Complex Trauma Regulation in Children: A Body-Based Attachment Approach [1st ed. 2023] 3031403193, 9783031403194

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Suellen Thomson-Link

Complex Trauma Regulation in Children A Body-Based Attachment Approach

Complex Trauma Regulation in Children

Suellen Thomson-Link

Complex Trauma Regulation in Children A Body-Based Attachment Approach

Suellen Thomson-Link Brodhead, WI, USA

ISBN 978-3-031-40319-4    ISBN 978-3-031-40320-0 (eBook) https://doi.org/10.1007/978-3-031-40320-0 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

To my children, Syon, Acaya, and Sundara, who constantly teach me about the importance of love, resiliency, and growth.

Preface

Children and adolescents who have experienced complex trauma have special regulation needs. Their trauma has most often been perpetrated by their caregivers, the ones who are meant to protect them. This places their attachment and sense of a secure base in jeopardy. In order to cope with this violation, they develop a vast array of managing behaviors. These behaviors serve to protect and help the child cope with the missing experience of a safe and secure attachment figure. This book has been written to provide a comprehensive background on a child’s development within a healthy relationship and to emphasize the challenges which can present should these experience be absent or inconsistent. Combining this theory and with a body-based approach, this book provides the carers and therapists with intervention strategies to improve the child’s ability to internalize regulation and provide them a foundation of safety. From this secure base, the child can more successfully socially engage with others and venture out into their world. Brodhead, WI, USA  Suellen Thomson-Link

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Introduction

Why This Book? And the day came When the risk to remain Closed tightly in a bud Became more painful Than the risk it took To Blossom. (Anais Nin)

I don’t know if it was staring down the “wrong” end of a shotgun barrel, or maybe it was the article I came across in high school which was titled, “The Battered Baby Syndrome,” but I do know they had a visceral impact on me. They felt like pieces of a puzzle that, unbeknownst to me, had germinated my interest in body language and trauma. My meandering professional path has led me to work in a variety of settings and countries. As a new graduate, I could have sworn, I would not have set foot in the area of mental health, but instead, I have discovered a wonderful world which blends many of my experiences into one. This gradual accumulation of experiences is something I would like to share with you. I encourage you to explore some of the journeys, new as they may seem. Take from them what you can absorb. Others, you may need to ruminate on for a while or even push aside. But what I have gained over the years of working as an occupational therapist is that this work is not limited to the use of only one lens, and we are now in a time of growth in the arena of complex trauma with children and adolescents. This book is written to encourage whoever reads it to have a better understanding of the multiple layers and domains in which a child’s complex trauma experience places them. Too often, I have found professionally we view only through one focal point such as sensory or developmental skills or behaviors. We take ownership of the theory, the techniques, and even the equipment. Here, there will be activities and interactions more easily applied by occupational therapists due to the nature of their clinic spaces; however, I encourage you as a foster parent, counselor, child protection worker, or parent to incorporate and possibly include ix

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equipment or even the use of office or home space differently, maybe outside of what is typically expected of you by yourself or others. Here I wish you to see how closely this knowledge is so interconnected and interrelated, to become more familiar with going on a walk along the path of discovery, for your child and yourself. As you feel more comfortable, consider stepping out of your usual way of viewing the issues and shifting to another place and perspective. Understand that feeling less comfortable with this newness may also be similar to your child’s, adolescent’s, and/or client's own experiences. Take the time to notice your own inner sensations and understand you are not in isolation. We are interconnected; the dances vary, but they are present if you can allow your awareness to shift. A different lens may broaden your understanding and perspective and hopefully heighten your compassion and growth. I trained as an Occupational Therapist in Western Australia and upon graduating decided to leave the city where most of my peers had settled and took on the task of establishing a new clinic “up north” in the state’s desert. It did not take me long to realize that there were others with specialty skills I certainly lacked. Unless I started to ask questions and throw in a dab of creativity, the professional challenge would be insurmountable. My “Ahhha” moment! This was the beginning of my professional path of discovery. I had started to ask the question “Why?” And this probably drove many people I worked with or who have taught me, onto the brink of despair. But it has become a fundamental question I ask and incorporate into training the people I work with. In sustaining the Why question, we must however constantly face a state of “not knowing.” It can be difficult for a qualified professional to accept this state of mind, but I believe it is essential for personal and professional growth. If something just doesn’t feel it is connecting with a client, or not making sense somehow, then I encourage you to shift your lens! View it from a different place within yourself or externally. This question “Why?” has become an integral part of the assessment and treatment process we utilize in our clinic. We do not do this to place a particular label on a certain behavior but to expand our awareness of the child’s possible ways of managing and how/why they are recruited by the child. This broader perspective shifts the focus away from standardized curriculum and moves toward a more individualized approach needed for these children. As a new graduate, I had been given multiple treatment approaches for providing occupational therapy services to diverse populations and the impression I would be surrounded with “a nice clinic full of supplies and clinicians around to resource,” but no-one had hinted on the reality of me flying with the Flying Doctor service out to far stations (farms) and being unable to bring my equipment, or even to set up a base to work from. I found myself having to observe what was happening around me, connect with the people, and then try to place the importance of my clinical perspective into the reality of a person’s life, support, and customs. I questioned, “What was the applicability of a developmental assessment created and tested on Caucasian Midwest Americans in the middle of the Pilbara region, with an

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Indigenous Australian population?” The skills of these children were diverse and yet could not be captured accurately by the assessment tool. The items were simply not relevant, nor of any particular interest to the children. It wasn’t that they were all delayed! I had to sit, watch, and listen… and to understand. Gaining a better understanding of another does not always come in the form of a test or questionnaire. I had some wonderful experiences, but my restlessness to learn more from others persisted. I decided to hand over the department to another therapist, and I set off on international travel “to broaden my horizons, learning and experiences.” I did not realize this was to continue for several decades! But it did herald the second phase of my professional work and growth. I traveled across Canada, filling locums wherever a vacancy presented, again seeking the diverse or varied opportunity. However, it was in New Brunswick, on the east coast of Canada, where my occupational therapy career took a different turn. I was working in a rehabilitation center for the province, and one day, a 5-year-­ old girl was placed on my caseload. My role was to assess her developmental status and to provide Activities of Daily Living Skills as needed. I swung into the room and found a small girl in the corner, verbally uncommunicative and anything but willing to engage in the activities I had been allocated to assess. This child had been involved in a car accident. Both her parents and her sibling had all been killed. She had “survived” but sustained multiple fractures and physical injuries. What had not been described in her medical history was her state of shock and social withdrawal. I had not understood, nor been trained in any way, shape, or form, on how devastating the impact of trauma can be on a person, let alone on a young child. In the subsequent team meetings, I became more and more dismayed at the lack of resources available for this child. This was a time when the “decade of the brain” and the expansion of trauma research had not yet flourished. The center primarily worked with adults, but because her relatives lived close by and she had no other support systems, she was placed with us for services. Sadly, however, her developmental rehabilitation was designated by profession…one staff worked with the child’s motor skills, the next with speech, the next with psyche, the next with diet. There was no malicious intent on the part of the caring staff, but the lack of a holistic approach meant that this child was never treated as a whole person and the staff were at a loss concerning the impenetrable nature of this child’s lack of engagement in treatment. She had closed herself off to all the adults surrounding her… but no-one knew how to engage her non verbally. What was she trying to tell us? People were floundering. Labels would arise concerning her behavior and non-cooperation. I certainly did not feel I had many tools to access or at least engage with this child adequately. I again, did what I knew how to do, I searched for someone who had a better understanding of this area! I researched training courses and professions and settled on going back to graduate school to study and train to become a Dance/ Movement Therapist. I wanted to gain a better understanding of body language and non-verbal communication.

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Dance and Movement This was a time of discovery and pushing boundaries I had never known existed. I had come from a relatively conservative Australian home, with parents who had both experienced World War II and multiple losses involved. One did not share inner thoughts and feelings; let alone was anyone encouraged to actually focus on these inner experiences! Suddenly I found my interest in mental health flourishing because observation was something that felt familiar and had always set me slightly apart. I had never understood this possible connection, and I was amazed at this “new” focus on the development of one’s sense of self and how it was not only reflected in the psyche, but in close relation with the exploration and engagement in our own approach to the surrounding world. I was presented with intensive exposure to the psychoanalytic work of Bowlby, Spitz, Mahler, and Kaplan and found myself immersed in particular with the writings of Kaplan. She wrote with passion about the progression of a child through synchronicity with her caregiver to individualization (Kaplin, 1978). These readings and the dance/movement program allowed me to view the development of the child in a closer relationship with the child’s motor skills and also their social and interpersonal engagement with the world. It was like opening Pandora’s box. Suddenly interconnections overflowed, and I was able to glimpse some of the complexities and interrelationships in a child’s development through several different approaches and lenses.

Movement Notation: Laban and Kestenberg During my graduate experience, I was also exposed to movement notation. This gave me the language to understand what I had been seeing. Just as one can write the notes of music and have another understand the piece and have a chance of replicating it, a person can also notate and write the components of a movement. The work of Laban was formative in this awareness. The observable movement qualities of weight, time, direction, and flow were analyzed. Nonverbals became alive with messages that I had simply not been able to label but had been noticing from a young age. As the program progressed, the work of Laban was then further analyzed and set into a psychoanalytic framework called Kestenberg’s Movement profile. Dr Kestenberg had set up a center for children in Long Island, New  York, and was working in collaboration with others trained in movement analysis. She linked attachment into her own expansion on Laban’s notation work, capturing micro-­ movements, qualities, shapes, predominance of patterns, and their flow in relation to the child’s primary caregiver. After graduating, I relocated to New York City to work in a research child and adolescent day treatment program as an occupational therapist, and to also study on Long Island with Dr Kestenberg as a postgraduate student.

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The subtle view of development became no longer a linear process but multidimensional, and my lens was becoming much wider. The child’s individual experiences and internal drive impacted their relationships and their ventures into their world. Kestenberg studied the intimate relationship between the child and mother in detail, notated the ebb and flow of their interactions, and noted clashes and predominant strategies both would utilize in relaxation and times of stress (Kestenberg, 1967; Berstein & Singer, 1982; Csikszentmihalyi, 2008). All this was happening in the absence of verbal language. The development of the child became intertwined in multiple domains and was not a simple, step-by-step sequence anymore. At that time, I found my work as an occupational therapist also became more focused on relationships and psyche development, beyond the psychoeducation skills I had been trained to share and teach. While at the child and adolescent program, I was involved in helping develop a research preschool program for children exposed to “crack.” I was encouraged to continue the questioning process, observe others, and establish possible assessment procedures and intervention details. Sadly, however, the traditional psychoeducation role I was placed in had me questioning how much of what was being taught was actually being absorbed by the children. I noticed the carryover of information and skills was limited. The children seemed to be caught in the cycle of set behaviors and responses. Why?

Cultural Lens I have had the opportunity to travel among many different cultures, spending time with and observing interactions and child-rearing customs that appear so different from the Western exposure I had experienced. I remember one day being stunned as we slowly moved in a small 12-seat taxi boat through a swamp region in Malaysia. A mother calmly stood up from the nearby seat. She carried her baby to the open toilet hole in the boat, held her child, who appeared to be 8 months old, over the toilet, and the child urinated. The mother then unhurriedly walked back and continued her conversation with her friend, while she allowed her child to breastfeed. The two were so “in sync” with each other… no diapers, no mess, a happy baby, and a dry mother. I began noticing the children around me were constantly carried, swaddled, or strapped to their mother as she worked. There appeared to be no complaining, and if it did occur, someone immediately met the child’s needs. The children were surrounded and interacting with peers, youngers, “olders,” and the elderly. It was rare to hear any reprimand or cries of protest. I was reminded of the work of Prescott (2004). He had focused his research on the peaceful communities in the world and had repeatedly noted the constant attention for the children and their training from a young age to understand their part in the community. All the community interacted with the children, and even when their mother was tired, another would step in to fill the possible void. The world of the child was safe and contained. The community was peaceful. But still… how did this mother know her child needed to urinate? How did she become so attuned?

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I continued to pay attention to the yin and yang of interactions, the ebb and flow, the forward movement and the subtle retreats. My occupational therapy groups became more interactive, motor, and nonverbal…. The children stayed in group!!! I had rare conflicts, and I realized the movement analysis I had been trained in had helped me notice movements called pre-efforts.

Pre-efforts These pre-efforts are present as one is about to start a movement….often before most will see the movement. There is a channeling of focus and the change occurs. Simply put, the way some mothers know their child is about to reach for the cookie before it actually happens or that their child is about to fall, and she catches them before they do. By noticing this change in the movement qualities, the therapy sessions began to match and attune to the client in a way similar to the primary caregiver dancing in synchronicity with his or her child. This dance is more than the body language explored in the 1970s. There are no general movements which consistently mean the same thing. Movement needs to be put in context, and I found that the more I could understand the child’s or adolescent’s history, the more I could assist with regulation and have a better understanding of the attachment challenges of the individual child. So frequently, I noticed the amazing skills of my colleagues were not being integrated within the children and adolescents. The children appeared so immersed in their defensive strategies that they had difficulty engaging the cognitive components being shared.

Sensorimotor Psychotherapy Pat Ogden’s work in Sensorimotor Psychotherapy drew my attention. So much research and literature was emphasizing the need to engage in trauma recovery through a body based approach. I sought to refine my focus and immersed myself in sensorimotor psychotherapy training. The strength and resilience of individuals, how they reflected their trauma experiences in the history of their body and its acknowledgment, became an additional pathway to working with the children and adolescents coming to the clinic with regulation challenges. So much of what they had experienced was before or beyond verbal processing. How could these incredible resources be interwoven to help create a stronger regulation foundation for these children, where for many of them, the stability of these essential building blocks had been poorly established or significantly disrupted? The perpetrators of their trauma are usually their own caregivers. Yet the regulation research, particularly by Allen Schore (1996, 2000, 2001, 2009), indicated the need to provide

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stability before the mobility of growth and social engagement. How could one recreate the foundation stones for the building of regulation and modulation skills, so the child could move into the more detailed processing of their experiences and expand on their resilience and growth from their trauma. But none of these observations, I believe, can be seen in isolation from the neurology, physiology, and resilience research on the child who has experienced complex trauma. The works of Perry, Schore, Ogden, Levine, and Porges are but a few of the outstanding people who have written extensively about the impact of trauma on the developing child. They call into consideration the age of the impact, the chronic or acute nature of the trauma, and always refer to the need for the child to experience trust and safety. If 85% of the people who perpetuate the trauma on the child are their own caregivers, (indicated in national and regional statistics), then how does this impact the child’s development of regulation? How can we as therapists narrow our focus to only sensory or motor skills? Mountains of existing research and our observations support a more integrated way of working with these children. This book is the summation of my experiences. I am proposing a different lens through which to view regulation. Since my work is primarily with children and adolescents who have experienced trauma, regulation is paramount and often absent, or at least poorly modulated. Frequently, the child comes to therapy due to “their behaviors.” Often they have “failed out of talk therapy.” I am proposing we need to assist with coregulating the child and to guide them to learn what regulation can feel like. We need to actually examine what “felt” safety is and provide experiences where this is embodied and not just a known and accepted concept. This book, however, is not ever intended to be a curriculum. That would be too narrow and narrowing. It is a collection of observations and experiences from my clinical work. I hope some of these ideas can be considered when working with this group of children whether it be in the home, school, community, or clinic. It is not intended to be owned by one profession over another. It is ideally the starting point of a discussion about creating that place from which a child can safely develop and to understand the amazing adaptability and resilience of these children. I welcome further debate and discussion.

References Berstein, P. L., & Singer, D. L (Eds.). (1982). The choreography of object relations: Advances in dance-movement therapy. Antioch/New England Graduate School. Csikszentmihalyi, M. (2008). Flow: The psychology of optimal experience. Harper Perennial Modern Classics. Kaplin, L. J. (1978). Oneness & separateness: From infant to individual. A Touchstone Book. Kestenberg, J. S. (1967). The role of movement patterns in development, Vol 1. Dance Notation Bureau Press. Prescott, J. W. (2004). The origins of love and violence. Byronchild Magazine, 9, 18–22.

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Schore, A. (1996). The experience dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Development and Psychopathology, 8, 59–87. Schore, A. (2000). Attachment and the regulation of the right brain. Attachment and Human Development, 2(1), 23–47. https://doi.org/10.1080/146167300361309 Schore, A. (2001). The effects of a secure attachment relationship on right brain development, affect regulation & infant mental health. Infant Mental Health Journal, 22(1–2), 201–269. Schore, A. N. (2009). Relational trauma and the developing right brain: An interface of psychoanalytic self psychology and neuroscience. Self and Systems: Annals of New York Academy of Science, 1159, 189–203.

Acknowledgments

I wish to give special thanks to Peter Blake for his ongoing support and encouragement throughout my dissertation and the writing of this book. His expertise in child and adolescent psychotherapy continues to profoundly inspire me. I would also like to thank my colleagues for their constant encouragement to put this approach down in writing. You kept my motivation moving on. Thank you to the children and adolescents who have taught and shared with me so much about their lives and their incredible resilience. Finally, thanks to my wonderful children, who are my foundation of safety and encourage me to keep venturing out into the world!

