Adverse childhood experiences (ACEs) and poverty are potential bedfellows. As part of a special five-part series, we highlight articles from MWS blog archive that address the deep-rooted causes of poverty, and examine how MWS responds holistically to issues arising from the impact of ACEs.
Most of us have likely read distressing news of children being physically abused, neglected or affected by their parents’ divorce. You may even know such individuals within your own community or have come across them in the course of your work.
These adverse childhood experiences (ACEs), typically occurring from birth till the age of 18, are more common here than some may think.
According to a study led by researchers from the Institute of Mental Health (IMH), the Ministry of Health (MOH) and National University of Singapore (NUS), about 2 in 3 or 64% of adult residents in Singapore had experienced at least 1 ACE in the first 18 years of their life.
The research is part of the Singapore Mental Health Study in 2016, which looked at the prevalence of ACEs and their link to mental illnesses.
Another alarming finding points to the rise in child abuse over the last 10 years. According to the Ministry of Social and Family Development’s (MSF)¹ Child Protective Service (CPS), the number of cases investigated have shot up from 390 in 2010 to 1,088 in 2019. This translates into nearly 3 times more children who have been seriously harmed or are at risk of serious harm.
MSF’s statistics also highlighted the most common types of ACEs here, with almost half or 48% indicated as physical abuse, followed by neglect (34%) and sexual abuse (18%).
The residents undergoing therapy programmes at the MWS Girls’ Residence (GR) are key examples of those who have experienced various ACEs. MWS GR provides a community-based haven for troubled and at-risk girls aged between 15 and 21.
Its Head, Audrey Rajalingam, has seen several common manifestations of post-traumatic stress symptoms due to possible exposure to repeated adversities.
“One of the most common manifestations is sleeping dificulties. Another manifestation is a flashback — they can get it at any time in the day and it could be triggered by certain reminders. They may dysregulate, which means they can’t regulate their emotions and may become self-destructive.
“We also see them trying to harm themselves. Most of the girls will try and get any sharp object, something as simple as a pen or a pencil to start jabbing or scratching themselves.
“Another symptom may be mood changes — they can be very low on certain days. At other times, because of something that happened, they may withdraw into a state of sadness and refuse to participate in programmes or just wish to be left alone,” she detailed.
Audrey explained that if left untreated, repeated exposure to ACEs can have a myriad of negative effects on the individual when he or she reaches adulthood.
She has seen adult women in their 40s who have unprocessed trauma precipitated by sexual assaults that happened in their younger days. They experience flashbacks during intimate moments with their spouses, which frequently cause marital problems or breakdowns.
These women may also develop an overprotective parenting style which leads to poor relationships with their children, said Audrey.
“They get a heightened fear of something happening to the child and may find it hard to differentiate when the child needs space, like going out with friends. They imagine the same horrible things that happened to them may also happen to their child. They are too ashamed to tell their child what had happened to them, so they may be overly protective to the point that their child ‘suffocates’, resulting in a split between parent and child,” she explained.
Untreated ACEs may also lead to financial poverty because these traumatised individuals may have difficulty holding down a job.
“Stress or flashbacks may affect the person’s ability to perform at work, resulting in poor reviews. Over time, if the person doesn’t seek help, he or she is likely to have difficulty holding down a regular job. In the long term, the constant change of jobs may reflect poorly on the person’s employability and affect his financial prospects,” explained Audrey.
Many early childhood and family resources also link ACEs to a host of other negative outcomes in adulthood, including chronic health problems, mental illness, and substance misuse.
MWS takes a holistic approach towards addressing issues arising from the impact of ACEs. Interventions are designed along a spectrum according to the needs of the client. On the preventive end, the MWS Family Support Programme (FSP) reaches out to parents who need support in relating to their pre-teen and teen children.
Launched in October 2019, one of the key services that MWS FSP offers is the Positive Parenting Program (Triple P). A team of MWS Family Life Educators (FLE) run Triple P to counsel and empower parents with simple and practical strategies to help them build strong and healthy relationships with their children.
These strategies help parents to manage their children’s behaviours and prevent problems from developing in the future (read this article to find out what 2 mums have to say about the programme).
MWS FLE Halbert Louis highlighted that the top issues that parents grapple with include lack of communication between parent and child, harsh or inconsistent punishment, as well as difficulties in meeting the emotional needs of the child.
Based on his observations, parent-child relationships generally improved after using Triple P strategies. He added that the issues parents face with their preteens and teens are unlikely to escalate into more serious family problems as long as parents make a concerted effort to continue applying the strategies.
“Giving advice to parents on their child management style is a good way to prevent parent-child issues from developing into something more serious,” Halbert said. In addition, the programme aims to bridge the emotional divide between parent and child, enable the child to be self-disciplined and not become addicted to gadgets, as well as help the child manage emotions and stress.
In 2019, MWS Family Service Centres (FSCs) adopted a safe practice that is centred on the needs of vulnerable persons and guided by trauma-informed care (TIC) principles. MWS FSCs aim to integrate in their service delivery an understanding of the impact of trauma on the biopsychosocial functioning of individuals and families, and prevent, reduce and ameliorate the effects of trauma in the people it serves.
According to Alvin Goh, then Cluster Director of MWS Family Services, TIC was introduced because majority of the families served by the FSCs have experienced traumatic events. Some experienced abuse and violence when they were children, while others were exposed to more recent traumatic events like divorce, accidents or the sudden demise of loved ones as adults.
