The Cost of Trauma - my most downloaded article

Q. Why do I feel sorry for social workers?

A. Because many social workers and social care managers know that most children who are adopted will need significant therapeutic input. 

Q. Why do adopted (and many fostered) children need significant therapeutic input?

A. Because their view of themselves has been distorted by their repeated traumatic experiences; be it neglect, abuse, frequent changes of carer, domestic violence, etc. - that general sense of chaos and fear. 

Unfortunately that message is not heard by enough budget holders and decision makers; either in local or national government. 

Within Adoption UK we recognise that adopters need to 'reparent' (fill in the gaps) and be 'therapeutic parents' (undoing some of the damage). This requires enormous parenting capacity and often external therapeutic input to assist a child in making sense of their past and place historic events in proper context. 

We all carry our past around with us, mainly in our unconscious mind. We use the learnings from the past to make decisions in the present and predict the future. (See previous articles 'what triggered that' and 'what was that about' for further detail). Traumatised children hold such extraordinary and distorted memories that their present day functioning is impaired and their future dark. 

Developmental Trauma Disorder

The diagnosis of Post Traumatic Stress Disorder (PTSD) is rarely applied to children; their complex, disordered traumatic experience creates something different because they are still being formed when the damage occurs. 

Metaphorically, if an adult has a traumatic event, which results in PTSD, it's as if a car has been involved in a crash, the body work is damaged maybe the chassis is twisted. The event happened to a properly constructed machine which had previously functioned well. 

If however some traumatic or disaster befalls the car during its manufacture, the effects are far more profound and quite hidden. Maybe a spark plug is missing or only three wheel nuts were secured, maybe smooth surfaces inside compression chambers are pitted and cracked, maybe the exhaust partly vents through the air conditioning. Few of these features would be noticed on a gentle journey, none when looking from the outside at the stationary vehicle; but on a long motorway drive there is a distinct possibility of spasmodic misfiring, sudden loss or surge of power, toxic fumes and a wheel falling off. 

When trauma occurs during an infant's development, the damage impacts the entire body system. The brains wiring (neurology), the body's fight/flight mechanisms, (physiology), the child's inner world (psychological), at a cellular level construction is impacted by ingested chemicals (nutrition, drugs). 

That's why a deep truly holistic assessment is required; followed by appropriate therapeutic interventions. Slack Harry and his rusty spanner just won't do. A systemic approach is essential. 

In their While Paper, the Complex Trauma Taskforce (part of the American National Child Traumatic Stress Network) used the term 'Developmental Trauma Disorder' as the provisional name given to children who have complex trauma histories [Found at www.NCTSnet.org, it is surprisingly readable with excellent explanations. Go via sidebar to 'trauma types' and 'complex trauma'].

Bessel Van der Kolk says "The proposed diagnosis of developmental trauma is organised around the issue of triggered dysregulation in response to traumatic reminders, stimulus generalisation and anticipatory organisation of behaviour to prevent the recurrence of the trauma effects."

'Traumatic reminders' might be a sensory clue - a small, a particular touch or sound (door bang, hand on knee) which sparks a spontaneous (over)reaction (running out of the room, screaming, anger outburst) and behaviour is (unconsciously) organised to avoid echoing old hurts. 

Sad Scenario

I originally constructed this 'Sad Scenario' for a presentation in 2000. At the time I thought it quite provocative, eight years later I think it's quite tame. It serves a useful purpose in demonstrating what might happen to a child who has 'developmental trauma disorder'. Anyone sitting on an adoption panel will recognise this sort of life history only too well.

Emotional Cost of Sad Scenario

Huge and immeasurable. (Let's not go there.)

Financial Cost of Sad Scenario

•  Three years as infant, in LA foster care £36K
• Two years as teenager in independent foster care placement £80K
• Unquantifiable's - social services costs, court costs, education extras, home education costs, assessments (medical, educational, psychological etc), reports, school disruptions, police time, etc, etc. 
• Her future might include prison, unemployment, drug rehabilitation, housing, continued social service involvement etc. 
• Her offspring will have significant needs too. Foetal exposure to drugs and alcohol has a life long impact etc. The costs just escalate. 

Comparable Relevant Costs/Data

• Assessment in one Mother and Baby Residential Unit (Northern England) is £1,784 per week. Annual +£92K
• Female local prison is £41K pa
• Male juvenile prison £40K pa
• Young offender's institution over £32K pa
• (Prison data taken from Prison Service Annual Report). 
• Eton, Harrow and Gordonstoun Schools - around £27K pa
• Local Authority Secure Unit around £250K pa
• Therapeutic Community / Children's Home (rural) about £4,000 pw i.e. over £200K pa
• The Social Care Inspectorate Report (2004) averaged the cost of local authority foster care at £234pw (£12K pa) and with an independent agency at £765pw (£40K pa)
• Cost of three year multidisciplinary assessment and treatment programme at Family Futures for a child with developmental trauma living with a permanent family would be about £50K - though obviously every child's situation is different so it's not set in stone.

This is not a full cost/benefit analysis. I have constructed it simply as a tool to demonstrate how rational systems thinking would be useful when planning adoption support and possibly as a tool for social care professionals and parents to help argue their case. 

Money for adoption support and therapeutic interventions come from a different source (budget) to foster care, education and the child mental health service. Sadly there is no system to connect, interrelate or take a long term strategic view. No one joins the dots. 

Adopted Children 'LACk'

Statistically the 'sad scenario' is classified as a 'successful adoption', simply because adoption breakdown statistics relate to disruptions before the final adoption court order - data after that is not captured. Adopted children become part of the 'normal system', not included in the LAC (Local Authority Care) children statistics. (I'm not sure whether the adoptive parents in the scenario would deem it a 'successful adoption'). 

I would argue adopted children are children who ‘LACk’ in many, many ways. Had the sad scenario child received significant and effective therapeutic interventions whilst at primary school, many of the later catastrophes and some of the hurt could have been avoided.

Bottom Line

Children traumatised in infancy need to understand what happened to them.They deserve therapeutic interventions that give them a ’coherent narrative’ i.e. make sense of their story, they need to know ‘it’s not your fault’, even though this ghastly stuff did happen, your adoptive parents will hold you safely while you process the rage, grief, sadness and fear that permeated to your very soul. Adopters can rarely do this alone, they need support from skilled therapists and even then it’s still very hard.Toughest thing I’ve ever done.

Choice

How would you spend £60K?

18 months of (independent) foster care or a three year developmental trauma assessment and treatment programme? If you think long term and join the dots, it really is a no-brainer.

© Helen Oakwater

This article was first published in Adoption Today in April 2008. Download it here.