms of Government spending, money.
- The longer such issues are left unresolved, the more they can become embedded in a person’s psyche and influence their mental processes and actions, causing problems for themselves and possibly others too. Because of this, prevention of ACEs is always the best option, morally, economically and practically.
ACEs and Suicide / self-harm
- ACEs are strongly correlated with both outcomes. For instance, a study of ACEs across eight Eastern European countries (Bellis et al. 2014)[ii] found that each individually increased the likelihood of a person reporting that they had ever attempted suicide, to different extents.
Table 2. Impact of individual ACEs on likelihood of attempting suicide
- However, it is the experience of multiple ACEs, including the increased likelihood for trauma this produces, that correlates most strongly with these outcomes. A meta-analysis of ACE studies (Hughes et al., 2017)[iii] found that suicide attempts had the strongest correlation of any outcome with a person’s ACE score, with the odds ratio averaging at 30.14 across the 3 studies (n=24,858).
- This is supported by a recent UK study (Hughes et al., 2018)[iv] that found a strong correlation between ACE score and whether a person reports having ever felt suicidal or self-harmed:
Table 3. Correlations between ACE scores and suicidal ideation/ self-harming
- Further studies (Dube et al. 2001)[v] have shown that the same correlation holds for whether a person attempted suicide during childhood/adolescence or adulthood.
Table 4. Correlations between ACE scores and suicide attempts
Why trauma during the early years (conception to age 3) is particularly impactful
- A child’s brain grows at its fastest rate during its earliest years, growing to 25%[vi] of its adult size by birth and to 80%[vii] by age 3. During this period, the brain is very sensitive to being affected by its external environment and interpersonal experiences. It is also very elastic, able to learn and un-learn information more easily that at any other point in life.
- During this period, synapses (connections) are added at a rate of more than 1 million per second. Afterwards, they are pruned faster than they are added, leaving the adult brain with 50 to 60% of the synapses of a 3-year-old. Before 3, many of these connections become hard-wired through repeat use, whereas under-used genes are switched off. As a result, a young child’s brain development reflects the world in which they are raised, from their behavioural patterns to their emotions, language capabilities and mental health.
- Beyond 3-years-old, the speed at which their brain develops slows down and this elasticity is replaced by a mindset that becomes increasingly set in its ways.
- Due to this, a child raised in a loving, nurturing environment which is free from persistent, “toxic” stress will develop as healthy a brain as is possible. In contrast, a child raised in an environment of abuse, neglect or household dysfunction will see their cognitive abilities and emotional development severely impaired, moreso than if the damage were to have occurred at any other time in their life.
- These impacts can be identified very early on. A 2003 study (Shaw et al., 2003) showed how the effects of low maternal responsiveness at 10-12 months (a stressor for babies given their appreciation for how dependent they are on adult caregivers) kick in early, predicting higher levels of aggression, non-compliance and temper tantrums at 1.5 years; lower compliance, attention-getting and hitting at 2 years; problems with other children at 3 years; coercive behaviour at 3.5 years; and fighting and stealing at 6 years.
- As such, this period carries both enormous opportunity and risk for the later life mental health of each child. As Sir Michael Marmot said in his report on health inequalities: “The foundations for virtually every aspect of human development – physical, intellectual and emotional– are laid in early childhood. What happens during these early years (starting in the womb) has lifelong effects on many aspects of health and well-being.” (Marmot, 2010)[viii]
Our proposed solutions
Primary prevention of early years trauma
- To tackle trauma in the most effective way – and therefore contribute significantly towards efforts to improve mental and physical illness among children – we must prioritise its prevention during the first few years of life, when the brain is at its most vulnerable and the impact most severe.
- In 2013, WAVE published a framework on how to achieve this (Conception to Age 2, 2013[ix]). This outlined our Pioneer Communities model to prevent trauma during the first 1,001 days and ensure optimum brain development, both for as many infants as possible. This was co-designed with senior staff at the Institute of Health Visiting and the Royal College of Midwives, among others.
- In 2014, the UK Treasury endorsed an ACE-prevention project for implementation in four English localities using this model. Unfortunately, the funding was cut following a change of Government in 2015.
