Addressing the needs of children who have experienced environmental trauma
Peter Eastaugh, Kerri-Anne Souter, Jenny Manuel, Marian Wetherbee, Peta Van Popering & Donna Berry
The Shepparton Neighbourhood Schools is a collective of three schools which service some of the most disadvantaged communities/children in the Shepparton region.
The schools work together to provide a coordinated approach to educational and ancillary services to address the specific needs of their school communities. In 2011,
the Neighbourhood Schools, and two Mooroopna schools also servicing a largely disadvantaged community, formed a partnership with a paediatrician, Dr Peter Eastaugh, to provide paediatric services to students from vulnerable families.
At that time there were in excess of 200 children from schools in the Shepparton district who were on a waiting list for developmental or behavioural paediatric assessment. Approximately 50 per cent of these children attended the Neighbourhood Schools. Several reasons existed for such an extensive waiting list, not the least being the escalating numbers of children in all schools who were experiencing substantial developmental learning and behavioural problems. These problems were having a major effect on the capacity of schools to engage such students in their education, and their behaviour also had a wider impact on other children.
Teachers felt very under resourced, untrained and unsupported and there was no satisfactory structure available to schools to provide a coordinated management process for these children. Since the 1980s school support services had been progressively diminished with many of these services supposedly outsourced, but with insufficient funding to go anywhere near addressing the high needs and increasing complexities of the children.
Despite international literature to the contrary, the area Paediatric Mental Health Services considered that these children had behavioural problems and did not have a mental health problem. The attitude of Mental Health Services has changed somewhat following a recent review, but they are unable to meet the complex therapeutic needs of this growing cohort of disadvantaged children in primary schools. The escalation in numbers should also be considered against a background of increasing disadvantage in the community, the changing developmental environment which children are presently experiencing, and exposure of children to circumstances that have a major impact on their neurological development.
From a paediatric assessment perspective, the additional barriers were: the very high poor attendance rates at prearranged appointments, the lack of appropriately trained paediatricians to undertake the assessments, and the fact that these assessments are often considered by paediatricians to be onerous because of the complexity of the children’s problems and the time commitment and follow-up commitment that is required. It is also very frustrating for the paediatricians who undertake the assessments to have limited therapeutic support services and/or processes to refer children to following assessments.
After almost 40 years in paediatric practice, the paediatrician (Dr Peter Eastaugh) expressed concerns that despite investment in many parent support services, the
number of children requiring support continued to escalate. This raised doubts about the sufficiency of parental support and parenting programs to alter the intergenerational trajectory that would seem to have become inevitable. Recent (past 20 years) escalating knowledge concerning the neurological impact of environmental trauma and the need for therapeutic intervention has been supported by a large body of medical researchers (Tronick, Siegel, Perry), neuropsychologists (Schore, Hughes, Baylin, Carter, Seligman, Teicher) and behavioural therapists.
Child Centred Play Therapy
Following discussions amongst the partnership, the concept of a project based on therapeutic play was developed. Non-directive Child Centred Play Therapy (Therapeutic Play) is a developmentally appropriate counselling approach for children from the age of two years. The purpose of the play-based therapeutic intervention is an endeavour to repair the neurological impairments that have resulted from early childhood trauma. Child Centred Play Therapy (CCPT) was originally created by Virginia Axline and has been practised for over 80 years. Its methodology, tenets and principles distinguish it from other play therapy approaches.
Through their language of play, children can use toys and materials to express themselves within the context of a safe therapeutic relationship. CCPT must be followed in its totality and is not a set of techniques or principles that can be employed at the discretion of the therapist. This method permits a focus on the child, most particularly his or her inner self, maintaining the assumption that play therapy can be most effective when the therapist does not direct but allows the child to take responsibility for the direction of the play therapy agenda. In CCPT children work through life experiences (past or present, conscious or unconscious), traumas and anxieties using symbolic and metaphoric means. Play allows children to re-enact frightening real life events through the use of toys and does not rely on verbal communication, as this narrative is often inaccessible to the child on a verbal level. The re-enactment is important because it provides a way for children to control
in fantasy what is unmanageable in reality.
By participating in play and the safety of the therapeutic relationship, children can begin to make sense of their experiences and are free to transform an event and change their role from one of passivity into a role of active investigator or controller. Children who experience this gain an increased understanding of self, their world and past experiences, which nourishes the development of new neural connections within the child’s brain. As a consequence, children develop an understanding of self, gain psychological insight and develop social, emotional, relational, and problem-solving skills and strategies – all of which leads to healing, self-discovery and growth.
The Neighbourhood Schools Paediatric Services Project has agreed that child centred play based therapy should be delivered through trained and accredited Play Therapists. The training program for Child Centered Play Therapy is provided by Play Therapy Australia which offers clinical training to mental health professionals. The course is delivered over a one year period and is presented in intensive modules with 50 hours of online learning in between each module to assist with immersion into the modality. The Australian Play Therapists Association (APTA) is Australia’s peak professional body offering professional registration for play therapists. As part of this project all therapists, and the clinical psychologist who supervises the therapists, will be registered with APTA where standards require members to have completed sufficient clinical practice hours under clinical supervision alongside personal therapy.
The Project Process
- The classroom teacher identifies a child with significant developmental, learning and /or behavioural challenges or a child who has experienced significant environmental trauma.