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Contents

Part I Background Theory and Research 1

What Is Complex Trauma? ��������������������������������������������������������������������    3 Sam-Abandonment����������������������������������������������������������������������������������     5 A Flared Focus����������������������������������������������������������������������������������������     6 Attachment and Brain Development��������������������������������������������������������     7 Physiology������������������������������������������������������������������������������������������������     8 The Use of Yourself����������������������������������������������������������������������������������     8 References������������������������������������������������������������������������������������������������     9

2

The Process of Attachment����������������������������������������������������������������������   11 John Bowlby��������������������������������������������������������������������������������������������    12 Bowlby and Infant Observation ��������������������������������������������������������������    13 Mary Ainsworth ��������������������������������������������������������������������������������������    13 Strange Situation and Attachment Styles������������������������������������������������    14 Secure Attachment ����������������������������������������������������������������������������������    15 Insecure Avoidant������������������������������������������������������������������������������������    15 Insecure Ambivalent��������������������������������������������������������������������������������    15 Disorganized Disoriented������������������������������������������������������������������������    16 Allen��������������������������������������������������������������������������������������������������������    17 Attachment, Neglect, and Abuse��������������������������������������������������������������    17 Alice��������������������������������������������������������������������������������������������������������    18 Donald Winnicott ������������������������������������������������������������������������������������    18 “Good Enough Mother”��������������������������������������������������������������������������    20 Pam����������������������������������������������������������������������������������������������������������    20 Wilfred Bion��������������������������������������������������������������������������������������������    20 Peter Fonagy: A Theory of the Mind ������������������������������������������������������    21 Louise Kaplan������������������������������������������������������������������������������������������    22 Sophie������������������������������������������������������������������������������������������������������    23 Nancy ������������������������������������������������������������������������������������������������������    23 Judith Kestenberg: Attunement and Flow������������������������������������������������    24 References������������������������������������������������������������������������������������������������    25 xix

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 Neurology and the Development of Regulation������������������������������������   29 The Early Brain����������������������������������������������������������������������������������������    30 Neurology and Attachment����������������������������������������������������������������������    31 Awareness of the Neurological Basis of Regulation and Behaviors��������    32 Ryan ��������������������������������������������������������������������������������������������������������    33 The Brain ������������������������������������������������������������������������������������������������    34 The Brain’s Structure ������������������������������������������������������������������������������    35 Lower Brain Regions ��������������������������������������������������������������������������    35 The Cerebellum������������������������������������������������������������������������������������    36 The Limbic System������������������������������������������������������������������������������    36 The Cerebral Cortex����������������������������������������������������������������������������    38 Vulnerability����������������������������������������������������������������������������������������    39 Attachment and the Development of Regulation ��������������������������������    40 Neurological Changes and Dysregulation�������������������������������������������    41 John������������������������������������������������������������������������������������������������������    43 The Impact of Trauma on the Developing Brain ��������������������������������    44 Brain Integration����������������������������������������������������������������������������������    46 Fear of Novelty������������������������������������������������������������������������������������    48 Summary����������������������������������������������������������������������������������������������    48 Damage or Adaption?��������������������������������������������������������������������������    49 Adrian��������������������������������������������������������������������������������������������������    49 References������������������������������������������������������������������������������������������������    50

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 But Physiology Plays a Part in Complex Trauma!��������������������������������   57 Balance and Homeostasis������������������������������������������������������������������������    57 Stress Systems������������������������������������������������������������������������������������������    57 Hypothalamic–Pituitary–Adrenal Axis (HPA Axis)��������������������������������    58 The Hypothalamus ������������������������������������������������������������������������������    58 The Pituitary����������������������������������������������������������������������������������������    58 Cortisol and Adrenaline ����������������������������������������������������������������������    58 Feedback Loop������������������������������������������������������������������������������������    59 Chronic Stress and Cortisol ��������������������������������������������������������������������    59 Priming����������������������������������������������������������������������������������������������������    60 In Utero: Stress and the Fetus������������������������������������������������������������������    60 Drug Exposure: Early Physiological Developments��������������������������������    61 Stress and the Polyvagal Theory��������������������������������������������������������������    61 Social Engagement System: Ventral Vagal Circuit����������������������������������    62 Play����������������������������������������������������������������������������������������������������������    63 Sympathetic Circuit: Fight or Flight��������������������������������������������������������    63 Dorsal Vagal Circuit: Shutting Down or “Playing Possum”��������������������    63 Neuroception Versus Perception��������������������������������������������������������������    64 “My Sweater Tried to Kill Me”: A Neglected 7-Year-Old Boy��������������    64 Background������������������������������������������������������������������������������������������    64 Clinical Presentation����������������������������������������������������������������������������    64 Therapy������������������������������������������������������������������������������������������������    65 The Sweater Incident ��������������������������������������������������������������������������    65

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Regression-Survival and Safety ��������������������������������������������������������������    65 The “Window of Tolerance”��������������������������������������������������������������������    66 A World View������������������������������������������������������������������������������������������    66 A Sensitized Alarm Response������������������������������������������������������������������    67 The Polyvagal Ladder������������������������������������������������������������������������������    68 Marianne��������������������������������������������������������������������������������������������������    68 Annie: Dorsal Vagal Response����������������������������������������������������������������    68 David: Sympathetic Response: Fight and Flight�������������������������������������    69 Fawning����������������������������������������������������������������������������������������������������    69 Allostatic Load����������������������������������������������������������������������������������������    70 Stress in Infancy��������������������������������������������������������������������������������������    70 Use Dependent Shifts������������������������������������������������������������������������������    71 The Adverse Childhood Experience (ACE) Study: Childhood Matters ����������������������������������������������������������������������������������    71 Even Sleep!����������������������������������������������������������������������������������������������    72 The Effects of Stress on Genetics and Priming����������������������������������������    73 Endogenous Opiate Response to Stress ��������������������������������������������������    74 Oxytocin��������������������������������������������������������������������������������������������������    74 Being Proactive����������������������������������������������������������������������������������������    74 Avoiding the Deer on the Road����������������������������������������������������������������    75 References������������������������������������������������������������������������������������������������    75 5

 The Child’s Managing Behaviors ����������������������������������������������������������   79 Regulation in a Caring Environment��������������������������������������������������������    79 Our View of the Managing Behaviors Matters����������������������������������������    80 Management and Understanding: Two Important Pillars������������������������    81 Resetting a Secure Base ��������������������������������������������������������������������������    81 What Do Animals Do When Under Threat?��������������������������������������������    82 The Experiential Canalization Theory ����������������������������������������������������    82 Secondary Strategies to Attachment��������������������������������������������������������    82 Sonny ������������������������������������������������������������������������������������������������������    83 Anticipation of Threat: Sensory Vigilance����������������������������������������������    84 Attention Deficit Disorder������������������������������������������������������������������������    84 Visual Bias ����������������������������������������������������������������������������������������������    84 Auditory Bias and Stress��������������������������������������������������������������������������    85 Language Changes ����������������������������������������������������������������������������������    86 Managing the Stress Through Behaviors ������������������������������������������������    87 Aggression: Fight������������������������������������������������������������������������������������    87 Dissociation: Freezing ����������������������������������������������������������������������������    88 Sandra������������������������������������������������������������������������������������������������������    88 Domestic Violence ����������������������������������������������������������������������������������    89 Sexual Abuse��������������������������������������������������������������������������������������������    89 Neglect ����������������������������������������������������������������������������������������������������    90 Medical Procedures and the Neonatal Intensive Care Unit (NICU)��������    90 Dysregulated or Unregulated? ����������������������������������������������������������������    91 A Traumatized Child’s Managing Behaviors in the School Setting��������    91

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In the Classroom��������������������������������������������������������������������������������������    92 Rewards and Consequences ��������������������������������������������������������������������    93 Resilience������������������������������������������������������������������������������������������������    94 Trying to Feel Safe����������������������������������������������������������������������������������    94 References������������������������������������������������������������������������������������������������    95 6

How Does the Modulating Caregiver Impact a Child’s Regulation? ����������������������������������������������������������������  101 Attunement?��������������������������������������������������������������������������������������������   101 Mirror Neurons����������������������������������������������������������������������������������������   102 Feelings in the Body��������������������������������������������������������������������������������   102 The Impact of How We Move and Respond: Kestenberg������������������������   103 William: Regulating with a Sigh��������������������������������������������������������������   103 The Elements of a Movement������������������������������������������������������������������   104 Pre-efforts������������������������������������������������������������������������������������������������   106 Genuine Attunement��������������������������������������������������������������������������������   107 Intersubjective Experiences ��������������������������������������������������������������������   107 Right Brain to Right Brain����������������������������������������������������������������������   108 Neural Connections����������������������������������������������������������������������������������   108 Interactive Slow Frame Movement Observations������������������������������������   109 Social Engagement: Polyvagal Theory����������������������������������������������������   109 On the Inpatient Unit ������������������������������������������������������������������������������   110 Synchronicity of Heart Rhythms ������������������������������������������������������������   110 Take a Breath ������������������������������������������������������������������������������������������   111 Eye Gaze��������������������������������������������������������������������������������������������������   111 Pupil Dilation ������������������������������������������������������������������������������������������   111 Gaze Patterns and Dynamics�������������������������������������������������������������������   112 Increasing Self Control����������������������������������������������������������������������������   112 Motherese������������������������������������������������������������������������������������������������   113 Womb Security and Rhythm��������������������������������������������������������������������   113 Biochemistry��������������������������������������������������������������������������������������������   114 Touch Communicates Support and Protection����������������������������������������   115 Aliveness��������������������������������������������������������������������������������������������������   115 Putting These Elements Together������������������������������������������������������������   116 Charlene: I Don’t Want to Be Here. I Was Forced to Come!��������������   116 References������������������������������������������������������������������������������������������������   117

Part II Intervention: The Body-Based and Attachment Approach to Complex Trauma Regulation in Children 7

Safety and Attunement����������������������������������������������������������������������������  125 Secure Base����������������������������������������������������������������������������������������������   125 Mabel ������������������������������������������������������������������������������������������������������   126 “Being Contained” and “Being Held” ����������������������������������������������������   127 References������������������������������������������������������������������������������������������������   127

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 The Assessment of the Child with a Complex Trauma History ����������  129 The Start of the Assessment Process��������������������������������������������������������   129 Occupational Therapy������������������������������������������������������������������������������   129 Observations��������������������������������������������������������������������������������������������   130 Questionnaires������������������������������������������������������������������������������������������   130 The Telephone Intake������������������������������������������������������������������������������   131 Other Sources of Information������������������������������������������������������������������   131 The Waiting Room ����������������������������������������������������������������������������������   132 Transitions������������������������������������������������������������������������������������������������   133 Entering the Clinic Room������������������������������������������������������������������������   133 The Formal Set-Up of Assessments��������������������������������������������������������   134 Safety First ����������������������������������������������������������������������������������������������   135 Keeping Predictability�����������������������������������������������������������������������������   135 Verbal Processing or Modeling����������������������������������������������������������������   136 Formal Assessment Tools������������������������������������������������������������������������   137 The Puzzle������������������������������������������������������������������������������������������������   137 References������������������������������������������������������������������������������������������������   138

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The Environmental “Container”������������������������������������������������������������  139 Primary Safety ����������������������������������������������������������������������������������������   139 The Surrounding Physical Space Does Matter����������������������������������������   140 It Takes Time��������������������������������������������������������������������������������������������   140 Let’s Look at the “Physical” Container ��������������������������������������������������   141 Maybe This Room Is Too Large! ������������������������������������������������������������   141 What Is the Child Selecting?��������������������������������������������������������������������   141 Small Can Be Good ��������������������������������������������������������������������������������   142 Now Let’s Talk About Open Spaces��������������������������������������������������������   142 Consistency in Space Use������������������������������������������������������������������������   143 The Guided Use of the Equipment and Physical Safety��������������������������   143 The “Just Enough” Challenge������������������������������������������������������������������   144 Equipment: Containment Qualities����������������������������������������������������������   144 What Are Other Container Choices in a Room?��������������������������������������   145 The Ball Pit����������������������������������������������������������������������������������������������   145 Michael����������������������������������������������������������������������������������������������������   145 Ground With the Ground!������������������������������������������������������������������������   146 Even Cardboard Blocks Can Create a Secure Base ��������������������������������   146 Adam��������������������������������������������������������������������������������������������������������   146 How Much? Which Swing? ��������������������������������������������������������������������   147 But Isn’t This Like the Sensory Integration or Sensory Processing Approach?������������������������������������������������������������   148 “Stability Before Mobility”….“I Am, I Do”��������������������������������������������   148 Triggers����������������������������������������������������������������������������������������������������   151 Now How Can We Use the Swing Differently?��������������������������������������   151 Swings and Matching Them to the Child’s Attachment “Container” Needs ����������������������������������������������������������������������������������   152 Fred����������������������������������������������������������������������������������������������������������   153

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Find Me!��������������������������������������������������������������������������������������������������   154 Phillip������������������������������������������������������������������������������������������������������   155 Susan��������������������������������������������������������������������������������������������������������   157 Past Reflections����������������������������������������������������������������������������������������   157 Out of the Clinic��������������������������������������������������������������������������������������   158 When Does the Felt Sense of Safety Start? ��������������������������������������������   159 Can I Take the Risk?��������������������������������������������������������������������������������   159 References������������������������������������������������������������������������������������������������   160 10 Safety  and the Therapeutic Management Strategies for Carers and Therapists ����������������������������������������������������������������������  161 The Therapeutic Use of Self��������������������������������������������������������������������   161 Mirrors and Reflections ��������������������������������������������������������������������������   162 What Can We Notice? ����������������������������������������������������������������������������   163 Body Language����������������������������������������������������������������������������������������   163 Literal “Holding”������������������������������������������������������������������������������������   164 Primary Caregiver Holding����������������������������������������������������������������������   164 The Therapist������������������������������������������������������������������������������������������   165 Perceived Holding and Creating a Sense of Safety: Shaping and Response����������������������������������������������������������������������������   165 Proximity ������������������������������������������������������������������������������������������������   166 Postures and Gestures������������������������������������������������������������������������������   167 Posture: Full Body Involvement��������������������������������������������������������������   167 Stillness����������������������������������������������������������������������������������������������������   167 Here Are Those Elements Again: Weight, Time, and Direction��������������   168 Playing With Equipment Adjustments����������������������������������������������������   168 Get Out of Your Head and Into Your Body����������������������������������������������   169 The Pre-effort Elements��������������������������������������������������������������������������   169 Eye Gaze and Orienting��������������������������������������������������������������������������   169 Samuel ����������������������������������������������������������������������������������������������������   170 Brian��������������������������������������������������������������������������������������������������������   171 Voice Prosody������������������������������������������������������������������������������������������   172 Rhythm����������������������������������������������������������������������������������������������������   173 Music ������������������������������������������������������������������������������������������������������   173 Touch ������������������������������������������������������������������������������������������������������   173 Heidi��������������������������������������������������������������������������������������������������������   174 Brushing��������������������������������������������������������������������������������������������������   175 The Brush������������������������������������������������������������������������������������������������   175 The Technique ����������������������������������������������������������������������������������������   176 Warmth����������������������������������������������������������������������������������������������������   177 And Don’t Forget Playfulness!����������������������������������������������������������������   177 Caregiver Education��������������������������������������������������������������������������������   178 References ����������������������������������������������������������������������������������������������   180 Conclusion��������������������������������������������������������������������������������������������������������  183 Index������������������������������������������������������������������������������������������������������������������  185

About the Author

Suellen  Thomson-Link  grew up in Perth, Western Australia, but has lived and worked in Canada and the United States for 42 years. She has her doctorate in occupational therapy and is also a registered dance/movement therapist. Suellen specializes in working with children and adolescents who have a complex trauma history and regulation challenges. She incorporates her years of bodywork and mental health training into her unique treatment approach. Suellen has owned and operated a successful private practice for many years in Wisconsin working with these children. She has trained many mental health professionals, child protections workers, teachers, and primary caregivers in her treatment theory and interventions. She now works with these children and adolescents in Perth and continues to teach.

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Part I

Background Theory and Research

Chapter 1

What Is Complex Trauma?

There has been an ongoing debate about the inclusion of a new diagnostic group in the Trauma and Stress-Related Disorders in the DSM V (Diagnostic and Statistical Manual of Mental Disorders). The trauma community has recognized, particularly in the child and adolescent population, the existence of a chronic form of trauma perpetrated on children primarily by their caregivers, the persons who are meant to protect their children. They instead are the ones violating these children, and the attachment and developmental impact affect them on multiple levels. Hence a proposal has been put forward to include a diagnosis of Developmental Trauma or Complex Trauma. The current Post Traumatic Stress Disorder (PTSD) criterion A often eliminates the child’s chronic experience of trauma, and rules out the diagnosis of PTSD, because of the need to have “exposure to actual or threatened death, serious injury or sexual violence” (American Psychiatric Association, 2022). Yet when one looks at the child abuse and neglect criteria, it is clear to note in the national and state statistics that the predominant type of trauma impacting children in the below 6 years age group is neglect. The child with this type of chronic exposure is physically, emotionally, socially, and cognitively impacted. The implications on their future skill development are significantly challenged. Cook et al. (2005) have recognized seven distinct domains impacted including attachment, biology, affect regulation, dissociation, behavioral control, cognition, and self-concept. They have highlighted the impairments with numerous examples. To name but a few include interpersonal difficulties, poor sleep, challenges with self-regulation, poor body image, problems with processing new information, and difficulty communicating their needs and/or wishes. The list is extensive. All these factors impact on the child’s sense of being. Thus, the importance of implementing a comprehensive assessment is significant. There is a tendency to use a limited lens when a child comes in for an intake and this will not do justice to the child’s needs for the effectiveness of the interventions. Without a comprehensive history and awareness of this complex series of interconnections, it is not

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_1

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uncommon for a child to receive multiple diagnoses that highlight the behaviors but not the cause. The limitations when people identify a single behavior or element, such as hyperactivity or sensory processing, and attempt to target it as an individual issue, narrow the focus too much and pay little attention to the active role managing strategies play in the child’s perceived and actual felt sense of safety. This, I believe, does not do justice to the complex needs of the child. I have personally drawn a sample of 185 children from my own practice and had the child’s caregivers complete a trauma inventory. All recorded at least one form of identified trauma and had presented with regulation and significant behavior challenges. Less than a quarter of the children had a PTSD diagnosis. The most common diagnoses included Attention Deficit Disorder, Oppositional Defiant Disorder, Anxiety Disorders, and Disruptive Mood Dysregulation Disorder. The concern with these diagnoses, which often do coexist in the presence of complex trauma, is they do not give a comprehensive view of the child’s experience. I have had clinician’s focus, for example, on a child’s hyperactivity because their diagnosis was Attention Deficit Hyperactivity Disorder (ADHD), but despite the child’s constant movement and switching from one activity to another, the diagnosis does not account for their obvious hypervigilance and activity, which is actually trauma related. They do have similar presentations but when trauma is obtained in the child’s history, treatment can focus on perceived and actual safety and can elicit a calming impact on the child, which is not seen in a child with a more traditional ADHD presentation. Complex trauma awareness places the constant need to question and connect behaviors, experiences, and safety into the forefront of treatment. Without this, one may be like a dog chasing its tail. What then is Developmental or Complex Trauma? The Children’s Trauma Assessment Center (2020) describes it as an ongoing experience of emotional, physical or sexual abuse, neglect, medical trauma, exposure to domestic or community violence, and loss. The child has endured multiple interpersonal traumatic events. It is different from one-time trauma events such as a hurricane or a robbery, because of its chronic, often ongoing interpersonal nature. The National Report on Child Maltreatment (U.S. Department of Health and Human Services, 2023), reflects the largest age group of abuse and neglect is in the 0–1 age group followed by the 1- to 3-year-old age group. This report also acknowledges that 85% of the perpetrators are the child’s primary caretakers. The detrimental impact of the carer perpetrating this maltreatment occurs during the time the brain and the body’s physiology is in a major growth spurt. New pathways are being developed and those not being stimulated are pruned (Perry et al., 1996; Schore, 1996; Balbernie, 2001). A child growing up in a world where their focus needs to be on their own safety and survival is a world deprived of exploration and growth. The child’s energy is devoted to existence and meeting their basic needs. We often see a child trying to control their environment, who is fearful of novelty, has poor problem-solving and time awareness, and who has difficulty with social engagement. This is a child who frequently perpetuates their lack of positive experiences and becomes entwined in a spiral of reinforcing their beliefs about their world, both internal and external, as a place to be cautious and wary of. When a strong foundation, facilitated by a healthy caregiving relationship is not

Sam-Abandonment

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established, the child can often struggle to develop skill sets which match their biological age and their responses can subsequently be misinterpreted as intentional behaviors or a lack of willingness to change.

