Toxic trio is a term that I have heard used a lot in school nursing in terms of safeguarding children. When I first joined the school health service 7 years ago, I quickly understood that there was a link between domestic abuse, parental substance misuse and parental mental health, and the likelihood of a detrimental impact on the wellbeing of children living in this toxic environment. Serious case reviews show that the combination of these three elements is an indicator of an increased risk of harm to children and young people (Brandon, 2009). I had become aware of the link between children living in these toxic environments and them being on a child protection plan. Working with these children and families, and attending conferences, I started to understand how these issues were affecting the lived experiences of the child and the detrimental impact it was having on their emotional, physical and social wellbeing. The work we would be asked to do with the child on a child protection plan would often be to support their emotional health, such as a referral to a children's mental health service or one-to-one work with our service. Talking to the children in one-to-one sessions, I realised that the environment they were living in often led them to feel anxious, have low self-esteem and lack in confidence. There were reports from school to say they were ‘acting up’ in class, displaying anger and aggressive behaviour toward their peers and teachers and they were often struggling to manage their emotions. There were reports from home to say their behaviour was deteriorating and were hitting out at their parents or siblings, older children and young people were getting caught up in the wrong crowd and at risk of criminal or sexual exploitation, they were getting into drink and drugs. These are just a snapshot of an extensive list of issues I was often asked to support the child or young people with. I would often question, ‘why are they behaving this way?’ and I became overwhelmed with the feeling of ‘I do not know how to help this child’. I would try my best to do some one-to-one work to try and get the voice of the child and talk through how they can manage their emotions and anxieties. Most of the time I would just be there to listen. I would do referrals to other services, such as children and adolescent mental health services. A lot of the time I felt out of my depth as I was not specifically trained in emotional health and I would often question whether I said the right thing or if I was doing enough to help the child who was struggling. Whether I could do more to help would often play on my mind but I did not fully understand why their home environment was resulting in the behaviours they were displaying.
‘When I first joined the school health service 7 years ago, I quickly understood that there was a link between domestic abuse, parental substance misuse and parental mental health, and the likelihood of a detrimental impact on the wellbeing of children living in this toxic environment.’
Adverse childhood experiences
After several years working in the school health service, I went along to a training day called ‘Resilience: The Biology of Stress and The Science of Hope’, which was presented by Enterprising Youth (2019). The training included the viewing and discussion of the film Resilience: The Biology of Stress and the Science of Hope, which was created and directed by James Redford in 2016. Dr Nadine Burke-Harris featured in the film and talked about how she has carried out research in the United States on how adverse childhood experiences has a toxic effect on a child physically, emotionally and socially. The film described the biological effect that trauma has on a child and how it makes them feel constantly in a fight, flight or freeze mode. This then causes the release of cortisol and when this happens at an increased rate it will have a detrimental impact on the child's physical health and even their DNA (Harris, 2018). It increases a child's risk of developing chronic health conditions as an adult and decreases their life expectancy (Purewal et al, 2016). The child is learning to survive from whatever the situation is at home, which means they are in a constant heightened state of alert. When they are in a safe settled environment, they are unable to switch off this state of alert easily and therefore can find it difficult to concentrate in class or listen to the teacher. They may be displaying angry and aggressive behaviour because they are mimicking what they have seen at home and also because they are still in fight or flight mode. They lose trust in people such as professionals because they have learnt to defend themselves from the people who are supposed to protect them. They blame themselves and have low self-esteem because it is easier for a child to rationalise in their head that they are to blame rather than accept that their parents let them down. These feelings a child has will feel overwhelming for them to cope with and will result in a range of different behaviours. It could range from a child being introverted, shy and having low self-esteem to a child being extremely disruptive in class.
‘These feelings a child has will feel overwhelming for them to cope with and will result in a range of different behaviours. It could range from a child being introverted, shy and having low self-esteem to a child being extremely disruptive in class.’
Connecting the dots
At this point I had not heard of ACEs before but this training connected the dots for me and answered so many of the questions I had. It changed my practice, my understanding, empathy and the view I had on the lived experiences of the children living in a toxic environment. It was a lightbulb moment for me and helped me to understand how I can try to help these young people and children who are struggling emotionally. I had an understanding of the link between children living in a toxic environment and the effects it has on their emotional health, behaviour and future. I started seeing the referrals we were receiving with a different perspective. Rather than asking, ‘why is this child behaving this way’. I was asking ‘what has happened to this child’ and started to look more into the daily lived experiences and past trauma. I began to look more into a child's health records for any signs of domestic violence in the past, for example, or speak with the school to see if there were any concerns about their home life. I felt that if I had a better understanding of whether the child had suffered trauma I would feel in a better position to support their needs.
‘… this training connected the dots for me and answered so many of the questions I had. It changed my practice, my understanding, empathy and the view I had on the lived experiences of the children living in a toxic environment.’
‘A large part of our role now is providing low-level emotional support to children and young people, and working with children on child protection plans. Therefore it made sense to me that all school nurses should become ACE aware as many of the children and young people we work with have suffered from trauma.’