- The classroom teacher consults through the school process and a decision is made by the school leadership team whether a paediatric assessment is required.
- The principal/assistant principal prioritises the child/family according to their school referral process or waiting list.
- The school wellbeing and engagement team facilitates the process of parents attending their general practitioner to obtain a referral to a paediatrician.
- Paediatric consultation is undertaken in the school environment. It involves a one hour consultation with parents and their child and a senior school administrator. Interpreters or indigenous liaison staff are provided by the school if required. The parents are encouraged to present with family members or advocates for additional support.
- Following paediatric consultation, all materials related to the child are assessed and a comprehensive report is prepared. A copy of this report is sent to the parents, the school and the referring general practitioner.
- At the next school clinic (generally in three weeks), the school arranges for the attendance of all professionals involved in the individual child’s life including: the classroom teacher, allied health, social work, child protection or any other professional organisation that the parents feel would contribute to the case management discussion.
- After the case management discussion has been undertaken, the paediatrician produces a case management plan and timelines for interventions and support strategies at a classroom level.
- A minimum of two case plan management meetings per year are undertaken. These may occur more frequently if significant problems are identified.
- Using the general practitioner referral, all consultations and case conferences are bulk billed through Medicare.
- Existing parent support and additional parent support - Family Care, Families First, Child Protection, Aboriginal Family Service, other NGO support services and services provided through the Education Department (SSSO) support services program - continue.
An essential part of the project is an ongoing research study to provide evidence that the project, and the theory behind the project, is a valid means of addressing developmental and behavioural problems in children, and is therefore worth incorporating into mainstream education. Participants in the project believe that schools can no longer be institutions that provide only learning and social development, but must also offer some therapeutic interventions.
This research involves using the Achenbach Child Behaviour Checklist to monitor the child’s progress. It is undertaken at the initial consultation and is repeated 6 to 12 months into the program, and in subsequent further assessment as required. The Checklist is a multifactorial assessment tool that has been extensively used and validated to measure developmental behaviour and mental health in children.
Over the years 2013-2016 data has been collected on 300 children. The data includes demographic data, up to four episodes of Achenbach and both parent and teacher
responses. The students involved were from three Shepparton primary schools – St Georges Rd, Wilmot Rd and Gowrie St. Mooroopna students did not enter the program until 2017. The gender break-up of students was: 93 female and 203 male. Students were from a range of cultural backgrounds including: 67 Indigenous, 41Iraqui, 18 Afghan, 7 Samoan and 7 African.
The diagnosis results identified a range of learning and behavioural problems in the children who were assessed: Learning difficulties (13.7%), Behavioural difficulties/autistic (10.5%), Environmental trauma (25.0%), ADHD (6.5%), Physical disorder (8.2%), Psychosocial (8.6%), Oppositional Defiant Disorder (2.7%), Mental health (6.6%), Speech disorder (5.5%), Foetal Alcohol Syndrome disorder (5.7%), Low Intelligence (2.3%), Intellectual disability (3.5%), Conduct disorder (0.9%), Addiction (0.3%).
At least 60 per cent (170) of the children who have been assessed have been diagnosed with developmental or behavioural problems attributed to complex environmental early childhood trauma. A small number of children (8 per year) have received therapeutic play.
Significant support has been received from the Sir Andrew and Lady Fairley Foundation which contributed $30,000 to train three therapeutic play specialists. This training was arranged through the Australasian Play Therapy Association (APTA). The three Neighbourhood Schools, joined by the two Mooroopna Primary Schools, have used recent State Government Equity Funding to employ one fully trained and three in-training therapeutic play specialists to join the project and to provide intervention for children identified through the paediatric assessment process as having been exposed to environmental trauma. These play specialists are completing Play Therapy Australia’s clinical program and are working towards Clinical Membership with APTA. The specialist clinical program consists of both theoretical and experiential components. As part of the program all four therapeutic play specialists will work under the supervision of an experienced clinician.
Data collection will continue and additional data will be collected using a therapeutic play assessment tool - Child Initiated Pretend Play Assessment. Negotiations have commenced with a major university to obtain a PhD student to use existing data and to analyse future data as a method of project evaluation. The Fairley Foundation has continued to advocate on behalf of the project and philanthropic funding will fund the evaluation project. Anecdotally, the three schools report improved school engagement from children involved in the program, improved parent/ family engagement and increased teacher empathy, knowledge, skill base and use of relevant strategies to support diverse student learning and behavioural needs. All the professionals involved in this project believe that the model is essential for long term community well-being.
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Landreth, Gary L. (2002), Play Therapy The Art of the Relationship, Routledge.
Schore, Allan N. (2012), The Science of the Art of Psychotherapy, Norton Series on Interpersonal Neurobiology.
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Peter Eastaugh is a paediatrician with a community child health based practice. He has been a consultant general and community paediatrician in Shepparton for nearly 38 years.
Kerri-Anne Souter is the Principal at St Georges Rd Primary School in Shepparton.
Jenny Manuel is the Principal at Wilmot Rd Primary School in Shepparton.
Marian Wetherby is the Principal at Gowrie St Primary School in Shepparton.
Peta Van Popering is a social worker and play therapist at St George’s Rd primary School and currently coordinates the play therapist team across five schools.
Donna Berry is a social worker and play therapist and the Director of Play Therapy Australia.