Sam-Abandonment Sam was such a child. He was 7 years old and had come to me dysregulated, hyperactive, constantly in arguments at school and home, fighting with siblings, and significantly struggling at school academically. His mother was a single mother with two other children, but when Sam was 2.5 years old, his father was involved in a serious car accident and was placed in the ICU for 5 weeks. His mother needed to be available around the clock for medical decisions and during this time Sam was cared for by friends and grandmother. His father died at the end of the 5th week. Sam had been unable to spend any of the hospital time with him. His mother then tried to raise Sam alone but discovered she was pregnant. After the child’s birth, she started using cocaine and became even more absent, in and out of Sam’s life. His maternal grandmother became his primary caregiver. After 3 years, his mother attained sobriety, and Sam returned to live with her full-time. Sam’s mother graduated college and became more financially stable. Sam, however, continued to struggle markedly at school. He ran out of class, evaded teachers, threw objects, avoided schoolwork, and required multiple interventions due to his disruptive behaviors. I had been called in for a school meeting to address Sam’s “behavior issues,” and was in the process of discussing the ramifications of trauma on learning when the walkie-talkies sounded. The school staff bolted up from the table and ran down the hallway, some splitting off to block doorways and the others to accost Sam who had started to run and throw things at the teacher. After chasing him around the class, they put him in a two-point shoulder hold and marched him to the seclusion room. Sam was screaming, trying to free himself, but the adults were able to pull him into the seclusion room and announced they had called the police. All were crowded around the door to prevent him from escaping. Sam was screaming and pounding on the walls, begging for his mother to come and to be set free. The staff were demanding he give a reason for his outburst and again reminded him the police were coming. He was terrified. He saw me. He paused in recognition. I walked toward the door and said “You are not alone Sam. May I come in.” Again, he paused, made direct eye contact, and quietly nodded his head. His aloneness was recognized. He perceived an element of safety. This was the first time he demonstrated some brief regulation. Sam and I had worked together for several months. Over that time, he had been able to move from hyperactivity and multi-focus to orienting to me as a trusted other and experiencing some calm and reflection. He knew the structure of our sessions, the time was kept consistent and the environment was known and familiar. Whatever had occurred at school existed, but the behavior and dysregulation could be contained in our familiar environment and he was able to maintain regulation after the

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initial dysregulation moments of the transition period. Gradually, he was able to speak more about his concerns of abandonment and distrust of the school staff and children. This had been the point at which I had stepped into the school and witnessed the seclusion event. The focal point of abandonment was emphasized to the school staff. Remediation was made with calls being allowed to check in with his mother at regular times and less calls by the school to his mother to implement the punishment/consequence of his behavior at school. (Her relationship, which had significantly improved, was being put to test by the school calls following dysregulation periods.) There was a consistent schedule and smaller classes were made available for regular academics. He had time for pairing and availability to play with his friends, rather than having this removed as a consequence of his actions. This play opportunity was supervised to ensure competitiveness did not erupt. A calmer, more attuned staff member, who themselves more regulated, worked with Sam during this play period and on his academics. His academics were presented in both practical and written parts. He was presented with only small amounts on a worksheet so as to not be overwhelmed or aggravated by the repetition of a skill attained. His ability to stay on task and to remain more regulated began to improve. The assumption had been that Sam was a defiant child, who did not want to learn despite an aide being placed with him. Sadly, if a more trauma-aware focus had been initiated, the staff would have learned that Sam had recently been told his grandmother, who had literally raised him in early childhood, was dying of cancer. He also had had a substitute teacher for the past 3 days who had a directive style of class management and little knowledge of Sam’s history. She had also moved Sam away from his seat next to his best and only friend. All of this had been too much…… He felt he was abandoned and terrified. A wrong comment and raised tone of voice by the teacher to another child, and he had anticipated a threat and he had erupted….. No amount of questioning, reasoning for understanding, nor punishment would have changed his course, once his sense of safety was challenged and his adrenaline surging. A different proactive scenario, with up-to-date knowledge of Sam’s present home situation, a trauma understanding of threshold fatigue, perceived threat and his immediate need for safety and security would likely have changed the course of this entire situation.

A Flared Focus The identification of Complex Trauma in children and adolescents as a diagnostic category in the DSM has my full support. The more I interact with these children and adolescents the more I become aware of the developmental complexity of their needs. I believe when working and being involved with these children, that one needs to have an awareness of the interlap of attachment, neurology, physiology, cognition, and social engagement development. One needs to have a flared focus and a strong understanding of the ripple effect of one event on many other domains.

Attachment and Brain Development

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Between 1995 and 1997, Kaiser Permanente and the Center for Disease Control and Prevention completed a study of approximately 17,000 adult volunteers and noted the presence or absence of Adverse Childhood Experiences (ACE) within the population. Ten adverse childhood experiences were included in the survey questionnaire. These included physical, emotional and sexual abuse, physical and emotional neglect, and household dysfunction with mental illness, history of mother being treated violently, divorce, an incarcerated relative, and/or substance abuse. The outcome revealed that ACEs are common and that nearly two-thirds of the adults reported at least one. They found if the participant had one, there was an 87% chance that they would have two or more. The more ACEs they had, the greater the risk for chronic disease, mental illness, violence, and being a victim of violence (Felitti et al., 1998). The implication is profound. Children who are experiencing complex childhood trauma and the associated chronic stress are likely to be detrimentally impacted in their developmental, physiological, and behavioral realms well into their adult lives (Chrousos, 2009; Kain & Terrell, 2018) The layout of this book will address these different topics and aim not to make you specialists in each area, but to hopefully entice you to seek further information and understanding of these complex interconnections. Maybe step back and pause. Be less inclined to simply label a child’s response as an intentional behavior, cognitively selected to achieve a certain outcome.

Attachment and Brain Development I will discuss the ontogeny of attachment theory development and its significance in observing and researching the healthy caregiving relationship, the creation of a child’s essential foundations, and the development of management behaviors by the child in an attempt to establish homeostasis in him/herself. Allen Schore (2008) has written extensively, and has now reflected on the possibility of renaming “attachment theory” to “regulation theory.” He has been able to link attachment, neurology, and regulation in a closely related and interconnected way. Research from other’s perspectives will also be explored, to highlight the developmental process of the brain and self-regulation. Attachment provides the foundation for regulation and the child’s sense of homeostasis. If a child has been raised in an environment where there is consistent love and attention, emotional processing, shown containment and modulation and felt the inner sense of safety and trust, that child is far more likely to be able to adjust to the stress or unpredictability of life’s events and reach out for support from others if needed. Safety and trust are paramount. No matter the cognitive strategies we try to impart to our clients, if safety is not established, very little frontal lobe cognitive resourcing can be accessed, despite how valid the technique is. Just as no reward or consequence system will be effective in the long term. Safety and trust are number one.

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Physiology The physiology of the body is constantly being referred to by trauma therapists and significant research and writing are available on the development of the body’s responses to trauma. Stephen Porges (2011), who developed the Polyvagal Theory, has turned the physiology of trauma on its head and has tied it to the qualities of social engagement that are so frequently challenged in the managing strategies of the children I have been working with. Again, one cannot separate the interrelationships of the body’s responses from regulation, cognition, and social skills. On multiple occasions, I have also noticed judgments of the children’s behaviors. Were their behaviors simply to “get attention” and to “avoid doing something they don’t want to do”? Much labeling and simplification have me cringing. I truly believe we all seek homeostasis and social connectedness. However, if one has experienced foundation disruption of these essential elements, how can these children be to blame for trying within their repertoire, to try to make sense of their world, and to avoid being retraumatized? I am constantly amazed at the intricacy of the management/defensive strategies these children employ. Climbing on top of television monitors high in the cafeteria to avoid pursuing staff, cursing and throwing objects to keep distance between themselves and potentially risky others, and controlling peers and interactions in a way that stops bullying or being rejected. I totally agree that these are not socially convenient, but we as clinicians and caregivers must shift our lens and give credit where credit is due…if others have failed this child, they must use their own resources. Redl and Wineman (1951) in their work with “children who hate,” became aware of the children, however, having islands of knowledge and strength, where they identified value systems and could briefly demonstrate some social awareness, despite then dipping into their more frequently identified dysregulated behaviors. These defensive or managing strategies are again interrelated to their attachment and biological development. Do we simply demand they discard them without first throwing them a buoy?

The Use of Yourself Because again the body is so integrally entwined, I would like to highlight the research on mirror neurons, movement observation, and micromovements. Is what we are doing merely intuitive, the therapeutic use of self or is it that some people are able to notice in a different way? Is it all these elements or none? What are we saying when we talk about this therapeutic use of self? I have certainly wished on more than one occasion the therapist would be more aware of themselves and be less cognitively directed and disengaged. Why are some people more effective in doing this sort of work and others less attuned? Dr. Kestenberg, Beatrice Beebe, Pat Ogden, Janina Fischer, and Peter Levine’s work cannot be ignored within this

References

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regulation perspective. If nonverbal communication is ontologically developed before language, why are so many resources funded for cognitive behavioral approaches only? Are the funding resources established by those who are more left-­ brain developed…linear, logical, and language-based? What are the components of a healthy relationship that provide the necessary foundations for the development of regulation? I would like to shift the focus from the mere concept and discussion of the need to create safety, to a more physical application created by the use of self and the components of the environment that are available. How can a space create a sense of safety? How can one person feel safer than another? How can some equipment be utilized to viscerally provide a different experience than that known by the traumatized child? Here, I would also like to explore the components of movement qualities that vary from the traditional sensory approach of occupational therapists and other professionals. I fully understand there will be those who have difficulty with shifting labels and categories and will continue to try to fit the existing model of sensory processing to the treatment of the complex trauma child. I would, however, like to at least stretch the perspective, to have the boundaries become more porous and the lens broadened, to remove so many of the labels we are keen to attach to the individual in front of us. Please remember, there is no one way to treat a person. Many paths exist. Our error as clinicians is to narrow our focus, to attach labels, to become just way too cognitive…ahhh….you see I have already started to do it! I invite you to take this dance, move as you feel comfortable, but try to learn to notice whatever comes forward……

References American Psychiatric Association. (2022). Diagnostic and statistical manual of mental health disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787 Balbernie, R. (2001). Circuits and circumstances: The neurobiological consequences of early relationship experiences and how they shape later behaviour. Journal of Child Psychotherapy, 27(3), 237–255. Children’s Trauma Assessment Center. (2020). Resources. https://wmich.edu/traumacenter/ resources-­0 Chrousos, G. P. (2009). Stress and disorders of the stress system. National Review of Endocrinology, 5(7), 374–381. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., & Van der Kolk, B. (2005). Complex trauma. Psychiatric Annals, 35(5), 390–398. Felitti, V.  J., Anda, R.  F., Nordenberg, D., Williamson, D.  F., Spitz, A.  M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/ S0749-­3797(98)00017-­8 Kain, K. L., & Terrell, S. J. (2018). Nurturing resilience: Helping clients move forward from developmental trauma. North Atlantic Books.

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Perry, B. D., Pollard, R. A., Blakley, T. L., Baker, W. L., & Vigilante, D. (1996). Childhood trauma, the neurobiology of adaption & use-dependent development of the brain: How states become traits. Infant Mental Health Journal, 16(4), 271–291. Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological foundations of emotions, attachment, communication, self-regulation. W.W. Norton & Company, Inc. Redl, F., & Wineman, D. (1951). Children who hate. The Free Press. Schore, A. (1996). The experience dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Development and Psychopathology, 8, 59–87. Schore, J. R., & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36(1), 9–20. https://doi. org/10.1007/s10615-­007-­0111-­7 U.S.  Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2023). Child maltreatment 2021. Available from https://www.acf.hhs.gov/cb/report/child-maltreatment-2021.

Chapter 2

The Process of Attachment

I have worked for a number of years with children and adolescents who have histories of complex trauma. What stands out for me is the difficulty most have with social engagement and the ability to establish a sense of attachment and trust without employing the defenses that appear so readily on the surface of each encounter. Once again, the majority of these children have experienced trauma at the hands of their caregivers. If this violation has occurred, it does not fall far from the tree that their ability to establish, experience, and maintain attachment is likely to be highly compromised. If one does not attend to these past and sometimes current experiences, then appeals to teach or mobilize new concepts and engagement strategies are likely to fall on deaf ears. I truly believe an understanding of how we learn to attach can help us not only relate to these children, but also to understand our own ways of relating to others, sometimes giving us the ability to acknowledge our own shortcomings or strengths. So, often the focus is primarily on the child, but as caregivers, we also have a significant impact on the regulation of these children. Frequently, I have noticed that by attending to changes in the parenting end of the interaction and in taking the time to understand the parent’s own attachment experiences, one can yield amazing changes in the child’s sense of safety, trust, and self-awareness, and then subsequently their readiness for change. If a child has experienced an attuned and secure attachment, they can develop an internalized sense of their own security and self-worth. This positively impacts their ability to relate to others, to understand empathy, and to be more open to other’s views and experiences. This would be in contrast to the child who has dealt with insecurity and inconsistency and a lack of acknowledgement to their own needs. These children will be more likely to try to control their own environment, to try to be individually reliant, and have their focus on internal versus external awareness and priorities for survival. In a healthy attachment scenario, where the child has the ability to experience stability, it frees them to access valuable brain resources for

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_2

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exploration, and emotional processing through play and learning. I want to emphasize that this feeling of safety and stability is an essential component in interventions dealing with regulation, and also brings about gains in other areas of their development. Attachment theory has changed over the years from a conceptual model with an inner world focus to one with a dynamic awareness of the child in relation to others and his/her surroundings. The child regulation skills develop through their reflective coregulation relationships, securing a foundation to become more socially engaged and flexible in their interactions.

John Bowlby John Bowlby is considered the pioneer of the attachment theory. His theory of development was different from the traditional conceptual framework of the psychoanalysts of the time and was more observational. During Bowlby’s own early life, he was raised in a period where parents did not want to spoil the child and hence Bowlby had 1 h a day where he saw his mother. During the summer, she was sometimes more available, and during these periods, she introduced Bowlby to the joys of nature, but becoming too involved with children was not the belief of the time, and these interactions were limited. Bowlby’s father was also relatively absent and served as a physician to the king. Bowlby rarely saw him. His primary caregiver was his nanny, to whom he felt very attached, but she left when Bowlby was age 4, and he described it as one of the greatest losses in his life. At the outbreak of World War One, at age 7, he was sent to boarding school to avoid the risks of the war. This was a traumatic event for him and he later recounted to his wife, he would not send a “dog” away at such a young age (Coates, 2004). Before entering medical school, Bowlby worked for several months at two residential schools with 3- to 18-year-olds who were considered “maladjusted” or “challenging” children. During this time, Bowlby noted that many of the children had had disrupted or poor attachment experiences and his interest in the relationship of attachment as both internally and externally generated, was something he continued to pursue into medical school (Bowlby, 1944). This approach placed him at odds with much of the psychoanalytic community and in direct conflict with his supervisor Klein, who actually prohibited him from speaking with the child’s mother who appeared to exhibit similar behaviors as her child. He continued, however, walking this new edge of treatment consideration and wanted to demonstrate the importance and interwoven nature of real-life experiences and that their consequences had a significant impact on a child’s overall development. So significant was Bowlby’s acknowledgment of the importance of the caregiver in the child’s world, when he took over the children’s department at the Tavistock clinic, he renamed it the Department for Children and Parents.