Raising school nurses' awareness
I had gained a lot of valuable knowledge from learning about ACEs and felt that it was very relevant to school nurses and the work we do. A large part of our role now is providing low-level emotional support to children and young people, and working with children on child protection plans. Therefore it made sense to me that all school nurses should become ACE aware as many of the children and young people we work with have suffered from trauma. I did not understand why school health professionals were not offered more training on ACEs and I was not sure what I could do about this. A short time later I got a place on the Specialist Public Health Nurse degree course and part of the course was to lead a project on service development. I was excited that I had been given the opportunity to develop some training for school nurses on ACEs. I began networking to find out what services in other areas were already doing with regards to ACEs. I found out that NHS Scotland had been integrating ACEs within their service for over 5 years and, while speaking to them, I found this extremely helpful in my understanding of how professionals can approach not just children but also adults who suffered trauma. NHS Scotland is now an ACE-aware service and staff members who work within the service are trauma-informed. This means that every member of staff receives training on ACEs as they may all be in contact at some point with someone who has suffered trauma. They believe that if everyone becomes ACE aware and trauma informed then staff members will be more empathetic and build trust in patients. Public Health Scotland (2021) says that making every contact a positive one will help people who have suffered trauma feel more valued, and sometimes a positive professional relationship can help buffer the trauma. A child who has suffered ACEs may not have a positive and caring role model in their life and if they are given some care and attention for only a short time then this can help guide them (Scottish Public Health Network, 2016). It may be what they need to feel that they are important and that they do matter. I found this an interesting perspective when looking at how school nurses can support young people. Unfortunately, we may not be able to stop the trauma or help them forget what they have been through but we can provide them with support where needed. The training that I developed explains what ACEs are, what impact they can have on a child's overall health, how we can help support them and, moving forward, what we can do now that we are aware of ACEs.
Baby steps
The number of children and young people suffering from emotional health issues is a national crisis and the likelihood of a young person developing a mental health problem has increased by 50% in the last 3 years. Children are developing mental health problems at an increasingly younger age. Now, one in six children aged 5–16 years old now have a mental health problem in the UK. That is five children in every classroom of 30 children (The Children's Society, 2021). Cleare et al (2018) studied patients who had been admitted for self-harm and found those who had suffered four or more ACES had a significantly higher chance of repeat self-harm compared to those who had three or fewer ACEs.
Becoming ACE aware and trauma informed is something that we as professionals working in the health service can do to start taking the baby steps to tackle the effects trauma is having on young people today. If we are more aware of why and how trauma affects young people we can develop the strategies to help support them. Dr Harris (2018) carried out research to see the effects that providing a therapeutic intervention can have on children who have suffered from ACEs. Dr Burke Harris scanned the brain of children who suffered from ACEs before and after interventions had been put in place and she found that it has a positive effect on the fear centre of the brain and also the emotional regulation part of the brain. If a child has witnessed domestic violence in the home the family is provided with a therapeutic intervention.
Training/project
The training I delivered included:
- A definition of what ACEs are
- A brief explanation of where the idea came from
- What is classed as an ACE
- Toxic stress physical impact on the child
- The impact on a child's behaviour and emotional health
- The implications that four or more ACEs can have on a childs life
- Statistics of how four or more ACEs can affect health and future prospects
- Animations of ACE
- Discussion on NHS Scotland and their trauma-informed workforce
- Services that are out there to help children who have witnessed Domestic Violence
- A real-life case study of a celebrity who had experienced ACEs and has had a successful career with the help of a teacher who had a positive influence
- How school nurses can help provide a positive professional relationship to a child and help build their resilience.
‘…school nurses and public mental health services, saw a reduction of £700 million to their funding between 2014/15 and 2020/21. The impact of these cuts has been overwhelming …’
Moving forward
When I delivered the training to school nurses in my trust, I was overwhelmed with the response I received. I have been asked to deliver the training to new staff members who joined school nursing, health visitors, students and other members of the service who could not attend the training. I was pleased that it was so well received because it is a subject that I am passionate about, and it is an essential topic school nurses should be made aware of. School health services are often overlooked because it is difficult to measure the outcomes or the effectiveness of the work we do. With children and young people's mental health services becoming overstretched, we have been taking on more emotional health referrals than ever before. We have developed resources and tools to help guide us on issues such as self-harm, for example. Bespoke training in emotional health should be provided more regularly for school nurses.
Over recent years there have been funding cuts to mental health services and this includes cuts to child and adolescent mental health services, to the detriment of children and young people who need these services. The Local Government Association (2022) states that school nurses and public mental health services, saw a reduction of £700 million to their funding between 2014/15 and 2020/21. The impact of these cuts has been overwhelming, in my opinion, and it feels like we have been trying to put a plaster over a deeper and growing problem. The government has now promised a £79 million boost to be allocated to children's and young people's mental health (Department of Health and Social Care, 2021). School nurses would previously have been available to bridge the gap to give some form of emotional support at tier 1 while they are on the waiting list. If more is invested into low-level emotional support then there would hopefully be less of a demand on tier 2 and above mental health services. Unfortunately, due to the increasing demand of safeguarding cases and staff cuts there are now not enough school nurses to be able to facilitate going into schools to provide the amount of support that is needed. It is a very frustrating and desperate time for the school health service as we are unable to carry out the public health side of the role without more staffing. It is a huge concern that the mental health and emotional wellbeing of our children and young people has been pushed aside due to a lack of funding. Knowing what we know about trauma and how it can affect a child's physical and emotional health, this situation is likely to get worse. We are unable to stop most of the trauma from occurring in the first place but there are services that could help buffer the effects ACEs have on the future of a child. In the long term, this would lead to a reduction in costs to the NHS.
A useful first step would be for all school nurses to receive ACE awareness training and for more school nurses to be employed to help provide the necessary support for children and young people who have been affected. The increase in funding for child and adolescent mental health services is desperately needed so that children who have suffered ACEs can receive therapy as required. Funding cuts to these essential services need to stop as our children and young people are paying the price.
‘Unfortunately, we may not be able to stop the trauma or help them forget what they have been through but we can provide them with support where needed.’