- The Pioneer Communities Model covers:
- Areas of child development that need to be addressed to fulfil these aims (e.g. attunement, attachment)
- Risk factors and processes that need to be taken into consideration and assessed, including:
- Pre-natally: household drug abuse, alcohol abuse, domestic violence, parental mental health problems and intergenerational adverse childhood experiences
- Post-natally at 3-6 months: the quality of interaction (attunement) between child and parent
- Post-natally at 15-18 months: the quality of attachment between child and parent
- A series of programmes and initiatives which have an evidence base suggesting they might be helpful in delivering the goals of the project.
- Collaboration with the wider community in pursuit of these goals, including dissemination of information about the key areas of the model.
Parent-Child Psychological Service (PCPS)
- The early years programme we would recommend most highly is PCPS. PCPS is a clinical-based programme to support healthy growth and development of infants, with particular focus on parent-child interactions, bonding, attachment and infant social and emotional development.
- Positive outcomes include improvements in attachment levels. For instance, secure and disorganised attachment levels among PCPS recipients in a low socio-economic sample (SES) stood at 74.5% and 5.8% respectively, compared to 48.1% and 25.1% in a non-PCPS low SES population.
- To be trauma-informed is for a person or organisation to understand what trauma is, the impact it can have on peoples’ behaviour and how to respond most effectively to this. It involves integrating this knowledge into day-to-day practices, procedures and policies.
- This practice has had a very positive impact on outcomes across a variety of sectors, including schools, healthcare, prisons, housing and children’s services. We will focus on the two areas raised by the enquiry’s call to evidence.
Trauma-informed and attachment-aware schooling
- If the committee wishes to propose recommendations that will ensure thorough mental health support within schools in a manner that is effective, affordable (including potentially cost-free beyond initial implementation) and in line with the current shift in many local education sectors across the UK, trauma-informed schooling should play a key part in them.
- Trauma is particularly relevant to schools, including with regards to challenging and vulnerable behaviour. For example, a 2011 study[x] of youths in a low-income area of San Francisco found that of the 32.8% who said they had 0 ACEs, only 3% had learning and/or behavioural problems. By contrast, 51.2% of the 12% who said they had 4 or more ACEs had these problems.
- The amount of time children spend in school, and around school staff, also provides a sustained period within which meaningful relationships, the bedrock of trauma-informed practice, can be built. See Appendix A for an overview of what it means to be a trauma-informed school.
- WAVE conducts research into the impact of trauma-informed and attachment-aware schooling, as well as similar approaches, on a regular basis. Supported by substantial positive anecdotal feedback from senior staff, quantitative data shows a positive impact on children’s well-being and staff members’ ability to support this. Examples include:
- Attachment-aware schools project, Bath and North-East Somerset: Reductions were achieved in scores for emotional problems (-23%), conduct problems (-19%), peer problems (-19%) and hyperactivity (-15%). Pro-social behaviour increased by 27%.[xi]
- Alex Timpson Attachment and Trauma Awareness in Schools Programme (survey of staff from 24 schools): After 1 year, the percentage of staff saying they somewhat or strongly agreed that they were confident working with vulnerable young people was 80.3%, compared to 50.6% in the control group.[xii]
- The approach has also consistently achieved positive results across a range of outcomes that indicate improved mental well-being among students and staff, including:
- Exclusions: (Oasis Academy Primary School, Manchester) Between 2017/8 and 2018/19, fixed-term exclusions were reduced by 88%.[xiii]
- Disciplinary referrals: (Vallejo Unified School District, California) Between 2010/11 and 2012/13, referrals were reduced by 75%.[xiv]
- Aggression levels: (Healthy Environments and Response to Trauma in Schools [HEARTS] programme, San Francisco) Incidents involving physical aggression reduced 43% after 1 year and 86% after 5 years.[xv]
- Academic attainment, especially among vulnerable pupils: (Lincoln High School, Washington State) Between 2012 and 2013, state assessment scores increased for writing (67% to 81%); algebra (25% to 52%); and science (21% to 57%).[xvi]
- Staff absence rates: (The Key Education Centre, Hampshire) Between 2018 and 2019, staff absences fell by 70%.[xvii]
Trauma-informed healthcare practice
- With regards to providing effective training for the mental health workforce that, among other things, ensures that inpatient care does not result in children and young people undergoing additional stress, we would also recommend trauma-informed practice, especially for frontline-facing staff.