“Even though they don’t come to us to address the issues that pertain to their traumatic events, as a result of the symptoms they experience from these traumatic events, they usually seek help for their challenges in employment, marital issues and financial difficulties. We realise that what is happening to them in the present context has to do with what had happened to them in the course of their lives,” he explained.
At the FSCs, staff are guided by 5 foundational principles of TIC, namely safety, trustworthiness, choice, collaboration and empowerment. Director of MWS FSCs, Mrs Cindy Ng-Tay, highlighted the importance of ‘choice’, one of the common principles applied at the FSCs.
“Always give clients a choice even if it’s not warranted. That’s why a number of the FSCs have stopped giving food rations because food rations don’t give our clients a choice. Instead, we provide vouchers so they can get what they really need,” she shared (See a case study here).
Another often-used principle is ‘collaboration’, revealed Alvin.
“We don’t give solutions, as if we are the experts of their lives. Trauma-informed care tells us that if we do this, we disempower them. Instead of being prescriptive, we try and engage the clients with, ‘What do you need? What do you think will work for you?’,” he explained.
A service delivery Standards Framework has been established to embody TIC principles in MWS’ professional code of conduct and ethics, and MWS’ Philosophy of Care. The Standards Framework sets clear directions for programmes and activities, particularly in safe and person-centric practices, to support clients affected by trauma.
A series of professional development workshops and a Competency Framework for social service practitioners were also launched to implement these standards.
MWS FSCs are currently working towards measuring the impact of TIC on its clients. A TIC protocol is also in the works to guide service delivery processes and workflows.
For individuals who have faced or are facing ACEs, intervention is taken to the next level. At MWS GR, 80% of the young women had experienced 4 to 7 ACEs by the time they entered.
Out of the 10 girls served from April 2019 to March 2020, 8 of them underwent a trauma-informed and holistic therapy programme that considers the insights and impact from trauma.
Upon admission to MWS GR, every girl is given an individualised care plan to meet her specific needs. This is supported by a level progression system that enables her to strive towards rehabilitation with rewards such as handphone time.
It adopts the concept of a butterfly’s metamorphosis, where every girl starts of as an ‘egg’, and progresses to ‘larva’, then ‘pupa’, and finally, ‘butterfly’ as she meets certain milestones on her care plan.
Subsequently, the girl will be supported by a care team comprising a case worker, therapists, counsellors, and general staff, who play different roles ranging from day-to-day care to counselling and implementing the care plan.
A key aspect of the TIC is creating a culture of safety within MWS GR, one of the 5 principles mentioned earlier. It includes establishing a safe and nurturing environment, as well as consistency in care.
“The child is here every day, so she needs to feel safe with many different staff. We also ensure there’s no bullying. Staff attend to cases of girls who are harsh with other girls.
“Safety also comes with regularity. We provide a routine to give them a sense of predictability or control. For example, they should know when their mealtimes are.
“Safety is also offered in staff responses. We aim for 80 to 90% consistency in how we respond if a girl comes to us for help. For example, we would never say, ‘Sorry, I have no time’. Staff are also taught to ask, ‘What’s wrong?’ or do little check-ins like, ‘How was your day?’,” explained Audrey.
Fresh entrant at the stage of assimilation, family visits are allowed. A safe and nurturing environment is created to impart a culture of safety.
Ready to manage more tasks, and achieves a bigger sense of freedom. Home leave is permitted.
Shows leadership potential, demonstrates an ability to manage herself, and achieves goals. Handphone time is given.
Displays leadership qualities, and demonstrates an ability to manage herself and lead others. Gets an upgrade to a bigger room.
For the girls at MWS GR, managing the manifestations of ACEs is paramount to their rehabilitation. According to Audrey, there are many trauma-based therapies.
One which the trained staff employs is EMDR (Eye Movement Desensitisation and Reprocessing) psychotherapy to manage dysregulation and co-manage regulation. The girls are also empowered to apply the technique on their own.
“Some of these principles are used to help regulate the young person who’s having a flashback and it involves getting her back to the present slowly by doing a series of light tappings on her wrist. Over time, we see that they can deal with a certain flashback, and take less time to dysregulate,” she elaborated.
MWS GR also has a trauma-focused activity known as the Mindful Movement Programme. It integrates mindfulness principles and practices with movement to help girls understand and express themselves, and aims to modify behaviour in an afirming, non-judgmental environment.
The programme’s main benefits are in reducing stress, encouraging expression of emotions, and promoting positive self-image and confidence.
The trauma-informed approach seems to have borne fruit so far, as Audrey reported that the girls generally feel cared for by MWS GR. There has also been improvement in the areas of trustworthiness and collaboration, 2 of the principles in TIC (click here for a resident’s success story).
“They trust that when they have needs, these will be attended to. For example, when they say they’re sick, they are taken to a doctor.
“We are also working a lot more closely with the girls’ families. Staff initiate regular contact, like monthly meet-ups, with the girls’ families,” shared Audrey.
MWS GR is planning to strengthen its post-therapy care programme which involves the implementation of a postcare plan 6 months before the girl leaves the facility.
¹ MSF Child Abuse & Protection Statistics (updated Apr 2020). Retrieved from https://www.msf.gov.sg/research-and-data/Research-and-Statistics/Pages/Child-Abuse-Investigations.aspx
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