Mary Ainsworth

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Bowlby and Infant Observation Bowlby proposed that the positive experiences of the child in relation to his or her sensitive interaction with the mother create a sense of security. From this secure base, the child could explore the surrounding environment and learn to tolerate his/ her inner responsivity and regulation shifts. He believed that the caregiver assisted the infant in learning to modulate experiences in both positive and negative nature, by providing stable and consistent attunement and helping to attend to his or her immediate needs. Secure attachment correlated with maternal sensitivity. He noted that in the absence of such a stable relationship or attunement, the child would have difficulty with exploration and reregulating when experiencing a dysregulation shift. Bowlby advocated for the importance of caregiver–child observation and during his framework and theory development, he also saw parallels within biological and animal studies of attachment behaviors (Bowlby, 1988). Lorenz’s work (1935) on duckling imprinting demonstrated attachment based on an individual other figure separate from food provision, a more accepted psychoanalytic concept, and also similar work of Harlow with rhesus macaques. In Harlow and Zimmermann’s (1959) research, they consistently found that separated infants would seek the soft padding of a surrogate artificial mother, over one that was hard, but provided food. Again, this supported Bowlby’s developing theory of attachment based on elements of security and protection, and away from the previously identified food and sexual drives of the older psychoanalytic model. The importance of close and non-­ judgmental observation led Bowlby to introduce infant observation into the child psychoanalytic training at the Tavistock Clinic in 1948. This placed him in controversy with the more traditional analysts but gradually research by others also gained momentum. There was increasing evidence that both the impact of healthy relationships and unhealthy ones began to reinforce this close connection on the socio-­ emotional development of the child in a relationship with his/her primary caregiver. Bowlby was also interested in attaining the attachment history of the parent and exploring the intergenerational transmission of attachment styles. He noted during his work that the attachment history of the parent was frequently reflected in how they then behaved and related to their own child. He believed that work with the parents affected the work with the children and the two were intertwined and not exclusive (Novick & Novick, 2005; Schore, 2000; Seigel, 2001). This was a marked shift in the more conservative therapy approach, to one with dynamic and interactive involvement of the child in their internal and external worlds (Bretherton, 1992; Marrone, 2014; van Duken et al., 1998).

Mary Ainsworth In 1950, Mary Ainsworth joined Bowlby in his research. She had already studied the work of Blatz’s security theory. Blatz viewed the child’s relationship with the caregiver as a perceived sense of security which then led to the child beginning to

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explore the world. Ainsworth varied slightly in her approach with this theory. She viewed security as an actual experienced bond with the attachment figure, which is stable and not threatened (Ainsworth, 1988). She sought to expand on Bowlby’s attachment theory and pursued the naturalistic and detailed observational work of Robertson. Robertson who had joined Bowlby’s research team 2 years earlier had helped Bowlby observe and record children’s responses to separation from their caregivers when hospitalized. He subsequently made a movie with Bowlby reflecting a 2-year-old’s own hospital experience where she was removed from contact with her mother and this had a great impact on the outside world because the child’s perspective and apparent distress were brought into the limelight. In 1953 upon leaving the clinic when she moved to Uganda, she continued her attachment studies and was able to record, in particular, the mother’s sensitivity to the signals given by her infant. She noted that those mothers who appeared more in tune with their child, their infants appeared to be more secure in their attachment and explored their surroundings with more confidence. Those children with mothers who appeared detached from their child’s, insecurely attached, appeared more apprehensive about exploration, or were concerned with having their mother always nearby. Her observational skills and detailed records yielded support and helped to expand and elaborate on Bowlby’s attachment theory and their collaboration continued throughout their lives. This concept of the “secure base,” to which Bowlby gives Ainsworth credit, was explored further by Ainsworth in her Baltimore project studies. She followed 26 children, recruited before birth. They were aged between 3 and 54 weeks old. These children were visited at home and each time were observed for 4 h in 18 home visits. During this time, the observers noted the interactive behaviors of the mother and child. At 1 year of age, these children were then engaged in a 20-min interactive situation and again the behaviors of the mother and child were observed. These observations were further expanded by adding an additional 83 children and are now recognized as part of the Strange Situation paradigms.

Strange Situation and Attachment Styles Although this experimental situation has moved into the forefront of Ainsworth recognition, the observational data obtained from the home visits and the subsequent 1-year-old observations which documented attachment styles in early infancy clearly reflected the close interconnection between the early caregiving situation experiences and the attachment behavior of the same child at a later stage. The similarities between the two were significant. In the home situations where the mother had been sensitive to her infants’ needs, the child later was observed to be able to maintain exploration and to recover more quickly when separated from the mother. In the cases of the less responsive mother, the children in the 1-year experiment were disorganized and more insecure in their attachment style.

Insecure Ambivalent

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The experiment was standardized to observe the attachment behavior between the mother and child with the stress of separation and then reunification. The child and mother were observed as the child was exposed to a variety of standardized, varying combination scenarios of approximately 3  min each where he/she is left alone with a stranger, with mother and stranger, totally alone and then reunited with his/her mother and stranger has left. Detailed records were made of these interactions and responses (Ainsworth & Wittig, 1969; Salter Ainsworth & Bell, 1970).

Secure Attachment Those children who had been raised in a secure and stable relationship were able to tolerate the absence of the mother, entrance of a stranger and then re-regulate by seeking comfort from the mother on her reentrance and once again return to play activities. This group of children was described as securely attached.

Insecure Avoidant However, when the mother was anxious, inaccessible, or unresponsive, the infant responded differently. This group was identified as Insecure Avoidant. These children did not display their feelings to the mother and avoided showing their distress. They were independent of the attachment figure and did not seek contact when emotionally upset. During home observations, these mothers had been less sensitive to the child’s needs and were often unavailable when the child had been distressed.

Insecure Ambivalent A third group Ainsworth recognized was called the Insecure/Ambivalent group. These infants would sometimes show their distress even before the attachment figure had left and when their mother returned, they appeared untrusting of her response and seemed frustrated or had difficulty connecting with her again (McLeod, 2016; Cherry, 2020). Ainsworth suggested that the sensitivity of the caregiver was closely correlated to the development of the child’s own sense of self and the child’s attachment style.

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Disorganized Disoriented Several years later, in Main and Solomon (1990) identified a fourth group and identified this group as having a Disorganized/Disoriented attachment style. These children appeared dazed and uncertain about how to respond in the presence of the caregiver on her return. They both sought and wanted to avoid their caregiver and Main proposed the inconsistency of the caregiver with sometimes being comforting and other times being frightening, resulting in confusion for the child. Not infrequently, the parent’s own experiences as a child transferred to their own parenting style (Duschinsky, 2015). Slade et al. (2005) describe this impact in their reflections on a home-visiting program that was initiated to assist “at-risk mothers” with an interdisciplinary home-visiting team. One of the clients they presented was a teenage mother who had herself had grown up in a chaotic home with poverty and violence. Her mother had left the home when she was 5 and her father was violent, erratic, and used drugs and alcohol. Her grandfather had raped her. Her partner had been incarcerated, had a history of previous drug abuse, and continued to abuse her throughout her pregnancy and early motherhood. When this mother interacted with her child, she interpreted her cries of hunger and discomfort as intentional behaviors to irritate her and misunderstood the baby’s facial expressions of distress as anger at herself. She had grown up on the streets and also expected her child “to toughen up” and “stop demanding attention.” She acted roughly when changing the baby’s diaper and holding her, occasionally softening but almost catching herself doing so, and would then distance herself, physically or emotionally. Her own experiences of abandonment were paramount, not only triggering her when the child needed attention but also she lacked the foundation of the caring attachment experiences and modeling and repeated what she knew and had experienced herself. Thus, Bowlby in his famous work Attachment (1969) highlighted Ainsworth’s study findings. She emphasized the importance of the physical contact between the mother and the infant especially in the first 6 months of the infant’s life where she is able to contact and soothe when necessary, by holding him/her. He also acknowledged the importance of the mother’s sensitivity to her child when she attunes to the baby’s rhythms and needs and assists with meeting those needs successfully. Ainsworth determined that the child needed a consistent and predictable environment where the child has a sense of his/her impact in his/her surroundings. Bowlby (1979) suggested “the child needs to know who will be there when he/she wakes up.” And, perhaps most importantly, Ainsworth emphasized the existence of mutual delight, of the child and mother, in each other’s presence and interactions. She was attuned to the need for the sensitivity of the interaction with the caregiver. She believed that routine care and meeting the physical needs of the child was necessary for the child’s survival but the social interactive component, sensitivity was most important in the attachment development (Salter Ainsworth & Bowlby, 1991). This is something I am acutely aware of in working with these children and their caregivers. The caregiver can receive parenting and trauma psychoeducation but without the true attunement, the benefits lack “aliveness” and the conveyance of

Attachment, Neglect, and Abuse

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compassion and pleasure and subsequently the behavior changes, have difficulty being maintained in the longer term because they “feel” less believable and real. Winnicott (1965) stressed this authenticity as a key ingredient in emotional development.

Allen I had one such case where there was extreme anger existing between the mother and her 13-year-old son. Allen presented with extreme outbursts of aggressive behavior toward others and objects. He was struggling at school academically, but the primary referral concern was the aggression and arguing that occurred whenever the mother and her adolescent were together. The arguing would get so extreme that both the parent and teen would storm out, break something, or shout expletives at each other with demeaning comments flying. The father struggled as a passive participant in the interaction and often attempted to placate the two after the event. Allen would recount how his mother rarely did anything with him and that he spent most of his time at home on the video games or computer. The mother would agree with this account but would retreat and lock herself in her room or leave the house for hours when avoiding or reacting to the tension between her and her son. Even sitting in the waiting room together would have a high possibility of creating further stress between the two. Neither seemed to have any positive expectations of the other and the parent struggled to attune to any positive situation with her son. Each mirrored the other. Both claimed to want a positive relationship, but would then follow with a cascade of infractions the other had committed. The teenager’s mother did share that she had had her own difficult upbringing and she had partnered with a person who tended to manage his feelings through alcohol. Allen would arrive at a session attached to his tablet and was reactive to any suggestion, almost immediately, when requests were made to put it down, as an “attempt to control him.” It was clear, however, that what he actually sought was engagement from his parents and others and a sense of his own importance in life, because despite the strength of his defenses, there was definitely an ebb and flow in maintaining this barrier. Both the teen and the mother would put forward effort but lacked the attunement to each other’s rhythm and often mistimed/mismatched their attempts. Their efforts would then lack connection and a true commitment to the change process.

Attachment, Neglect, and Abuse Crittenden and Ainsworth (1989) later wrote about the attachment theory and its interconnectedness with the development of behavior styles in neglected and abused children. They concluded again that the way the infant attempted to attach to his/her

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primary caregiver was closely related to the behavior of the attachment figure. If the primary caregiver was inconsistent or unresponsive to the child, the child presented with behaviors associated with anxiety and insecure attachment. In cases where the mother was angry or rejecting and physical contact was rebuffed, the child would hover between wanting physical contact but becoming averse to it and using approach/avoidant patterns, seeking and sometimes becoming clingy, but at the same time being fearful of what they wanted and withdrawing as much of their body from contact as possible.

Alice This situation I can recount following an interaction I witnessed between a 5-year-­ old and her mother. Both had difficulty attaching to each other. Her mother had been involved in several relationships in which she had been abused and on one occasion trafficked. Her daughter, Alice, would play by herself or become antagonistic to her mother and hit and shout at her. As therapy progressed, Alice was able to crawl up into her mother’s lap and her mother was able to place her arms around her, but the aliveness was missing. The mother commented on how this felt scary to her and expected her child to eventually strike her. This was also evident in her mother’s light hesitant touch to her child. She did not have any full-body postural shaping or make a physical, secure container with her own body around her daughter. There was a sense the child could fall out of her lap with the slightest distraction. The attempts were painful to witness because again, the efforts were cognitive, and had not yet matched their bodies with their own sense of unity. Bowlby and Ainsworth have contributed significantly to the field of attachment research. Each dared to step out of the conventional norms and challenged existing theories and methods of research. This took a respectful amount of courage. Both sought to shift the focus of work with children from an internal fantasy world to one of interrelatedness and outward exploration. They believed that the foundation of a healthy relationship established a secure base for the child and a protective haven. A place that supported the child, and hence facilitated exploration, but provided safety to return to in times of need.

Donald Winnicott Winnicott, a British pediatrician and child psychoanalyst, in his relational model, described the effective caregiver as “one who makes active adaption to the infant’s needs, an active adaption that gradually lessens, according to the infant’s growing ability to account for failure of adaption and tolerate the results of frustration” (Winnicott, 1971, p. 10). He believed by maintaining attunement to her infant, the

Donald Winnicott

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mother gradually assisted the child to self-regulate and encouraged exploration of the external environment. From the advantage of a secure base, the infant had a greater sense of self-confidence and efficacy in the world and thus could take opportunities for growth and facilitate cognitive development (Murray, 1992; Cohen et al., 1999). Winnicott viewed this concept of “holding” as a physical act and as an emotional/mental process of the mother. “I am contented to use the word hold, and to extend its meaning to cover all that a mother is and does at this time….where she acts naturally, naturally.” “I am not simply referring to her being able to know whether the baby is or is not hungry, and all that sort of thing, I am referring to the innumerable subtle things” (Winnicott, 2002, p. 13). He famously stated, “there is no such thing as an infant” (Winnicott, 1975). He viewed the mother and the child as one. The mother psychically merges with the child and the sense of time dissolves in so much that the mother and the infant’s world become entwined to the rhythms of the child’s need for sleep, engagement during wakefulness, feeding, or diaper changes. Even the internal rhythms of heartbeat and breathing can become synchronized (Ogden, 2004). Bergmann (1985) described the perinatal preoccupation of the mother, as requiring the “ability to lose oneself in the other and emerge again” (p. 179). Many new mothers know this experience. They have a sense of time loss and the world shrinking to only the rhythms of the essential needs of both herself and the child. But being available at this level with the child is a level of attunement that exists in a healthy relationship. This intimate awareness of the child’s need, even as over time the threads of entwinement are loosened, the mother continues to attend to these psychic shifts and connections: perceiving when their child is not feeling well; when they are acting as if they are hungry, or even when they are starting to get frustrated. The mother’s selfless holding of the child allows the child to have his/her basic needs met and gradually a more aware sense of their needs being responded to. An increasing sense of themselves then develops in the child, and an increased awareness of the external attachment figure as a separate being starts to develop. This is a difficult concept to measure in research, but if one takes the time to step back and reflect on their own parent–child experiences, or of the ones they have witnessed with attunement, this shift from the physical holding of the infants and the meeting of the essential needs moves along the developmental continuum until the time where the child moves from an internal state of merger with the caregiver, to one with more social engagement and exploration outside of the relationship. The child, using Bowlby and Ainsworth perspective, has established the sense of safety and security, and evolved into a more interactive, separate being who then more confidently can reach out into the world. In Winnicott’s terms, their “soma and sense of self” are being integrated (Winnicott, 1971).

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“Good Enough Mother” A second and significant concept that is also associated with Winnicott is his concept of the “good enough mother.” This is the person, usually the mother, who overall interacts with her child in a positive manner and meets their needs with sensitivity. As the child develops, this role reduces, corresponding to the growing tolerance of the child to delays or frustrations. Thus, a “good enough mother” is not always being perfect but is an ongoing support and engenders a greater sense of self in the child’s own abilities. This concept in and of itself is worthy of consideration when working with these children. So often it has been acknowledged the parents themselves come with their own challenges, but if they can meet the basic needs of the child and with their own psychoeducation can learn to expand not only their own experiences but also their child’s, then growth and change is possible. Watching this unfold can be wonderful.

Pam A parent, Pam, had had her children removed by the Child Protection Department. One of her conditions for their return was that she engaged with them in a more age-­appropriate manner. Since these children were below the age of 4, this implied she played with them! She had no idea how to play! Pam had endured her own ongoing abuse and neglect as a child and was often left to fend for herself. Generating play had not been a priority in her survival. I literally joined her in play: a jiggling dance while waiting during transitions, stepped on cracks, and allowed moments to giggle together! As she started to internalize these experiences, she was more able to replicate playfulness, followed through with low-cost, home-made activities to create with her own children, and was able to positively experience and feel the joy of this engagement.

Wilfred Bion Bion (1962), a British psychoanalyst and contemporary of Winnicott, proposed a model of containment that some can confuse with Winnicott’s concept of holding. Bion, instead, perceived the early caregiver’s vital role in helping the infant with his/ her primary need of regulation. He viewed the mother in a secure relationship, to be the one that helped the child by transforming his/her fragmented frustrations and emotions. The child would project feelings that were intolerable onto the mother, who could feel them and not react, but then contain them and give the feelings back to the child in a more tolerable form. She created a container that translated “the baby’s distress for him, giving names to his hardships and anxieties and thus

Peter Fonagy: A Theory of the Mind

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calming and containing him” (Biran, 2015, p. 159). Thus, when the child was feeling frustrated with hunger, the mother fed and rocked him/her; when wanting to be shifted in position, she would pick them up and speak calmly, patting and rocking them until they were comforted. She would acknowledge the frustration, anger, and helplessness and attune to the child, acknowledging with her own increased voice tension or tone, her own increase in rapid movements, and reflecting back to the child, often unconsciously, that he was understood. Then the mother would reframe the frustration, slow her own voice, and movements, and present a calmer effect and the child would mirror her responses back with his/her needs also physically met and in a more regulated state. By creating this figurative container, the mother helped the child to modulate his body and sensory feelings, by transforming them in such a way the child could then tolerate them. This dyadic relationship, where each knows the other, laid the secure base for further exploration and self-regulation (Parry, 2010; Malone & Dayton, 2015).

Peter Fonagy: A Theory of the Mind Related to Bion’s way of thinking, Fonagy et al. (1991) described the child’s mind as inherently interpersonal and emphasized its evolution in the context of the infant– caregiver relationship. As the sensitive parent responds to the physical and affective needs of the child, that child gradually notices those outside of him/herself and starts to become more motivated to engage. Studies, for example, have demonstrated that if the mother has a positive emotional expression toward a stranger, the child tends to also positively interact with that person (Feiring et al., 1984). They gradually become more aware of other emotional expressions and entering into their second year start to demonstrate an interest in other’s feelings, being curious about why that person is crying, or how they are hurt, or why they are laughing. As empathic awareness of others increases, the toddler tries to make amends with a peer or reach their arm around a distressed friend. According to Fonagy et al. (1991), this demonstrates that the child, based on their own experience of their own mental state recognition, can start to reflect on the states of others and she/he will have a theory of the mind. This is an important concept to consider because the converse can exist if a child’s emotions and affect are not acknowledged or responded to. This child will have difficulty reflecting on others’ feelings and have difficulty understanding empathy and their own impact on other people. He believed the sensitivity of the caregiver to the child’s mental world led to attachment security. When the child’s mental state is anticipated and acted on, the child is helped to maintain “psychic equilibrium.” So often I hear children being appealed to for a sense of empathy and understanding for hurting another person, but when that child has not had their own feelings heard, or acknowledged, it can be difficult for them to understand how the other may feel because it has been disregarded in their own experience.