- See Appendix B for an overview of what it means to be a trauma-informed frontline healthcare practitioner. Within this, we have outlined our key messages that, when combined, are designed to create as non-stressful an environment as possible for all patients, where challenging incidents are also de-escalated as effectively as possible.
- A number of services have effectively used either trauma-informed practice or similar approaches based on the same ethos to reduce their use of physical restraints. For example, Springbank Ward (Cambridgeshire and Peterborough NHS Foundation Trust) is a specialist unit for treatment of severe borderline personality disorder in women. Since adopting an approach in line with trauma-informed practice, they have substantially reduced rates of physical restraint and rapid tranquilisations:
Table 5. Restraints and tranquilisations at Springbank Ward[xviii]
Trauma-informed Communities (TiC)
- A Trauma-informed Community (TiC) is a locality, town, city or region where an understanding of the way traumatic experiences can affect the brain, how best to respond to this and how to build emotional resilience against it is widespread among residents and embedded within practice throughout local statutory and support services. Residents, statutory services, the third sector, the private sector and others can all contribute towards the creation and maintenance of a TiC.
- Washington State has implemented ‘Self-Healing’ TiCs for more than 10 years. A comparison of counties adopting this approach with those that did not showed that the TiCs experienced significant reductions in issues with direct relevance to youth mental health problems (e.g. youth suicide); issues whose root causes tend to overlap with those that also cause youth mental health problems (e.g. youth violence, youth substance abuse, teenage pregnancy and school drop-outs); and issues that are common root causes of mental health problems, both in youth and later in life (e.g. child abuse and neglect, family violence) (Porter et al., 2016)[xix].
- Examples from individual counties include:
- Direct relevance: Youth suicide and suicide attempts reduced by 59% (Walla Walla County) and 98% (Cowlitz County).
- Frequently overlapping root causes with mental health problems: Youth arrests for violent crime reduced by 53% (Cowlitz County) and 66% (Okanogan County).
- Potential cause of mental health problems: Domestic violence rates reduced by 37% (Kitsap County).
- A report on this initiative showed that for an annual investment of $3.4 million, prevented cases saved $27.9 million per year, with significant additional indirect savings also (Schueler et al., 2009)[xx].
Our response to the ambitions laid out in the 2017 Green Paper
- In our submission to the Government’s Mental Health Green Paper in March 2018, we made the following points that we continue to stand by:
- Though the Green Paper contained much that was excellent, generally and in its summary it lacked the full possibility of prevention.
- The greatest missed opportunity was the lack of attention given to the prime root causes of mental health problems: ACEs, and their prevention as a means to prevent children from suffering mental health problems.
- Another missed opportunity was the lack of specific attention to the first 1001 days, without which its efforts to reduce the incidence of mental health problems would be seriously hindered.
- Our recommendations to this paper included:
- Recommendation 1: add a new section to the Mental Health Bill relating to preventing Adverse Childhood Experiences, because of their role as root causes of mental health issues.
- Recommendation 2: add a new section to the Mental Health Bill on preventing mental health problems though actions in the first 1001 days from conception to age 2, because of the critical nature of this period in the origins of later mental health problems.
Appendix A: Trauma-informed schooling
- In 2019-20, WAVE Trust was commissioned by the Association of the Directors of Public Health to conduct research into good trauma-informed schooling practice across the UK. The key messages we drew from that research are listed below.
Table 6. WAVE Trust Trauma-informed schooling research key messages
Appendix B: Trauma-informed healthcare
- In 2019-20, WAVE Trust was commissioned by the Association of the Directors of Public Health to conduct research into good trauma-informed frontline healthcare practice across the UK. The key messages we drew from that research are listed below.
