Abstract
CONTEXT:
Evidence from the COVID-19 crisis suggests that children and youth are more likely to be subjected to maltreatment and exposure to family violence, while experiencing limited access to the usual services that support vulnerable families and provide targeted services to meet their needs. The current global pandemic itself can also be experienced as a traumatic event. Trauma-informed care draws attention to the potential impacts, from the individual to the global, that myriad traumatic experiences can illicit and proposes using these understandings as foundational to the development and implementation of policy and practice.
OBJECTIVE:
The aim of this opinion paper is to offer insights to guide practices and policies during this unprecedented global crisis through a discussion of the Substance Abuse and Mental Health Services Administration (2014)’s six trauma-informed care principles: trustworthiness and transparency; safety; peer support; collaboration and mutuality; empowerment and choice; and cultural, historical and gender issues.
FINDINGS:
Specific recommendations based on these six principles and applied to the current situation are presented and discussed. These principles can serve both in the immediate crisis and as preventative measures against unforeseen future traumatic contexts.
CONCLUSION:
COVID-19 renews the imperative to maintain and strengthen trauma-informed practices and policies. We argue that never before has trauma-informed care been so important to promote the health and well-being of all and to protect our marginalized populations at greatest risk.
Over the past decade, trauma-informed care (TIC) in child and family services has been gaining traction. The growing empirical evidence base demonstrating both the high prevalence and detrimental impact of child trauma highlights imperatives to rethink child, youth, and family services to prevent these experiences from happening in the first place and to support victims and their families through recovery. Schools, social services, child protection, mental health and psychiatric services, the medical system, community organizations, and advocacy bodies all have the potential to become vectors of resilience and healing for children and youth affected by child trauma. Yet, traditional child-serving sectors too often adopt symptom-focused approaches that eschew root causes of mental health problems in favor of behavioral interventions (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). Even in child protection settings, the developmental nature of child trauma often goes undetected and therefore unaddressed despite the impairments children and youth in these settings suffer as a result of the high levels of adversity they have experienced (Griffin et al., 2011; Zelechoski et al., 2013).
TIC approaches to practice and policy have gradually emerged to promote a culture of safety, empowerment, and healing around victims of child abuse. TIC represents approaches to policy and practice that include “awareness of the prevalence of trauma, understanding the impact of trauma, and commitment to incorporating those understandings in policy, procedure, and practice” (Yatchmenoff et al., 2017, p. 167). TIC draws attention to the complex, transactional mechanisms through which the effects of trauma reverberate across all ecological levels (from the individual to the global), and proposes using this understanding as a foundation for the development and implementation of policy and practice (Hanson & Lang, 2016). The TIC movement is increasingly visible in newly-developed advocacy and legislative frameworks (ACEs Connection, 2019, Bowen & Murshid, 2016) and global policies and approaches, such as the World Health Organization’s violence prevention framework (World Health Organization, 2019). The current sociopolitical context, including the #MeToo movement, the Black Lives Matter movement, the Canadian Inquiry into Missing and Murdered Indigenous Women and Girls, demonstrates mounting public awareness and outcry for institutional responses to violence, and particularly to systemic trauma among racialized and marginalized communities. Recent global interest in TIC practice and policy has led to a significant increase in research endeavors that aim to produce empirically-based information and responses to child trauma.