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Louise Kaplan Kaplan’s work in her book, Oneness & Separateness (1978), ties together the developmental progression of the child’s physical and motor skills, corresponding to his/ her own sense of self and individualism. The infant moves from almost a sense of oneness with the mother to gradually become more aware of the world outside of him/herself and reaches out with the body, vocal, and with vision to the external world. By simply sitting and experiencing verticality, the child gains yet another perspective of the nearby world and beyond. From the place of security and with growing physical strength, the fascination or reaching and attaining that which is beyond his/her reach becomes a motivating force, and the child experiments with stepping forward. As they gingerly do this, they also tentatively experience the world more separate from their caregiver. They venture forward, however, with the knowledge retreat back to a secure haven is possible if threatened in any way. The mother gradually allows the child to struggle, but titrates the frustrations, allowing the child to move forward in their development. As the separation expands this knowledge of security continues and the caregiver’s image and sense of their presence can be transmitted to the object that the child carries with them into perhaps unfamiliar territory. Hence the case of the “blankie,” or the stuffed animal must be taken to any novel environment. This is what Winnicott (1971) called the “transitional object,” transitioning from oneness to twoness and then to separateness. There is now a “me” and a “not-me.” This child learns to carry that sense of safety into an external object if the caregiver is in a different space or is perceived as absent. The child expands not only their movements and their awareness of the world, but also their own sense of self, their confidence, and an increasing awareness of the mental and physical needs of others. I have used this transitional object concept with children who have to transition between two parent households. The olfactory sense is one of the first to develop in the attachment process (usually assisting with feeding and the infant bonding to the mother). I have had the mother give the child a T-shirt she has recently worn, and not washed, so the child can carry it with him/her. The child can resource themselves when anxious, by smelling the scent for the shirt. The visceral and physiological response can elicit some calming. The detrimental effects of this absence of security, however, can be reflected in children from environments such as orphanages where the availability of that secure caring consistent person is absent. These children exist in their inner world, venture within only close confines, and have a marked and poor social engagement or understanding of the feelings of the other.

Nancy

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Sophie Sophie was one of these children. She was 2 years old. She had been raised by a single mother, who also had a history of neglect. Sophie’s mother tended to engage in relationships with men who were unreliable and in and out of her life. Her mother would use drugs with these partners and strangers were often coming and going from the home. During most of the day, Sophie was designated to her playpen. Her mother’s own mental state, awareness, and attunement to Sophie’s emotional and physical needs were extremely poor and inconsistent. Sophie would often experience hunger, being wet, and had limited toys in her playpen to entertain herself with. When Sophie was being removed from the home after a sexual assault report had been established, she was brought for an assessment by her new foster parents. Sophie hesitantly entered the play area and although in the company of her foster parents, she was clearly reluctant to explore. Her affect was relatively expressionless, vocalizations negligible and she had very low eye contact. She did not exhibit any liveliness nor apparent interest/expectations in her new surroundings. Even with encouragement, she had marked difficulty engaging and after brief interactions with a toy versus a person, she went and curled up within the vicinity of her foster mother but did not seek consolation or comfort. The impact of neglect on this child and many others is so far-reaching. The importance of the early attachment relationship, sensitivity, attunement, and the child’s sense of safety and security are essential to the development of regulation and the child’s ability to expand their own internal and external development. Without these early foundations, the detrimental impact is significant. Attachment researchers such as Reite and Capitanio (1985) concluded the psychobiologically attuned caregiver, who has synchronicity with the infant, helps to minimize the negative experiences of the child and maximize the child’s positive affective states. They view the development of rhythmicity and synchronicity as perhaps the major component of mother/child bonding. In a world where a child does not have these, often their only choice initially will be protest. But when they are still not heard, they shut off not only from their world and the world of others but also from their own body and feelings.

Nancy Recently, I was working with a 10-year-old who, despite being now cared for by her cousin, had grown up with her biological mother but had experienced domestic violence, homelessness, and neglect. When her mother died, she was placed with her older cousin’s family. Nancy was delayed in many areas. She was very concrete in her attitude to life, displayed poor flexibility, and clearly announced she had absolutely no interest in learning or expanding on her skills. She would sit at home, separated from the rest of the family, and draw on her tablet.

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One day she shared this work with me and although scrolling through multiple pieces of work, declared she didn’t care much about them. When asked if she did have a preference for any of the drawings, she said she “didn’t care about any of them,” “didn’t feel happy when she had drawn one the way she had planned,” and “didn’t feel anything if it didn’t work out.” She was not interested in learning how to expand her skills and had no plans of what she would do with them beyond them being stored on her tablet. She had not even considered protecting them from loss nor appeared to care if all her work was to disappear one day. She did not have any attachment to the ”future.” Another adolescent I worked with was a “failure to thrive” baby. I would experience a visceral and massive void in the room when she “was present.” There was no energy, low interactive engagement, and barely any movement….even her breathing was shallow……stillness in every aspect….it was almost as if she had already disappeared…..

Judith Kestenberg: Attunement and Flow The attunement of the caregiver to her child is an important focal point of attachment and the subtle dance between the two is of upmost importance. Kestenberg, a psychoanalyst, noted that there was not sufficient understanding of these interactions and focused on dedicating her research to observing the mother–child body rhythms and the connection to the psychic processes she was observing in preschool children. At the time of her work, movement notation systems were being used by Laban (1975; Bartenieff & Lewis, 2002) to annotate subtle movement components and she became fascinated with its use, expanding the system to notate flow and “muscle tensions” between infants and their caregivers. She identified these patterns of movements in terms of the shape the body makes in stillness or in dynamic movement and the fluidity of the movements. She highlighted the variations as they developed and evolved, in psychoanalytic terms, but their application could be used in any observer context. It became apparent when the caregiver and the child were attuned to each other, there were physical bodily shifts and a synchronous dance was observed. As the infant breastfed, he would take a breath, expand his chest, and widen his body. His mother would harmonize with this shift, “by adjusting her chest and holding her arm in the horizontal plane, in which the infant alternatively gained more room for exhaling and came closer to the nipple on inhaling” (Kestenberg & Sossin, 1979, p. 21). When the attunement is present, the interactive dance appears to be without conscious awareness. This act of feeding is an example of the mother/child attunement and containment where the nipple can be maintained for the infant to effectively feed and is synchronized in timing so the two can be shaped to fill the other’s body spaces without clashing. As the child develops, the mother not only attunes to him but also teaches the child to choose appropriate rhythms and have the child to attune to her.

References

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As the child develops, Kestenberg describes the period of frustration and misattunement to be the base of different shaping and molding rhythms, and when there is a clash of function, either mother or child must reattune with the other to work again in harmony. If misattuned, in the case of an anxious mother, the mother may stiffen her body and lengthen it upward away from her child, creating a clash of rhythms and shaping. The infant would then have difficulty establishing a coordinated rhythm and he/she may need to gulp out of synchronicity with the mother’s milk flow and choke or fall asleep before becoming satiated (Kestenberg & Sossin, 1979). These perspectives are varied in their particular focal point, but all emphasize and demonstrate the importance of a healthy attachment process in relation to the development of the child from complete dependence in every aspect of their being, to gradual internalization of security and safety. The child then progresses in their skills toward more independence and confidence. Each theoretical approach also highlights the challenges that will potentially exist for the child if this foundation is not established and the ensuing delays and defenses that will need to be employed. Given that the vast majority of these children have had their perceived and often actual safety compromised by their own caregiver, this foundation of a secure base and haven is likely to have been threatened unless those engaged with these children look beyond the behaviors and understand that these managing behaviors may be used by the child to try to ensure some sense of safety, whether it be by evasion or withdrawal, then it will be unlikely interventions will have much staying power, particularly under additional stress.

References Ainsworth, M. (1988). On security. http://www.psychology.sunysb.edu/attachment/online/mda_ security.pdf Ainsworth, M. D. S., & Wittig, B. A. (1969). Attachment and exploratory behavior of one-year-­ olds in a strange situation. In B.  M. Foss (Ed.), Determinants of infant behavior (Vol. 4, pp. 111–136). Methuen & Co. Bartenieff, I., & Lewis, D. (2002). Body movement: Coping with the environment. Routledge. Bergman, A. (1985). The mother’s experience during the earliest phases of infant development. In E. J. Anthony & G. H. Pollock (Eds.), Parental influences in health and disease. Little, Brown. Bion, W. R. (1962). Learning from experience. Karnac Books, London. Biran, H. (2015). The courage of simplicity: Essential ideas in the work of W.R.  Bion. Karnac Books Ltd. Bowlby, J. (1944). Forty-four juvenile thieves: Their characters and home-life (II). The International Journal of Psycho-Analysis, 25, 107–128. Bowlby, J. (1969). Attachment. Attachment and loss: Vol. 1. Basic Books. Bowlby, J. (1979). Public lecture. Royal Children’s Hospital. Bowlby, J. (1988). A secure base: Parent-child attachment and health human development. Basic Books, Inc. Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28, 759–775.

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Cherry, K. (2020). The different types of attachment styles. https://www.verywellmind.com/ attachment-­styles-­2795344 Coates, S. W. (2004). John Bowlby and Margaret Mahler: Their lives and theories. Journal of the American Psychoanalytic Association, 52(2), 571–601. Cohen, N. J., Muir, E., Parker, C. J., Brown, M., Lojkasek, M., Muir, R., & Barwick, M. (1999). Watch, wait and wonder: Testing the effectiveness of a new approach to mother-infant psychotherapy. Infant Mental Health Journal, 20(4), 429–451. https://doi.org/10.1002/(SICI)1097­0355(199924)20:43.0.CO;2-­Q Crittenden, P. M., & Ainsworth, M. D. S. (1989). Child maltreatment and attachment theory. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 432–463). Cambridge UniversityPress. https:// doi.org/10.1017/CBO9780511665707.015 Duschinsky, R. (2015). The emergence of the disorganized/disoriented (D) attachment classification, 1979–1982. History of Psychology, 18(1), 32–46. Feiring, C., Lewis, M., & Starr, M. D. (1984). Indirect effects and infants’ reactions to strangers. Developmental Psychology, 20, 485–491. Fonagy, P., Steele, M., Steele, H., Moran, G. S., & Higgitt, A. C. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security and attachment. Infant Mental Health, 12(3), 201–218. Harlow, H. F., & Zimmermann, R. R. (1959). Affectional responses in the infant monkey. Science, 130(3373), 421–432. Kaplin, L. J. (1978). Oneness & separateness: From infant to individual. A Touchstone Book. Kestenberg, J. S., & Sossin, M. (1979). The role of the movement patterns in development (2nd ed.). Dance Notation Bureau, Inc. Laban, R. v. (1975). Laban’s principles of dance and movement notation (2nd ed.) (Roderyk Lange, Ed.). MacDonald & Evans. Lorenz, K. (1935). Der Kumpan in der Umwelt des Vogels. J. Orn. Berl, 83. English translation in C. H. Schiller (Ed.), Instinctive Behavior. International Universities Press. Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), The John D. and Catherine T. MacArthur Foundation series on mental health and development. Attachment in the preschool years: Theory, research, and intervention (pp. 121–160). University of Chicago Press. Malone, J. C., & Dayton, C. J. (2015). What is the container/contained when there are ghosts in the nursery? Joining Bion and Fraiberg in dyadic interventions with mother and infant. Infant Mental Health Journal, 36(3), 262–274. Marrone, M. (2014). Attachment and interaction: Bowlby to current clinical theory and practices (2nd ed.). Jessica Kingsley Publishers. McLeod, S.A. (2016). Mary Ainsworth. Retrieved from www.simplypsychology.org/mary-­ ainsworth.html Murray, L. (1992). The impact of postnatal depression on infant development. Journal of Child Psychology and Psychiatry, 33, 543–561. Novick, K., & Novick, J. (2005). Working with parents makes therapy work. Aronson. Ogden, T. H. (2004). On holding and containing, being and dreaming. International Journal of Psychoanalysis, 85, 1349–1364. Parry, R. (2010). A critical examination of Bion’s concept of containment and Winnicott’s concept of holding, and their psychotherapeutic implications. Unpublished thesis, University of Witwatersrand. Reite, M., & Capitanio, J. P. (1985). On the nature of social separation and attachment. In M. Reite & T. Field (Eds.), The psychobiology of attachment and separation. Academic. Salter Ainsworth, M. D., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behaviors of one-year-olds in a strange situation. Child Development. https://doi. org/10.2307/1127388. Corpus ID:3942480.

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Salter Ainsworth, M. D. & Bowlby, J. (1991, April). An ethological approach to personality development. American Psychologist, 333–341. Schore, A.  N. (2000). Attachment and the regulation of the right brain. Attachment & Human Development, 2(1), 23–47. Siegel, D. J. (2001). Towards and interpersonal neurobiology of the developing mind: Attachment relationships, “mindsight”, and neural integration. Infant Mental Health Journal, 22(1-2), 67–94. Slade, A., Sadler, L., Dios-Kenn, C.  D., Webb, D., Currier-Ezepchick, J., & Mayes, L. (2005). Minding the baby: A reflective parenting program. Psychoanalytic Study of the Child, 60, 74–100. van Duken, S., van der Veer, R., van Ijzendoorn, M.  H., & Kuipers, H. (1998). Bowlby before Bowlby: The source of an intellectual departure in psychoanalysis and psychology. Journal of the History of the Behavioral Sciences, 34(3), 247–269. Winnicott, D.  W. (1965). The maturational processes and the facilitating environment. Karnac Books Ltd. Winnicott, D. W. (1971). Playing and reality. Tavistock Publications. Winnicott, D. W. (1975). Lecture delivered at the Royal Children’s Hospital, Sydney, Australia. Winnicott, D. W. (2002). Winnicott on the child. Perseus Publishing.

Chapter 3

Neurology and the Development of Regulation

As the child is moving along in their attachment development, expanding their sense of self and explorations with the external world, the child’s brain is also developing. Multiple studies have demonstrated that our brains are experience-dependent and these experiences are shaping its structure and growth in a constant process (Beeghly et  al., 2016; Cassiers et  al., 2018; Li et  al., 2022; Lim et  al., 2020; McLaughlin et al., 2019; Schore, 2021). Neuronal pathways are laid down in areas of use. Research studies by Knickmeyer et al. (2008) indicate that the child’s brain volume increases by 101% in the first year and 15% in the second. The experiences the child is exposed to during this period will have a significant impact on the development of neurological foundations. Expansion in the arena of trauma research has also demonstrated that if these experiences are not optimum, there will be a negative impact on the brain development. This leads to significant challenges in the child’s ability to relate with others, to self-regulate, and to expand their attention to the tasks such as language development and learning (Perry & Dobson, 2013; van der Kolk, 2018; Siegel, 2018; Zilberstein, 2014). I propose when working or caring for these children, neurology and attachment should not be seen as separate entities. I believe it is essential to understand this close relationship. Too often a child is expected to function at their biological age and unless there is an understanding of these closely connected domains, a child may be expected to perform at a higher level when they are not only lacking the skill set but also the physical resources necessary to make the proposed changes. The implications are often that “the child needs to change their attitude,” or pull in cognition and “use coping strategies” or understand the importance of “getting along with people.” The brain thankfully is considered to be highly plastic. This means that it continues throughout life to potentially grow, to lay down new pathways, and even if things may not have been optimum, when exposed to consistent, new positive experiences, change, and growth can occur (Ludy-Dobson & Perry, 2010; Siegel, 2019;

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_3

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Shonkoff & Phillips, 2000). Studies by Bick et  al. (2015) using MRI scans, for example, demonstrated when institutionalized infants were placed into caring foster care, despite initial reduction in white matter connectivity in the limbic, frontal, and sensory processing areas, on re-evaluation at age 8, there was an observable improvement in the integrity of the fiber tracts. It is an encouraging aspect to understand when providing interventions for these children; progress can be made. Although I am in no way expecting you to absorb every detail of the neurology and to recite the names of the different anatomical areas and bodies, I would, however, like you to understand the interplay between attachment experiences and the way they are so intricately linked to the timing of brain development. Also, it is important to understand the close interconnection between the brain structures. They work in close synchronicity, often receiving and delivering information from one region to another. I have faith you can understand. Just as a child who has barely learned to talk can say “Tyrannosaurus Rex,” I believe you too can tolerate these anatomical names and descriptions. Even reading this chapter in small sections will likely increase your tolerance, understanding, and absorption. Try not to run and hide!

The Early Brain Given a healthy environment, the brain grows at an incredible rate in utero. During the early years of postpartum life, the brain reaches 80–90% of the adult size by the third year (Shen et  al., 2010). The infant is born with about 100 billion neurons (Ackerman, 1992). This is a very formative period because neurons (brain cells) are laid down in new pathways and those that are not used are pruned (Tierney & Nelson, 2009). Thus a caring environment will likely facilitate brain growth and development in a smooth developmental sequence, while an environment that if less supportive….will disturb such development (Perry, 2009; Schore, 2001; Siegel, 2018; McLaughlin et al., 2019). These connections, however, are complex and multidirectional. Input to one area of the brain can result in a cascade of interconnections to other areas. For example, when a child experiences a positive interaction with their caregiver, the visual, auditory, sensory areas evaluate the data, the child then draws from memories of past experiences and links them together, processes the experience in context, develops an interpretation of this information, and an action or integration can result. With similar exposures, those pathways associated with such experiences become more developed and more efficient. Memories are then laid down and with greater exposure, the interconnections and their output (response or behavior) can become procedural, requiring less active cognition. Due to this process, the child can then pay greater attention to elements of novelty and new tasks that are being introduced. Development expands. An example of this procedural learning occurs when starting

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to ride a bike. A great deal of attention is initially needed when learning how to balance, create momentum, pedal, steer, and learn how to apply the brakes on the bike. After many attempts, the skills gradually become more automated, and eventually the person can ride the bike without any apparent focus on the processes needed. They can socialize with their friends as they ride and attend to their surroundings with little difficulty. This was something totally overwhelming at the start of the learning curve. In a similar way, if all the child’s needs are met, the child’s own sense of self is reinforced, and they can direct their more outward attention to others and notice peer’s circumstances and needs. There is a corresponding step forward in their level of social understanding of empathy and engagement. The child learns through experiences how to attach to another. At the same time, their regulatory circuits are also neurologically developing. They are less visually obvious, but by no means less important.