Table 7. WAVE Trust Trauma-informed frontline healthcare practice research key messages
[i] Bellis, M. (2013). Adverse childhood experiences: retrospective study to determine their impact on adult health behaviours and health outcomes in a UK population. Journal of Public Health, Volume 36, Issue 1, 1 March 2014, Pages 81–91 [online] Available at: https://academic.oup.com/jpubhealth/article/36/1/81/1571104
Bellis, M. (2014) National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC Medicine, 2014, 12:72 [online] Available at: https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-12-72
Public Health Wales (2015). ACE Report 1 [online] Available at: http://www.wales.nhs.uk/sitesplus/888/page/88504
Public Health Wales (January 2018). ACE Resilience Report 1 [online] Available at: http://www.wales.nhs.uk/sitesplus/888/page/94697
[ii] Bellis et al. (2014). Adverse childhood experiences and associations with health-harming behaviours in young adults: surveys in eight eastern European countries. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4208567/
[iii] Hughes et al. (2017). The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. [online] Available at: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30118-4/fulltext#seccestitle120
Hughes et al. (2018). Sources of resilience and their moderating relationships with harms from adverse childhood experiences. [online] Available at: http://www.wales.nhs.uk/sitesplus/documents/888/ACE%20&%20Resilience%20Report%20(Eng_final2).pdf
[v] Dube et al. (2001). Childhood Abuse, Household Dysfunction, and the Risk of Attempted Suicide Throughout the Life Span. [online] Available at: https://jamanetwork.com/journals/jama/fullarticle/194504
[vi] Huelke, D. (1998). An Overview of Anatomical Considerations of Infants and Children in the Adult World of Automobile Safety Design. Annu Proc Assoc Adv Automot Med. 1998; 42: 93–113 [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3400202/
[vii] Walsh, I. and Hosking, G. (2013). Conception to age 2 – the age of opportunity. WAVE Trust [online] Available at: https://www.wavetrust.org/sites/default/files/reports/conception-to-age-2-full-report_0.pdf
[viii] Marmot, M. (2010). Fair Society, Healthy Lives, Strategic Review of Health Inequalities in England post 2010. Department of Health
[ix] WAVE Trust. (2013). Conception to Age 2 – the age of opportunity. [online] Available at: https://www.wavetrust.org/conception-to-age-2-the-age-of-opportunity
[x] Harris, N.B., et al. (2011). The impact of adverse childhood experiences on an urban pediatric population. Child Abuse and Neglect. 35(6):408-13 [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3119733/
[xi] Dingwall et al. (2018). Evaluation of The Attachment Aware Schools Programme Final Report. [online] Available at: http://www.education.ox.ac.uk/wp-content/uploads/2019/05/Bath-and-NE-Somerset-Attachment-Aware-Schools-Programme-Evaluation-report.pdf
[xii] Rees Centre (2020). Working paper 1: Attachment and trauma awareness training: analysis of pre-Covid survey data from staff in 24 primary schools. [online] Available at: http://www.education.ox.ac.uk/wp-content/uploads/2019/05/Timpson-working-paper-1.pdf
[xiii] Manchester City Council (2020). Does having a trauma-informed workforce at place level improve outcomes for local residents?
[xiv] Stevens (2013). In Vallejo, CA, schools — where referrals, suspensions, expulsions outnumbered students 5 to 1– there’s no place to go but up. [online] Available at: https://acestoohigh.com/2013/10/24/vallejoschools/
[xv] Dorado, J., Martinez, M., McArthur, L., & Leibovitz, T. (2016). Healthy Environments and Response to Trauma in Schools (HEARTS): A whole-school, multi-level, prevention and intervention program for creating trauma-informed, safe and supportive schools. School Mental Health, 8, 163-176. [online] Available at: http://design.fixschooldiscipline.org/wp-content/uploads/2016/12/Dorado-Martinez-McArthur-Leibovitz-SMH-2016-with-figures-1.pdf
[xvi] Sporleder et al. (2016) The Trauma-Informed School: A Step-by-Step Implementation Guide for Administrators and School Personnel.
[xvii] Powerpoint presentation shared with WAVE in October 2020.
[xviii] Briefing shared with WAVE in February 2020.
[xix] Porter et al. (2016). Self-Healing Communities: A Transformational Process Model for Improving Intergenerational Health. [online] Available at: https://www.rwjf.org/en/library/research/2016/06/self-healing-communities.html
[xx] Schueler et al. (2009). Projected cost savings due to caseloads avoided. [online] Available at: https://www.digitalarchives.wa.gov/do/DFDCC0A9E76F9B876E95F928303C9A59.pdf