The imperative for trauma-informed care practices and policies
In the current context of the global pandemic there is a renewed imperative to maintain and strengthen TIC practices and policies. First, the COVID-19 experience is, in itself, potentially traumatic for children, youth, and families. It is a stressful event that is unpredictable, extreme, prolonged, and based on an unknown/unfamiliar danger, which is likely to activate a physiological danger response and produce intense stress (Perry, 2020). That lack of predictability paired with lack of control exacerbates stress response. This reaction is compounded for victims and survivors of early childhood trauma whose anxiety responses can be triggered by the overall social climate of uncertainty and worry (Presley & Spinazzola, 2020). For children and youth with trauma histories, anxiety responses are likely to be reactivated and automatic physiological responses can be turned on: “The brain and body have already lived through ‘worst case scenario’ situations, know what it feels like and are hell-bent on never going back there again. The fight/flight/freeze response goes into overdrive. It’s like living with a fire alarm that goes off at random intervals 24 hours a day. It is extremely difficult for the rational brain to be convinced ‘that it won’t happen,’ because it already knows that it
Second, in its analysis of the current COVID-19 pandemic, UNICEF (2020a) identified several potential negative consequences for children and adolescents, including the increased risk of child maltreatment and exposure to violence. This negative outcome has been observed following other tragic events, such as natural disasters (for example, following Hurricane Harvey, Serrata & Hurtado Alvarado, 2019). To this end, the American Psychological Association has recently released guidelines to bring attention to family violence as a major social issue in the current crisis (American Psychological Association, 2020). This risk can result from an increase in caregiver distress and subsequent use of dysfunctional coping mechanisms (e.g. substance abuse), the disruption of support usually offered by social services, the loss of supportive social networks, and a sense of community belonging.
Third, the necessary public health strategies employed, including confinement and school closures, have underlined the failings of current protective systems to offer services to support vulnerable families and provide targeted and effective services to meet their needs. As stated by UNICEF, the consequences of the pandemic are expected to be much more pronounced for children with disabilities, marginalized children, and other vulnerable groups (UNICEF, 2020a, 2020b). The children and families hardest hit, may also be those with the most to lose as the school, community, and social aid resources upon which they rely are shuttered to control transmission of the virus. The current crisis demonstrates the lack of effective, reliable services responsive to the specific risks faced by marginalized populations.
Trauma-informed care principles to inform sound COVID-19 responses
We are currently facing an unprecedented crisis, with no pre-existing guidelines to follow. We suggest TIC principles be prioritized in the development of sound responses by stakeholders, from child-serving professionals to policy-makers. In that vein, the Substance Abuse and Mental Health Services Administration (SAHMSA, 2014)’s six TIC principles offer insights to guide this approach: (i) Trustworthiness and transparency principles imply that decisions are conducted with honesty, and that building and maintaining trust among staff, clients, and family members are central to organizational policies and practices. In the current pandemic context, and following trustworthiness and transparency as guiding principles, professionals must be prepared to respond to an increase of child maltreatment disclosures. Disclosure is a difficult and delicate process and must be received with empathy and sensitivity, especially given the enormous risk the child takes when making a disclosure. The adult’s response to disclosure has a significant impact on the abused child (Alaggia et al., 2019). When children feel that they are not being believed or taken seriously, or when child protection services and the police are called without notice, these children may say nothing more. Adults who receive disclosures may feel angry, helpless, and saddened. It is therefore important to present an emotional response that is as regulated and compassionate as possible, and to do this, they should take time to be attentive to their own psychological states, take opportunities to assess themselves, and seek formal and informal support (for example, see Public Health Agency of Canada, 2011). Further, children and families who have not previously endured traumatic experiences may be suffering due to fear, traumatic loss, or financial insecurity raised by the pandemic. Professionals must have a TIC knowledge-base from which to draw to support these children and families as they make sense of their painful experiences. The NCTSN offers a multitude of evidence-based trauma-informed resources for professionals interested in building their skills in TIC practices (www.nctsn.org). More specific to the current crisis, the Neurosequential Network features a COVID-19 Stress, Distress & Trauma Series that offers insights on how to best serve populations exposed to trauma (https://www.neurosequential.com/covid-19-resources). Safety principle refers to ensuring that clients and family members are experiencing security, at both physical and