Neurology and Attachment Schore (1994, 2000, 2001, 2009, 2011, 2017, 2021) and Schore and Schore (2008) has drawn attention to this close relationship between neurology and the development of the child’s sense of self and regulation. The timing of the brain’s regulation development and the child’s progression along the attachment process, are in synchronicity. Given a healthy relationship, it is often the “chicken or egg’ scenario. Is it the attachment experience or the neurological change that occurs first? It appears that they are in a very close relationship with each other and what happens first is a challenge to discern. The experiences of the child during this early period, thus have a vital influence on the circuits established or pruned. If a child is being raised in an environment where he/she needs to be on constant alert to ensure their own safety, their neural pathways and the child’s general physiology will reflect this need for vigilance. Pathways that support their survival will become more proficient and respond more rapidly because of this need and frequent use. The child who does not experience nurturing and exposure to supportive interactions will often display delays, not only in their social engagement skills but also in their motor, verbal, and cognitive skills (Perry et al., 1996; Sherin & Nemeroff, 2011; Teicher, 2002). Those pathways used, wire together and become more efficient. A child raised in inconsistent environment will likely be more anxious, more vigilant, and be apprehensive about the safety of exploration. This limits their chance of positive experiences in the world and reduces their exposure to novelty and further learning. The child then encounters increased support for their belief that the outside world is not a place of comfort or joy, and is constantly reinforces this by their self-limiting their exposure to a broader range of experiences.

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 wareness of the Neurological Basis of Regulation A and Behaviors This is often a frustration caregivers’ share, by the time their child has been referred for regulation services. The children are frequently functioning in multiple domains below their biological age. Psychoeducation of the caregivers and the child is important especially at this point. The caregivers are exhausted, impatient, and feel they have tried everything and implore “if only they tried harder!” It is important for them to understand that despite the child’s birth age and having some skills they can do at an age-appropriate level, they are not functioning at the same level in many other areas, often months or even years behind in some skills. Instead, when introducing skills, the caregiver is encouraged to understand the progression of a skills development rather than expecting a skill to suddenly emerge anew, as if it had been hidden. It is at this basic level of regulation that I have often found myself engaging with a child. Many programs do raise the topic of regulation, but there is frequently an essential expectation where the child needs to engage verbally, to have some problem-­solving skills, to be able to label emotions, and to understand empathy. If a child’s experiences have been limited in these areas, these skills may not have been internalized (Winnicott, 1971). When I am discussing regulation, it is at the level of establishing this internal experience. As a child slowly internalizes their attachment safety and trust, they will have an increasing tolerance for expanding their regulation to a greater variety of situations and experiences. If skills are taught before this level of internalization, they will need to rely on frontal lobe cognition. Under stress, the body responds for survival, and the lower brain centers will come online quickly, often responding before cognition in the cortical areas can be utilized. Hierarchical neurology and physiology takes over. In healthy development, a child learns these skills by co-regulation of the caregiver. They experience manageable exposure to frustrations and periods of dysregulation and then start to internalize the ability to regulate. With the repeated and consistent co-regulation of the caregiver, the child’s tolerance and adaptability improves. The caregiving and attachment instability with children, who have experienced complex trauma, means they have not had these repeated and consistent learning opportunities. Their foundations are often not at age level. They may continue to need the co-regulation assistance, sometimes at a significantly earlier developmental level, than anticipated. I have worked with many 6-year-olds who have motor skills closer to their birth age, however, continue to need more intense proximity support and 1:1 interactions which may be more identified with the skills set of a toddler.

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Ryan Ryan is a 6-year-old, the only child of a single mother. Ryan’s mother has had significant trauma in her own life and was raised by parents who were very authoritarian and inflicted corporal punishment on a regular basis. They had little time for her and she was expected to “be seen and not heard.” Ryan’s mother was determined not to repeat this type of child rearing and was permissive of Ryan’s choices to the extent that her opinion or request were consistently ignored by Ryan. Ryan would arrive to the waiting room, and despite it being a shared space, would run around loudly and would interject into the conversations of others. He would then further disrupt the “harmony” of the space by throwing objects into the air and loudly watching them fall or crash into the surrounding furniture. His mother would remain in her chair but give Ryan a constant barrage of comments about the inappropriateness of his behaviors. Ryan would continue to ignore her and was constantly in movement. I intervened and modeled co-regulation strategies for the mother. I moved closer to Ryan, used less verbal dialogue and redirection, and instead became more proactive in gaining his interest in an observation or activity. Just as one would anticipate that a younger child may not screen out potential risks or consider what may disrupt another, I guided him to less chaotic choices. I did not have long discussions regarding the appropriateness of his behaviors but instead engaged him with the positive interactions and observations before he became more disruptive. Although it was important to receive updates on the challenges Ryan’s mother was experiencing, it was arranged that these conversations could take place prior to sessions by a telephone call. This way Ryan was not waiting while these discussions occurred and full attention and co-regulation could be given to him by his mother or myself. Ryan also did not have to start a session with “all his dirty laundry” out for all to hear and see. He had a chance to share his experiences from a more regulated position, without concern for judgments being “set up even before the session started.” The focus was on engaging Ryan before he became more disruptive. Ryan’s mother began to learn to bring activities with her to the waiting room and used the time as a 1:1 play opportunity without the usual demands on her for household chores. By the conclusion of the treatment series, Ryan and his mother could be observed curled up on the couch together completing puzzles and coloring activities together. Both were giggling, looking at each other directly, and playing. They were using this time as a positive opportunity! I need to make it clear here, however, the child is still interacted with age-­ appropriate respect and not spoken down to. The support is given in a proactive manner. The child will “feel” safer. This co-regulation support will help them move along the developmental skill pathway. They will be more able to expand greater attention to challenges and new experiences. The laying down of earlier foundations of stability and support is given in small increments, just as a young child is exposed to a healthy environment. The child expands their skill set by increased tolerance

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and recovery from brief periods of dysregulation under the guidance of the caregiver, gradually requiring less external support and more internalized self-­ modulation. Particularly in the school setting, where there are multiple age-­appropriate functioning expectations such as working independently and understanding the social engagement rules of the classroom, these children frequently have disrupted and challenging behaviors because this early stability is not established. Although some may perceive this support to be “encouraging dependence on others,” when viewed from an attachment experience and clear neurological research, one has to remember these children have not come from a stable consistent caregiving environment and their strategies have been developed in an attempt to create some sense of stability for themselves and may not be convenient and fit into proposed curriculums and expected rates of achievement performance. As with most children, “time in,” is time saved! Once a child feels safe, neurologically and physiologically, they can bring in the cognitions that learning requires. The attachment process occurs during the primary period of brain development. It is here I would like to highlight the key brain regions and their intricate interconnections, to more clearly identify this close and important relationship. Schore and Schore (2008) have proposed that the attachment theory could be renamed the regulation theory for this reason.

The Brain The brain is made up of gray and white matter. The gray matter tends to store, gather, and modify information and the white matter bundles together and creates tracts to transfer information from one region of the brain to another (Tadi & Mercadante, 2022). From conception, the brain develops from the lower regions of the brain to the higher cortical regions (Grigorenko, 2017). The lower brain regions are essential for physiological survival. This area is responsible for the autonomic functions such as heart rate, breathing, blood pressure, body temperature, swallowing, sleep, appetite, and arousal. Above the brain stem and midbrain is an area identified as the limbic system. This region is strongly associated with the emotional and behavioral responses, especially those that help us to survive. The higher cortex area develops later in the developmental process and is involved in cognition such as consciousness, thinking, learning, problem-solving, language, motor function, processing sensory information, and personality (Beeghly et al., 2016). As the child experiences events, pathways are established, and processing regions become more highly defined. Thus, the brain too, is built with a survival foundation and as it develops, its functions become more sophisticated and complex. This development is clearly observed when one is in a room with a toddler and an older child who have both experienced a supportive and caring upbringing. Expectations

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on performance quality and the amount of guidance and instruction will directly correspond to the age of the child. One would not expect a toddler to understand the same degree of empathy, nor the same level of motor skill, for example, compared to a 9-year-old who would be expected to be more independent and have a greater understanding of interrelationships and communication skills. If a child has not had the experiences to form this base of skills, no amount of rewards or punishment, reasoning or appeal for better behavior, can make it magically develop. Experiences and understanding of this by others can make this development formative versus destructive.

The Brain’s Structure Lower Brain Regions This region connects the brain stem and cerebellum to the cortex (Fig.  3.1). It includes areas such as the pons, medulla, and midbrain. Many vital functions are in this area including blood pressure, breathing, heart rate, temperature regulation, consciousness, and sleep/wake cycles. The brain stem contains many important brain stem nuclei (collections of nerve cell bodies) and pathways to (afferent) and from (efferent) the brain and the body (Basinger & Hogg, 2022).The periaqueductal

Fig. 3.1  Brain anatomy: Midline view

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gray region, located in the midbrain, is described by van der Kolk (2018) as the “primitive danger-detector of the brain.” It has multiple connections to different areas of the prefrontal cortex, the amygdala, the anterior cingulate cortex, and the hypothalamus (Mohktar & Singh, 2022, Terpou et al., 2019).

The Cerebellum The cerebellum is located at the back lower part of the brain. As an occupational therapist, we were taught the cerebellum was considered the movement coordination center. Now it is recognized, particularly following the research by Schmahmann (1991) and Schmahmann and Sherman (1998) to play a significant role in the coordination of thoughts and emotions. “In the same way the cerebellum regulates the rate, rhythm, force and accuracy of movements, it may also regulate speed, consistency, capacity and appropriateness of mental and cognitive processes” (Schmahmann, 1998, p. 367). The cerebellum also has a high density of cortisol receptors which can make it more vulnerable to stress (Anderson et  al., 2002).This is important because the ongoing high level of cortisol in the bloodstream of children who experience chronic and ongoing stress can lead to cellular damage.

The Limbic System This system is recognized as the emotional, memory, and motivational region of the brain and lies underneath the cerebral cortex and above the brain stem. It includes a number of structures, which include the amygdala, hippocampus, thalamus, hypothalamus, basal ganglia, and cingulate gyrus. These names will frequently arise later in the chapter when I discuss current research regarding the impact of chronic trauma on a child’s developing brain. I would like to introduce their functions here, so the research and the neurological impacts can be more clearly understood. Amygdala  The amygdala is recognized for regulating fear, anxiety, and consolidating long-term memories of emotionally arousing situations. It has projections into many brain areas that process different kinds of memories and appear to attach emotional content to a memory, in particular, those related to fear (AbuHasan et al., 2022; McGaugh, 2004; Queensland Brain Institute, 2017a, b). Hippocampus  This seahorse-shaped structure has a key role in organizing and linking various memory components and it inscribes explicit time context to events, giving them a beginning, middle, and end. It has a role in recalling past experiences and imagining the future. It is vital for learning, memory, and spatial navigation (Addis & Schacter, 2012; Li et al., 2021; Morgado-Bernal, 2011).

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The Thalamus and Hypothalamus  The upmost region of the brain stem is also referred to as the diencephalon and consists of the thalamus and the hypothalamus. The thalamus is a major relay station for sensory and motor (movement) information. The thalamus has connections to the limbic system allowing it to be involved in learning and episodic memory (a collection of past experiences in context incorporating time, place, and associated emotions). It is also involved in the regulation of consciousness and alertness (Torrico & Munakomi, 2022). The hypothalamus has an important role in managing the body’s homeostasis (balance of functions) and releases hormones into the bloodstream called releasing hormones. These include Adrenocorticotrophic Hormone (ACTH) which is involved in the stress response of the body, and the non-releasing hormones such as oxytocin (important in attachment bonding) and vasopressin (which regulates blood pressure and can be affected by ongoing stress) (Sanchez Jimenez & De Jesus, 2021). Basal Ganglia This region of the brain includes a number of nuclei (small bundles of gray matter) located at the center of the brain. The nuclei include the striatum (caudate, putamen, and nucleus accumbens), globus pallidus, substantia nigra, and the subthalamic nucleus. The ventral striatum is involved in positive social attachment and is connected to strong feelings of being understood and interpersonal warmth. It appears to be involved in compassion and is activated with positive expressions of caring and pleasurable scenes (Sturm et al., 2016). But, it is important to understand that these nuclei have complex interconnections throughout the brain. The impact of one nucleic region can have an effect of other regions because each section can play a different role in a process. The basal ganglia are primarily involved in reinforcement reward and motivational learning. Research has also linked the cerebellum to this region and has expanded its function to include “emotion recognition, decision making, working memory (for example being able to hold small pieces of information about a toy while learning how to operate it) and paying attention to position of objects in space” (Pierce & Peron, 2020). Cingulate Cortex The cingulate cortex is located above the corpus callosum (a band of white matter that connects the right to the left side of the brain). The anterior cingulate gyrus has pathways to the limbic and prefrontal cortex and has a role in affect regulation. The middle has connections to the prefrontal regions, motor cortex and with pain and motor nuclei. The posterior cingulate gyrus has outputs to the hippocampus and is involved with memory. Because it has varied connections, the cingulate cortex is

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involved in processes such as emotion, memory, and in connecting rewards to actions/behaviors (Jumah & Dossani, 2022; Rolls, 2019; Stevens et al., 2011). Insula The insula has strong connections with the anterior cingulate gyrus, prefrontal cortex, and also afferent fibers from the spine and brain stem via the thalamus. The insula plays an important role in the subjective feeling states and in explicit motivation. When a person experiences pleasure from doing something, it creates a conscious desire to repeat certain behaviors, whereas negative events may elicit pain or discomfort and the same person will try to avoid repeating the behavior. In this way, the insula is considered as a cognitive, “reflective system” (Namkung et al., 2017). Corpus Callosum This is a large bundle of neural fibers that runs between the right and left hemispheres and lies below the cingulate cortex. It connects the two sides of the brain to each other and is important in the interhemispheric communication. Information is passed in both directions through this area of white matter. The communication is sensory, motor, and cognitive (Queensland Brain Institute, 2017a, b). The right side of the brain has marked growth during the early attachment period and is recognized as being the predominantly the nonverbal, passionate, reactive side of the brain. It has an important function involving regulation. The left hemisphere develops more extensively at about age 3. This is the same time as the child is starting to engage in more linear, logical, and language-based thinking and interactions.

The Cerebral Cortex The area called the cerebral cortex is primarily composed of gray matter, and is divided into four primary lobes: (1) frontal lobe, (2) parietal lobe, (3) occipital lobe, and (4) temporal lobe. Frontal Lobe The frontal lobe is the largest of the lobes and it is involved in movement and executive functions such as organization of information and structuring it for further evaluation, motivation, attention, regulation, short-term and working memory, behavioral inhibition, and the sequencing of data. Also located in this lobe is Broca’s area, which is responsible for motor control and spontaneous speech. On the underside of the frontal lobe is the orbitofrontal cortex. This region has a close connection with

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the limbic region and is closely involved in regulation, developing in conjunction with the attachment process (Ansell et  al., 2012; Kringelbach & Rolls, 2004; Petrovic et al., 2016; Schore, 1994). Parietal Lobe The parietal lobe is a processing center for the sense of touch, including temperature, pressure, vibration, pain, and also the ability to sense where your body parts are positioned in relation to each other. The parietal lobe helps you understand where things are around you and know if an object is on your left or right side (Cleveland Clinic, 2023). Occipital Lobe The occipital lobe is responsible for processing of visual information such as texture, shape, and other visual details of objects around you. It is also involved in-­ depth perception, color discrimination, facial and object recognition, and memory formation (Rehman & Khalili, 2022). Temporal Lobe The temporal lobe is involved in non-verbal processing and remembering visual information and such things as music. It is also the location of Wernicke’s area. This is an area that specializes in understanding and the comprehension of spoken language and auditory processing (Queensland Health, 2022).

Vulnerability Knickmeyer et al. (2008) completed structural MRI studies on the 98 healthy children aged birth to 2 years of age. They found within the first year, regions such as the cerebellum undergo an accelerated growth of 240%, the child’s total brain volume increased by 101%, and the hemispherical gray matter increased by 149%.This rapid brain growth, however, also exposes a marked vulnerability of the brain during this early period, to internal or external environmental insults such as drugs, alcohol, and neglect. These adverse experiences can lead to damage and disruption and affect developmental foundations across multiple domains (Perry, 2006, 2009, 2013). In Strathearn et al. (2020) study of 5200 children in a prenatal study extending over 20 years, they found emotional abuse and or neglect “was associated with the greatest number of adverse outcomes in almost all areas of assessment” (p. 1).

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Again I want to emphasize that experiences determine how the brain lays down the foundations for later growth and development. If these positive experiences are few and far between, survival behaviors are likely to predominate, with the brain responding at a more primitive survival level and the higher processing being less available. Appealing to the higher functions of reasoning, empathy, foresight, problem-­solving, and time sequencing may be expected of a child, but those who have experienced trauma may just simply not have pathways established to allow them to be retrievable, especially in situations under stress. Alvarez (2016) describes this as needing to make the possible distinction between an avoidant, withdrawn type of child and one who is “undrawn.” An “undrawn” child may never have had the experience of an attachment connection and not know what it looks or feels like.

