Using trauma-informed assessments for children and teenagers at risk of sexual exploitation – Dr Carmen Chan

Over recent years, there has been an increasing awareness of the impact of early adversity in childhood.  Despite some criticisms (e.g. not taking young people’s contextual circumstances into consideration), research on adverse childhood events (ACEs) has linked early trauma to increased physical and mental health difficulties.  Children and teenagers at risk of sexual exploitation, or who have already experienced exploitation, have often also experienced a number of other adversities aside from sexual trauma that can lead to a number of difficulties, including depression, anxiety, self-harm, posttraumatic stress disorder, relational difficulties, and so on and so forth.  Applying specific protocols or assessment tools is unlikely to fully address the heterogeneity of this vulnerable group of young people.  It is, furthermore, important to apply a framework around any approach or assessment process that focuses not on what is ‘wrong’ with a young person, but firmly rooted in understanding what has ‘happened’ – a trauma-informed approach.

What actually constitutes a trauma – a ‘resource-loss’ model?

Trauma can be defined as any experience that overwhelms the mind and body’s natural resources and resilience to heal it.  From a psychological perspective, key experiences in life can help build a child’s internal resources and resilience:

• The availability of basic needs, such as food, shelter, and clothing;
• safe, consistent, and predictable attachment relationships that form the template for future relationships; and,
• experiences that scaffold learning to help guide new experiences

With early interpersonal trauma, however, these 3 key pillars are challenged.  A child may not have had their basic needs met and lack sufficient food or a safe place to live.  Early caregivers may not have been protective, and some may have been dangerous, leading to unhealthy relationship templates.  Similarly, if early experiences have been neglectful, abusive, or even exploitative, then a child’s learning about the world will likely be seen through this lens.  Consequently, rather than early learning experiences being resource and resilience building, they are resource-depleting.  With little personal resilience, further experiences of adversity are more likely to overwhelm the young person’s available resources, leading to adverse events being experienced as traumatic experiences. 

A threat-focused mindset

During a traumatic event, the ‘thinking’ part of the brain (e.g. hippocampus and prefrontal cortex) shuts down and the emotional and ‘threat-focused’ part of the brain (e.g. amygdala) becomes more sensitive.  This serves an important evolutionary and protective function and the brain often returns back to ‘normal’ after the threat is removed.  What happens, though, when the threat and trauma are ongoing or a ‘normal’ part of a young person’s life, as is often the case with abuse and exploitation?  A ‘threat-focused’ mind becomes the new ‘normal’, with heightened sensitivity to anything that can be perceived as dangerous, including people or situations.  Within this mindset, only instinctual protective responses are available: fight, appease (or friend), flight, freeze, or flop.   

Importantly, the impact of sexual exploitation is rarely just on the young person, but ripples out to their wider network, such as family, friends, school and community.  As clinicians, we are, therefore, often working within a traumatized system which can only respond in a threat-based manner.

Problems are often just solutions to other problems 

For children who have experienced sexual exploitation, the list of ‘problems’ can appear endless and can, at times, be labelled as having ‘emerging’ personality disorders.  Labels like this can be experienced as damaging and often focus on what is wrong and not on what has happened to the child.  A trauma-informed assessment, however, takes a different view – children and teenagers are trying to do their best to survive.  In short, what is currently seen as a problem is often just their solution to another problem.  From this perspective, some key principles of a trauma-informed assessment might include:

• A thorough understanding of a child’s experience
• How these experiences might have led this child to problem solve in this way
• Couching all of this within neuroscience – the child is working from a threat-focused mindset and therefore, the capacity to think is challenged and s/he will be reacting in an instinctual and threat-focused manner
• Consideration of the context (e.g. within themselves, their family and social group, school/work environment, cultural influences) – where are the risk and vulnerability factors, and where are the protective factors?

What does this mean for what we do?

As the old saying goes – it takes a village to raise a child.  More often than not, a child who has experienced abuse or exploitation requires a multi-agency approach that consistently communicates and has a similar understanding about the impact of their experiences (e.g. of the threat-focused mindset of a child within a traumatised system).  The response should be collective and aimed at reducing vulnerability/risk factors in all areas of life and strengthening all the protective factors.  No one agency can do this on its own.

If current problems are the child’s solutions to other problems, then agencies should work together to not only help the child find alternative solutions but to also lay a firmer contextual and social framework on which these alternative solutions are possible.  In other words, if a child isn’t able to find another solution because of their social environment (e.g. not being in school, lack of safety within their home), then as professionals, our job is to help encourage a safer education/work environment or find safety within their home. 

Is the village equipped?

It is important to remember that professionals are human beings too.  Crucially, this means that when under high stress, our minds will also be functioning from a threat-focused mindset with a reduced capacity to think and impairing our creative problem-solving skills.  Professionals will fight (sometimes each other), flee, freeze, or appease and therefore limit effective communication but also, our own self-care.  An environment of increased cuts to services and greater pressure to be seen as the service that ‘solves all problems’ will only serve to increase stress on professionals.

As professionals, we need to remember that no one service can ‘do it all’.  We need to support each other and ourselves, so that we can we can be the best version of ourselves when supporting this vulnerable group of young people.

Dr Carmen Chan, Clinical Psychologist & Service Lead, Horizon: Supporting Young People and Families Affected by Sexual Harm, Oxford