psychological levels. At the organization level, this requires the setting up of policies that will encourage violence-free environments, for clients and service providers. School-based prevention programs to reduce the occurrence of violence—including bullying and sexual harassment—have been interrupted because of the pandemic, though they should be placed in high priority as schools gradually reopen in most countries. For professionals, clear policies and guidelines to prevent and address violence and aggression, as well as workplace social support targeting the needs of professionals exposed to the aversive details of traumatic experiences in the lives of the children and families they serve must be established (Strand & Sprang, 2018). When working with families, these security principles can be achieved, for example, by discussing the importance of keeping daily routines and setting up rituals, and actively using these to support adult and children/youth affect modulation (Presley & Spinazzola, 2020). These principles focus on caregivers affect management and promote a commitment to address children/youth’s problematic behaviors by avoiding the use of punitive measures (e.g. corporal punishment, restraints, isolations, timeouts). Peer support, or “survivors empowering survivors” programs can be powerful vehicles to recovery (Heal for Life Foundation, 2019; Silk, 2016). Social support has been shown to be one of the most impactful responses for people suffering post-traumatic impacts, and may prevent some degree of the potential negative impacts of trauma-exposure (Brewin et al., 2000; Charuvastra & Cloitre, 2008; Ozer et al., 2003). Peer support appears to act as a buffer between exposure to violence in the neighborhood, school, and media and adolescents’ internalizing and externalizing symptoms, and particularly for those who have cumulated different forms of adversity and present with complex trauma (Yearwood et al., 2019). The current pandemic has isolated children and youth from their friends and other allied adults, including teachers, service providers, and individuals from their community, who were providing support and comfort. Programs that purposefully reconnect vulnerable children to other trusted young people and adults (e.g. Big Brother Big Sister programs) should be prioritized to help traumatized children and youth maintain and nurture significant relationships during the pandemic. Collaboration and mutuality recognize that everyone has a role to play in a trauma-informed approach, and that healing happens in shared decision-making experiences. These principles can be achieved thought creating robust partnership plans between all parties involved in supporting trauma-impacted populations—schools, social services, child protection, mental health and psychiatric services, the medical system, community organizations––to ensure the maintenance and continuity of the collective response to the needs of vulnerable children and their families. TIC principals promote open dialogue and problem-solving toward the most efficient and effective strategies to promote safety. The current pandemic is forcing us to rethink mainstream service organizational paths and mandates. It creates an opportunity to revisit and improve collaboration and complementarity of services. For example, school and daycare systems could play a pivotal role for students and families by connecting them with community-based resources––from food banks to mental health services (Collin-Vézina & Milot, 2020). Empowerment and choice—which is a principle that focuses on strengths rather than clients’ deficits—are important values to address during this pandemic crisis as many individuals have experienced tremendous loss of control and mastery over their own lives. TIC emphasizes the importance of considering interpersonal violence, systemic violence, structural inequities, and cultural safety alongside childhood trauma experiences, as a means to integrate a person’s experiences of past and ongoing violence. Recognition of these experiences can reduce the potential for harm by transforming dynamics in helping relationships to equalize power and promote shared decision-making (Public Health Agency of Canada, 2018). By addressing the context of systemic marginality, TIC widens the view of service needs and in the COVID-19 context holds promise to generate new insights about the strengths and failings of our current system from the perspective of those served. Concretely, strategies to support telehealth service provision exemplify how empowerment and choice have been promoted during this pandemic crisis (see for example Blaustein & Kinniburgh, 2020). Cultural, historical and gender issues are paramount to TIC philosophy and practice. It means that: “
Conclusion
We argue that never before has a TIC approach been so important to promote the health and well-being of all and to protect our marginalized populations at greatest risk. Policies that are in place to prevent re-traumatization will limit the negative impacts of trauma exposure, whether applied in individual-client interactions or organization-wide implementation amid the current pandemic. Widespread TIC implementation serves both in the immediate crisis and as a preventative measure against unforeseen future traumatic contexts. Through widespread adoption of TIC policy and practice, our continuum of services can share the same knowledge-base, evidence-based practices, and language to meet the complex needs of the global community.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by a SSHRC Partnership grant # 895-2020-1016 awarded to Dr. Delphine Collin-Vézina.