Attachment and the Development of Regulation The work of Allan Schore (1994, 1996, 2001, 2017, 2021) and Schore and Schore (2008) has been fundamental in detailing the growth of the regulation areas of the brain. One needs to be aware of this close association because evidence now has come to light in research that the brain is also relatively plastic. With repeated experiences, due to this ability, the brain can compensate for some early challenges, and the side roads that may have been established have a chance of becoming main roads, highways, and possibly freeways in their growth and connectivity. There are many varied and available approaches to assist those who have experienced complex trauma. However, many of these rely on the individual to assess language or use executive functioning to follow through with the concepts and recommendations. Often the children I see in the clinic have difficulty with language or have found it to be ineffective. They have or are currently involved in “talk therapy,” but have failed out, or are “not applying the coping skills.” Luckily with the advances in trauma research, there is a greater recognition of the hierarchy of brain development. By working at the foundational level of the body, (a “bottom-up” approach), and helping to increase the positive experiences of regulation, the frontal region of the brain and the body’s physiology can then become more available and online (Payne et  al., 2015; Ogden & Fisher, 2015). Subsequently, if a child has lacked certain experiences of safety and has not had the opportunity to embody them, it is difficult for them to lower their defenses and change their “managing behaviors.” An understanding of the brain’s role in this is essential. Recognizing this interplay can allow us to view challenging behaviors not necessarily as volitional, but consider they may serve a purpose in the child’s line of defense when safety by others, in the past, has failed or been insufficient. I will address later in this book the characteristics of the co-regulation a child’s carer provides to assist in this process, but for now, I would like to discuss the areas of the brain that are more clearly identified in the process of developing regulation.

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Neurological Changes and Dysregulation Schore and Schore (2008) have conceptualized attachment theory as a theory of regulation. The role of the caregiver and the dyadic relationship between the mother and the infant serves as a regulator to develop the infant’s own internal sense of homeostasis and brain growth (Kohut, 1971; Ovtscharoff & Braun 2001; Schore, 2009). The orbitofrontal region lies between the cortex and the subcortex. The right orbitofrontal region is in a period of marked growth early in the attachment process and has a key role in the realm of socio-emotional development because of these cortical and limbic interconnections. It aids the child in monitoring facial expressions, auditory perceptions, gestural observations, and tactile information of their caregiver essential to the development of social interactions (Bourne & Todd, 2004; Schore, 2000, 2003, 2009, 2017). Trevarthen and Aitken (2001) also describe the intricacy of the communication between the mother and child as “rapid, reciprocal, bidirectional visual-facial, auditory-­prosodic, and tactile-gestural.” He believes that these interactions facilitate the experience-dependent development of the infant’s right brain before verbal language is developed. Porges (2011) views these attributes as an important component of the vagal regulation system and prominent in the process of a child’s own regulation development. Clinically, this non-verbal communication is clearly in existence between the parents and the child. I have one child, Peter, who I have seen on a weekly basis. Peter had experienced neglect, and had been subjected to and witnessed physical abuse to himself and his siblings. He had been recently adopted with his siblings to the same family and the waiting room was frequently a scene of chaos. The adoptive mother, who was extremely compassionate, would react to disruptions by giving verbal redirection but had marked difficulty with anticipating or having proactive plans to the weekly mayhem. On one occasion, I walked in to see the mother sobbing and Peter screaming and kicking at her, while she held him in a restraint. The other siblings continued to run around the room with apparent disinterest in the battle going on in the corner. My intervention focused on calming and hearing the mother. As long as she sobbed and expressed her dismay at her child, dysregulated herself, Peter a bright verbal child, was unable to hear her appeals for sibling empathy and kindness, and achieve his own regulation. As she calmed, her non-verbal body language reflected this, he relaxed more and the cycle of dysregulation was interrupted. Barbarnie (2001) identifies the development of three regulation circuits in the orbitofrontal region during early development. In the first 6 months, the child’s eye contact develops and there is a definite interplay of communication between the caregiver and the infant. If the play between the two has become too exciting, the infant learns to avert his/her gaze to allow calming to occur and the child gradually starts in the second 6 months, to recognize that they can have some control over these interactions. As the child’s world expands, in the second year, the child is exposed to regulate further in relation to others and the concept of shame starts to be experienced. The child becomes more aware of the impact of their own behavior

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on others and when another disapproves. In this phase, they learn to shift from the “sympathetic dominant system to the parasympathetic autonomic nervous system activity” and learn to modulate and have more control over their behaviors (Schore, 1994; Thompson et al., 2008). As the child continues to mature, Balbernie describes the connections becoming stronger between the left prefrontal cortex and the locus coeruleus (an area which releases norepinephrine and influences arousal). Language starts to come online. Until this time, the preverbal experiences can be stored in body memory. They, however, can surface later in life without conscious awareness, especially when relational issues arise. I have worked with many children who have had difficulty understanding this preverbal implicit memory and are confused when they become reactive to a trigger. One adolescent, Clara, was actively engaged in a conversation with me, relaxed and attentive to my face when she heard footsteps which echoed from the floor above our room. She literally froze, held her breath, attuned to the sound, and our conversation was gone! Recognizing she had dissociated, I was able to acknowledge this shift. I described the cause of the sound and focused on drawing her attention to the “here and now” of the moment, focusing on safety and the hammock she was currently lying in. She gradually returned to a more regulated state. Clara’s breathing became more even and she was able to attune again to my presence. Later in the session, when cognition was on board, we were able to focus on her response to the footsteps. She recalled the times when she and her siblings had been locked in their bedroom while her parents went out “partying.” The return of her parents was always announced by how they walked up the wooden stairs to their apartment. If she or her siblings were found out of bed, they could not avoid an abusive response. If they feigned sleep and stillness, there was a chance they would not be woken and punished. Clara had not been aware of why she had been hypervigilance and reactive to noise until this memory was recalled. She now had language available to describe her experience. Perlman and Pelphrey (2010) in their research identified the ventral anterior cingulate in the limbic system, to be more emotionally active in younger children. The later maturing of the dorsal anterior cingulate cortex gradually imposes a more cognitive influence on the balancing of emotions. These corresponding changes occur in the maturation process and impact the child’s attachment process. The child shifts their focus from internal distress, of early attachment, to more independently “develop self-soothing strategies and the ability to reorient attention towards more pleasant stimulus” (p. 533). Each level of attachment/social and neurological experience interplays with the other. Regulation development is an ongoing process of these interconnections. Schore (2001) draws attention to the neurological development occurring simultaneously in the orbitofrontal cortex “which is involved in procedural learning and the right cerebral hemisphere dominate in implicit learning” (p. 43). With this development, the experiences the child has during this early attachment process become more internalized and encoded in memory. When the child is under stress with repeated exposure to trauma, the brain rapidly becomes activated with this recall

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and the child’s responses become more automatic (Siegel, 1999). This can be reflected in our own lives and in the lives of the children’s parents. Suddenly we respond or are activated in an interaction with another person. This activation may be confusing for an observer or ourselves at the time. By stepping back, and processing these reactions possibly for the first time, connections may be found with our own attachment experiences!

John John was a slightly built, 6-year-old. He had experienced multiple foster placements with numerous foster siblings and this learning process was apparent. Whenever engaged in play with a toy, John was highly protective of it. He would become aggressive when others tried to reach for the toy even when the intent was not to take it away. He would lash out or run from the room. He had learned to hold close the toys he possessed, because experience had taught him they would be lost or broken. Until he perceived safety and trust in those around him, and experienced them stepping in consistently on his behalf, he continued with the same rapid response. Reasoning and appeals to share had no impact. He reacted from body memory. He had learned to protect what he had with passion and intensity. This type of response is what Klein (1975) called “memories in feelings.” The attachment experiences also impact the emotion-processing limbic system and cortical areas of the developing right hemisphere (Schore, 2009). The right hemisphere of the brain has many connections to the limbic and subcortical regions. It is described as the non-verbal, holistic, and gesturally oriented side of the brain, which regulates psychobiological states of the individual (Schore, 1994; Semrid-­ Clikeman et al., 2011). It is important and aids the child in monitoring the facial expressions, auditory perceptions, gestural observations, and tactile information of their caregiver (Bourne & Todd, 2004; Schore, 2003, 2009, 2017). As the brain matures, the later phase of emotional processing, social interaction and regulation become more refined (Schore, 2009, 2011) and we can notice the adaptive or flexible nature of the child’s responses given their experiences. This is often an area of challenge for the children I work with. Frequently, the transfer of one experience to another is difficult and the child then feels unjustly done by, and dysregulates. The biochemistry also needs to be considered in the neuronal growth and pruning. Schore (2001) has observed that “intense relational stress alters calcium metabolism in the infant’s brain, a critical mechanism for cell death” (p. 213). Consequently, compromised experiences such as neglect, exposure to interpersonal violence, the mental health of their caregivers, the age of the trauma, and its chronicity are likely to elicit chemical changes and have a negative impact on the child's brain and organization (Balbernie, 2001; Bick et al., 2015). Children with a history of complex trauma can become caught in a web of neurological and physiological challenges. Those caught in hypervigilance (which some describe, in error, as distractibility) expend energy on constant alertness to

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their external surroundings and others, rather than on growth and new experiences. They exhibit almost instant reactions to possible threats. These perceived threats may have gone unnoticed by those with a more developed and evaluative regulation system (Balbernie, 2001). I often hear the phrase “my child goes from zero to a hundred in seconds!” As clinicians and carers, it is important to consider the antecedents or the triggers to these responses because they do exist. We may think the reactions have come out of nowhere. I encourage you to question why the child reacted versus assuming “it is just their personality.” If we take this time to reflect, a wealth of information that can impact the effectiveness of treatment will be before us. Keep asking “Why?”. And it is also worth considering that the child’s reactions may not be associated with only one particular stressor. The child may have had repeated “minor exposures.” Unobserved, and overwhelmed with attempting any suppression, the child finally lashes out. No wonder! There is a game called The Last Straw. The players add small plastic straws, according to the roll of the dice, into the saddle of the camel. Eventually with this repetition, the camel collapses and the person placing the last straw loses the game. Small stressors in our lives add up. This game visually demonstrates how stress can build. As adults, we know only too well how a day can start with sleepy children who are dragging their feet to school. This then causes you to be late to work, and the rest of the day snowballs until you walk back in the door to a hungry family. Someone just looks at you “the wrong way,” and it develops into a major event with disgruntled and raised voices. If someone then attempts to correct you for “the misinterpretation,” without considering the rest of your day, you too may lash out and “have behaviors.” Relatedly, children’s emotional reactions may have a time delay, what Blake (2008) calls “emotional indigestion.” The child may have been upset about an earlier incident but may not react immediately. Later, with perhaps another small conflict, an “overreaction” can occur. The delayed response may be misunderstood by those around him/her and efforts be made to remediate the present situation with poor results because it was not the facilitating event. I have witnessed this many times with children “exploding” at school. If the staff can take the time to regularly check in with the child at the beginning of the day, they may find, for example, that the child has not slept well the night before because his/her parents had been fighting, or that they may have been bullied on the bus coming to school. This check-in can allow accommodations to be put into place to support the child rather than the child walking straight into the classroom and being “primed” for a reaction.

The Impact of Trauma on the Developing Brain Since the “decade of the brain,” researchers began to link chronic trauma with a child’s development. It has become evident, in multiple studies, that exposure to chronic stress impacts the developing brain (Hart & Ribia, 2012; Li et al., 2022). For example, researchers such as Cassiers et  al. (2018) reviewed neuroimaging

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findings associated with exposure to different childhood trauma subtypes. They noted that sexual abuse was associated with “structural deficits in the reward circuit and genitosensory cortex and amygdala hyperreactivity particularly during sad autobiographic memory recall” (p. 8). They also noted that children who had experienced emotional maltreatment were observed to have abnormalities in the fronto-­ limbic connections, while neglected children demonstrated interferences in the development of the white matter integrity and connections. In all types of maltreatment, there was a notable reduction in the frontal cortex volume in the subject’s brains. Bounoua et al. (2022) studied 137 adults with a history of childhood trauma and noted alteration in the reduced size of the medial orbitofrontal region and the amygdala. The authors identified that the orbitofrontal region was linked in previous studies to impulsivity. They concluded that the changes observed in the research supported the concept of disrupted modulation in higher brain regions. This disruption was closely linked to the chronic activity of the Hypothalamic–Pituitary– Adrenal axis (HPA axis) under sustained stress, and subsequent atrophy of these modulating regions. Another study by Luby et al. (2012) examined brain scans of 92 preschoolers and reported that children in a nurturing relationship had a hippocampus that was 10% larger than the children whose mothers were challenged when trying to give nurturing care. Since the hippocampus has a primary role in memory, emotional regulation, and modulating stress, this evidence indicates that while the brain is maturing, the early caregiver–child relationship can have a significant impact on the growth of this region and subsequently impact the development of a child’s regulation and modulation skills. Weissman et al. (2020) sampled 149 youth who had experienced physical abuse, sexual abuse, or been subjected to domestic violence and concluded that there was not only a reduction in the size of the child’s hippocampus and amygdala but also a close association with the subsequent development of depression over time. Li et al. (2021) also note mean volume reductions of 8.4–9.7% hippocampal fields in Post Traumatic Stress Disorder (PTSD) survivor children aged 11–16 years. Palacios-Barios and Hanson (2019) using a neuroscientific framework for examining the impact of poverty on self-regulation linked the negative impact of chronic environmental stressors on the child’s regulation development. They proposed two “bottom-up” and two “top-down “elements involved in self-regulation. They emphasized the regions of the brain involved in the “bottom-up” regulation, e.g., amygdala, hippocampus, and ventral striatum matured earlier in the developmental process and the “top-down” regions such as the structures in the prefrontal cortex region had a slower and later growth. The role of the “bottom-up” structures is the evaluation of the potential threat and its salience, interpretation, and context generalization. The “top-down” regulators were more actively involved in decision-­ making, emotional regulation, and executive functioning. This possibly accounts for the earlier developing structures coming “online” rapidly and less investment, by the child, in cognitive processing alternatives (Petrovic et  al., 2016). Current trauma research acknowledges this “bottom-up,” “body-based approach”

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particularly in the effective treatment of regulation disruption. When a child is dysregulated, they will be responding at this more “primitive” level. Broca’s area of the brain “goes offline” and language becomes difficult to utilize or process (Levine & Kline, 2007; Ogden & Fisher, 2015).

Brain Integration Schore (1994, 1996, 2001) and Schore and Schore (2008) wrote extensively concerning the close relationship between attachment/co-regulation support, self-regulation maturation, and the timing of neurological growth. He emphasized the important role of the caregiver in providing and acting as a filter and modifier for the young child (Bion, 1962; Fonagy et al., 1991). As the child moves from his internal orientation to a more interactive role in the surrounding environment, the regulation is shifting from the dependency on the caregiver, to the independence of the child’s experience and exposure. Meanwhile, the regions of the brain are myelinating at a great rate, the neural pathways are being formed, and the building blocks for higher levels of regulation are being attained. This interconnectedness of higher, lower, and lateral regions of the brain in the early years and the responsiveness of the caregiver is thus of vital importance to the neurological and psychological development of the child. If the experience-­dependent exposures have been misattuned between the mother and the infant, the neurological pathways are laid down on those experiences and less than optimal development of the brain is likely to occur (Perry, 2006; Siegel, 2006; van der Kolk & Fisler, 1994; Schore, 2000; Schore & Schore, 2008). Siegel (2018) further expands this concept to brain integration. Following chronic developmental trauma, he draws attention to the child’s lack of integration, occurring both vertically and laterally in the brain. He postulates this leads to a disruption between the thinking, emotional, and survival regions of the brain, leading to chaotic or rigid thinking. Perry (2006) reflected that “healthy organization of neural networks depends upon pattern, frequency, and timing of key elements during development. Chaotic, episodic experiences that are ‘out of sync’ with a child’s developmental stage create chaotic, developmentally delayed, and dysfunctional organization” (p. 344). A study completed by Jackowski et al. (2008) reported reduced fractional anisotropy in the medial and posterior corpus callosum in 17 maltreated children with PTSD. This reduction indicated evidence of disruption in the quality of the fiber tracts and demyelination of the corpus callosum pathways compared to normal controls. Since the corpus callosum contains many circuits that include emotional processing and memory roles, this can also account for some of the disturbances that are often seen in traumatized children. If the brain is not stimulated, those areas will be shaped and altered by the lack of experience (Perry, 2009: Perry & Dobson, 2013). MRI studies and detailed imaging of the brains of children who have been subjected to chronic abuse demonstrate a marked reduction in volume and development of multiple regions of both gray and

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white matter (Glaser, 2000; Bremner, 2006; CWIF, 2015; Lim et  al., 2014, 2018, 2020). Hart and Ribia (2012) also completed a critical review of numerous research-­ based neuroimaging of children subjected to abuse and reported significant correlations between childhood maltreatment and brain changes. Areas of the brain affected were the prefrontal cortex, orbitofrontal, anterior cingulate cortex, hippocampus, amygdala, corpus callosum, and cerebellum. There were also notable white matter abnormalities in communication tracts between regions and isolated areas of the brain affecting emotional control, language, and anxiety. Some of the functions impacted within these regions include memory, inhabitation, foresight, motivation, affect, attention, social cognition, motivation, emotion processing, discrimination, fear processing, suppression of irritability, and executive functions. De Bellis and Zisk (2014) also reviewed pediatric imaging studies that demonstrated not only smaller cerebral and cerebellar volumes but also smaller corpus callosum development in maltreated children. Implications from these studies have a marked impact on the child’s abilities for learning. Right–left interconnections are necessary for the processing of logic and reason, coordination of thought/emotion, and executive functioning such as organization, regulation, working memory, motivation, and flexibility of thinking (Scaer, 2012; Schmahmann, 2004). Bremner (2006) found alterations in memory functioning following traumatic stress; there were also changes in circuit brain areas, including the hippocampus, amygdala, and medial prefrontal cortex. In a similar MRI study, Carrion et  al. (2010) also observed reduced hippocampal and prefrontal activity in the brains of adolescents who had experienced childhood trauma. The adolescents performed poorly compared to non-traumatized youth, both in memory and executive functioning tasks. Exposure to domestic violence also needs to be highlighted here. Many people believe a child is unaffected if they have not seen the violence. Exposure, however, psychosocially induces biological alterations in the midbrain of the studied children. These children exhibited easy distractibility and difficulty with attending to tasks. They had changes in their limbic system, with hippocampal and cortex atrophy, creating challenges with memory formation and gauging the magnitude of responses. They also had smaller volumes in their corpus callosum and cerebellum (Tsavoussis et al., 2014). McLauglin et al. (2019) using a dimensional model of adversity and stress acceleration model reviewed 109 MRI studies and consistently reported a reduction in the amygdala, medial prefrontal cortex, and hippocampus with increased activation of the amygdala circuitry. Teicher et al. (2016) also noted study changes in the areas of the brain involving regulation, threat detection, and reward anticipation. The study involved adult women who had experienced childhood sexual where there was thinning in the cortical thickness of the sensory-motor cortex, specifically in the genital perception area, did this desensitization protect the women? In cases of emotional abuse, the thinning was more prevalent in the areas of the brain responsible for self-awareness and self-evaluation (Heim et al., 2013). Similarly in a study by Gee et al. (2013), they noticed early adversity to maternal deprivation resulted in the

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amygdala and the prefrontal region having accelerated growth and considered this to be a possible accommodation to reduce the experience of heightened anxiety.

Fear of Novelty Mitchell and his colleagues (1984, 1985) importantly noted in their work with animals that those animals under stress tended to avoid novelty and perseverate in familiar patterns regardless of the outcome. Often carers and therapists have difficulty understanding why a child does not utilize new ideas, and keeps repeating the same responses despite their known negative outcome. New increases anxiety. Anxiety is helpful in modulation because it focuses our attention to the new task. But with chronic stress, anxiety has a chronic presence. If a child is presented with a new event or activity, it is less anxiety evoking to tolerate unpleasant outcomes than to add an element of unpredictability caused by a novel and unknown situation (van der Kolk, 1989). Clinically, this may manifest in pseudo-maturity. I recall a particular 7-year-old client who had been raised in a home with marked domestic violence and the unpredictability of drug use by her parents. This child had significant challenges with playfulness and if imagination was incorporated into play that was not based in reality, e.g., the possibility that “dragons like to eat pizza,” she would adamantly argue this was not possible. Instead she would play house and look after the baby doll. There would be no playfulness in this, simply tending to the chores of motherhood. (This child was often left in charge of the neighbor’s 6-month-old while the adults socialized. Her mother was extremely proud that her daughter knew how to feed, wash, and diaper change the baby with no assistance.) In this household, there was a lack of predictability and low levels of praise and acknowledgment. When praise did occur, this child repeated that behavior, despite opportunities at other times to explore new play options. Study after study demonstrates the significant effect stress can have on a child’s developing brain.

Summary Our brains are amazing. The experiences we have become foundations for more complex levels of development. If a child experiences complex trauma early in their growth, the neurological impacts can be significant and impact their development across many different domains. It is clear from the research that this process is not linear and cognitive. Much of their trauma is held in their bodies and their responses may appear confusing. What is important is the child’s sense of safety and continuity. It is essential to provide a stable base from which exploration and growth can occur. The child’s behaviors may not be volitional. As therapists and caregivers, this

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neurological viewpoint will help you consider and be more tolerant of defensive behaviors. Instead, hopefully, this knowledge will be another pathway to increasing your understanding of the complexity of challenges a child who has experienced complex trauma may have to deal with on a day-to-day basis.

Damage or Adaption? Teicher et  al. (2016) importantly questioned whether these changes seen were a result of damage, or of the body’s adaption to modify the conscious awareness of repeated exposure and as a way of minimizing distress. This perspective of damage or adaption to maltreatment is worthy of strong consideration. Does the body respond to adversity by making adaptions to increase the chances of survival by changing the sensitivity to threats? In a similar way, one also needs to question the function of a child’s behaviors. Should the challenging behaviors of a child be viewed as “defenses” (possibly a more negative term) or as “managing behaviors” (a positive adaption), which helps the child perceive a sense of safety? They may act as strengths for the child despite the inconvenience and implications they present. Evaluating this perspective is valuable. If we teach a child to be assertive, do we ultimately place them at more risk when they confront their abuser? If we help them to dissociate less, will they become more overwhelmed with their past? The lens needs to be broad. Many aspects need to be considered when working with these children. Do they have a foundation of safety?

Adrian Adrian was referred for services, at age 8, following a history of neglect, multiple foster home placements, and significant regulation challenges. He presented with extremely rigid in his thinking and also in the way he moved his body. He lacked the quality of “aliveness” and playfulness. If Adrian did use his imagination, it was always on a factual recollection of carnivorous animal themes and no one who was playing with him could alter the scenario. He had difficulty integrating directions and requests, tended to self-isolate, and was extremely anxious with the presentation of any novelty. Adrian’s biological mother had an extensive history of drug use and several near-­ overdose experiences. Adrian received poor prenatal care. His father was currently in prison for domestic violence and also had a history of substance use. Adrian was removed from his parent’s home following severe neglect and lack of supervision, food deprivation, inconsistent housing, and was also suspected of being sexually abused. Subsequent to his removal, when he was also separated from his 4 siblings, he was placed in 3 foster homes before being adopted by his paternal grandmother. He occasionally sees his biological mother, however is aware of her wish to kill herself and lives in constant alertness to her safety.

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Adrian struggles at school. He has “friends” but wants to control the interaction, discussing his favorite topic of carnivores. He could recite every detail imaginable about any of these animals, but could not tolerate interruption or new facts. He tended to spend recess by himself, wandering off from the main group. He lagged behind in writing and reading, and initially enjoyed math because of the structure, however, has begun to fall behind as the work complexity increased. At home, Adrian was reported to have a low frustration tolerance, was “overly serious,” had no sense of humor, argued with his siblings constantly, would wake several times during the night and urinate on the floor of his bedroom, steal food, and was “stubborn and uncooperative.” On motor skills assessment, he was in the below average and well below average on all his motor skills. He was independent with dressing self, however, paid little attention to bathing or concern for clean clothes. He was an extremely picky eater and preferred high-­ carbohydrate foods. His neuropsychology assessment reflected low-performance scores in all realms, and he had multiple diagnoses including attention deficit disorder with hyperactivity, reactive attachment disorder, autism, oppositional deficient disorder, anxiety disorder, and depression. Adrian is an example of how severe neglect and poor caregiving at an early stage of a child’s development can impact multiple domains of his/her development. Adrian lacked consistent responses to his basic needs such as food, sleep, clean clothing, safety supervision, and stable housing/income. His parent's own mental health and use of drugs led to inconsistent attention and he was frequently left unattended with strangers or had to meet his own needs independently. He learned to survive his circumstances by withdrawing, detaching from his emotions, structuring his day in tasks he was familiar with, and meeting his needs in a very basic manner. He was not in an environment that encouraged exploration, discussion, learning, or creativity. His experiences were about survival!

References AbuHasan, Q., Reddy, V., & Siddiqui, W. (2022). Neuroanatomy, Amygdala. NCBI Bookshelf. https://www.ncbi.nim.nih.gov/books/NBK537102/ Ackerman, S. (1992). Discovering the brain. National Academics Press. Addis, D. R., & Schacter, D. I. (2012). The hippocampus and imagining the future: Where do we stand? Frontiers of Human Neuroscience. https://doi.org/10.3389/fnhum.2011.000173 Alvarez, A. (2016). Impaired interactions triggering defense or exposing deficit: Exploring the difference between the withdrawn and the “undrawn” autistic child. Commentary on “An integrative model of autism spectrum disorder: ASD as a neurobiological disorder of experienced environmental deprivation, early life stress, and allostatic overload” by William M. Singletary, M.D. Neuropsychoanalysis, 18(1), 3–7. https://doi.org/10.1080/15294145.2016.1151250 Anderson, C. M., Teicher, M. H., Polcari, A., & Renshaw, P. I. (2002). Abnormal T2 relaxation time in the cerebellar vermis of adults sexually abused in childhood: Potential role of the v­ ermis in stress-enhanced risk for drug abuse. Psychoneuroendocrinology, 27, 231–244. https://doi. org/10.1016/S0306-­4530(01)00047-­6

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Chapter 4

But Physiology Plays a Part in Complex Trauma!

Balance and Homeostasis Our body tries to seek balance and homeostasis but this is a dynamic process involving the interactive needs of both our internal and external environments. When this balance and variability are not functioning in a coordinated manner, impairments can be seen. Diseases in the cardiac, respiratory, immune, and inflammatory systems have been linked to dysfunctions in the regulation processes (Porges, 2011). We need to be able to alert ourselves and to also calm our responses to effectively interact in our world. Imbalance can lead to too much arousal and the body becoming vigilant and in fight or flight mode, or on the other extreme, withdrawn from our own external and internal awareness (Perry et al., 1995). To maintain our health, finding a balance and adaptability in our regulatory system is paramount. Chronic stress can cause detrimental physiological and anatomical changes.

Stress Systems Stress threatens the homeostasis of the individual. It can be a perceived or actual threat, and the body responds to these internal or external threats by utilizing the adaptive stress response mechanisms of the autonomic nervous system and the Hypothalamic–Pituitary–Adrenal axis (HPA axis). These systems impact the physiological and behavioral responses and are activated to regain balance within the body. The adaptions include changes in the cardiovascular tone, respiratory rate, and metabolism to promote the availability of resources for the body under stress (Smith & Vale, 2006; Bergland, 2013; Stephens & Wand, 2012). The body receives neurosensory signals from visual, auditory, olfactory, gustatory, higher cortical centers, the limbic system, interoceptive receptors, and the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_4

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biochemical components of the blood. It moves resources to areas which need to mobilize and inhibits less necessary functions such as appetite, gustatory functions, growth, immunity, and reproduction. Behaviorally there is an increase in focused attention, alertness, improved cognition, dysphoria or euphoria, increased analgesia, and a core temperature increase (Chrousos, 1998; Smith & Vale, 2006).

Hypothalamic–Pituitary–Adrenal Axis (HPA Axis) When the body is under stress, the sympathetic nervous system releases norepinephrine and adrenaline (LeBouef et al., 2020) and starts the mobilization process. Our body needs to have energy available to deal with reacting to the stressor. It releases stores of glucose to be able to mobilize in what is often called the “fight or flight” reaction. Seconds later, the HPA axis mobilizes.

The Hypothalamus The hypothalamus receives signals from the neurosensory areas to a potential stressor. The hypothalamus releases Corticotropin-Releasing Hormone (CRH) into the system and it travels to the pituitary.

The Pituitary The pituitary then releases Adrenocorticotrophic Hormone (ACTH), which flows through the body to the adrenal glands on the top of the kidneys.

Cortisol and Adrenaline Cortisol and adrenaline are released. They have an impact on the glucose stores and become more available for the body to respond to the stress. When there is enough cortisol in the body, a negative feedback loop happens and the cortisol then impacts the hypothalamus and pituitary and they shut off the flow of the stimulating hormones and the body then comes back into balance.

Chronic Stress and Cortisol

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Fig. 4.1  Poultry Bucket Waterer

Feedback Loop For those of you who are very visual and charts and descriptions simply do not work in understanding the concept of the negative feedback loop, let me try another visual (Fig. 4.1). There is a watering system used for poultry that functions in a similar way. It is a bucket or pail that is filled with water and it has a lid that snuggly fits in place to cover the top opening. Inside the bucket at the bottom is a small outlet value. If the pail is filled with water and the lid is on, the water will drain out into the surrounding dish on the outside of the bucket. When this dish fills, the water will completely cover the outlet and the water will stop flowing. If the chickens or ducks drink, they will lower the water level and the water will refill the dish, again stopping when the pressure inside and outside is balanced. Sadly, if one leaves the lid off after filling, the water will overflow and keep flowing until it is out of water or the tight lid is put back on. On the other extreme, if there is no water inside the pail, the system fails by having nothing flowing into the dish. The negative feedback loop of the HPA axis works like the well-balance system of the waterer. As long as all the components are in place, it works in an effective way, supplying water as needed and stopping when the need is met.

Chronic Stress and Cortisol However, if the stress is chronic, where norepinephrine improves cognition and attention under immediate stress, at high levels, the brain begins to shut down. The effectiveness of the cortisol under chronic release is blunted, and takes longer to return to pre-stress levels (Stephens & Wand, 2012). The cortisol floods the systems and exposes the body to high sustained levels and can cause physical damage within the various body systems.

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Priming De Bellis and Zisk (2014) describe the changes to the HPA axis in terms of priming. With greater exposure to cortisol, the system becomes primed and hyper responds to acute stress or as a response to traumatic triggering. In this way, implicit memory of trauma or perceived danger can be unconsciously triggered whenever a reminder occurs. Those people interacting with this group of children understand this response well. The threat may or not be real, but the age of the trauma, the severity, the chronic nature of the trauma have an impact on lowering the sensitivity to the response and the threshold required to trigger the response. The body is then flooded with the adrenaline and subsequently the cortisol. This ongoing surge of cortisol has an impact on the hippocampus and its learning and memory formation, creating a negative feedback loop of behaviors, anxiety, and depression (Siegel, 2001). In the young child, the biochemical chronic stress response significantly impacts the developing brain, physiological growth, and the healthy functioning of the immune, digestive, and metabolic systems (Bremner, 2006; McEwen & Gianaros, 2010; Schore, 2017).

In Utero: Stress and the Fetus Studies by Poggi Davis et  al., 2011 and Poggi Davis and Sandman, 2012 have examined the impact of prenatal maternal stress on the infant’s own stress regulation development. The mother’s cortisol level naturally increases during the course of pregnancy but the infant’s exposure is regulated by a placental enzyme, which oxidizes the cortisol to an inactive form. This enzyme, however, provides only partial protection, and excess cortisol can pass through the blood–brain barrier and impact the neurological development of the infant and the potential connectivity of the regulating region. If the mother is experiencing high stress with heightened anxiety and depression, there appears to be a close correlation between this and the infant having an increased behavioral reactivity and a slower rate of recovery when exposed to a stressful situation. The authors further predict the easily aroused infant will likely be more inhibited as a child and have a higher risk of social anxiety in adolescence. Swales et al. (2018) also found a close correlation between elevated levels of prenatal maternal cortisol and the behavioral, cognitive, poor physical, and psychological outcomes in children and adolescents exposed prenatally. They concluded the prenatal HPA axis functioning of the mother, when she had experienced her own childhood trauma, had a potential intergenerational impact on the developing fetus by affecting the development and programing of the regulation functions in the child.

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Drug Exposure: Early Physiological Developments The impact of in-utero exposure to drugs can also significantly impact the developing fetus. If the mother’s self-management of her own trauma experiences is by drug use, the child will be exposed to these substances in utero. Khan et al. (2021) noted “ drugs mimic naturally occurring neurotransmitters, such as cannabis stimulates anadamides; opiates act like endorphins, and psychostimulants increase dopamine and serotonin in the synapses of the mesolimbic pathways” (p.  331). They concluded multiple behavioral changes in these children. Changes included difficulties with attention, impulsivity, irritability, memory, aggression, language, motor and academic development. Lester and Lagasse, 2010 noted the impact of the substances disrupted and “altered the HPA set point of the infant and can lead to later behavioral, emotional and neurocognitive deficits later in childhood” (p.  269). Once again, the complexity of a child’s experience extends beyond the presenting behaviors of the child. Consideration also needs to be paid to their preconception, prenatal, and post-partum experiences and environments to gain a more comprehensive understanding of their behavioral responses.

Stress and the Polyvagal Theory When I was training as an occupational therapist, the autonomic nervous system was presented to me as a binary balanced system. The sympathetic system signaled the body to respond to stressors in a fight or flight mode and the parasympathetic system helped put the brakes on and bring the balance back to the body so it could return to a calmer state. This system still of course exists but the work of Stephen Porges has made a significant contribution to our understanding of the body’s response to stress. Porges has identified the vagus nerve involvement in the parasympathetic system and the two different responses it can elicit (Fig. 4.2). The myelinated ventral vagus, located toward the front of the body, innervates the heart, bronchi, and the striated muscles of the face and head. This includes the muscles of mastication, middle ear, larynx, pharynx, and neck. The more primitive dorsal vagus is unmyelinated and is located toward the back of the body. It innervates sub-diaphragmatic organs but also has branches to the heart and bronchi. The systems follow a phylogenic path with the more primitive system (dorsal vagus) facilitating immobilization; the second, (sympathetic system), mobilization; and the third, ventral vagus linked to social engagement and communication. Depending on the challenges imposed on the individual, the most recently developed system, the ventral vagus (the social engagement system) is pulled into action. However, if this system is unable to function adequately, the lower systems are then utilized to enhance survival.

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Fig. 4.2  The Polyvagal System

Social Engagement System: Ventral Vagal Circuit The ventral vagal is ontologically the most recent branch of the autonomic nervous system and is involved in social engagement and connectedness. This ventral portion of the vagus has a calming influence on the heart and the HPA axis (Weber et  al., 2012). By creating calmness in the body, the social engagement system becomes more available. This ventral vagus nerve is myelinated and this is a characteristic only found in mammals. Porges describes this development as essential in linking the face-to-heart connection with social behavior and the interactive component of the autonomic regulation. The ventral vagus is responsible for the innervation of facial expression, vocalization prosody, and listening. Hence the important qualities of social engagement, attunement, and the process of attachment are available to the child. In this calm state, the body’s resources also become available and the child’s systems can grow and repair creating the foundation for more complex functions. A child who plays interactively, modifying their responses in consideration to whom they are playing, and tolerates the input of others, even with the occasional laugh, is a child able to utilize their ventral system in an adaptive social manner. Improvement in a child’s regulation capabilities can be noticed by observing these socialization changes, even if they are momentary!!!! The ventral vagus slows the body enough for us to engage and notice others. This is ideally our first line of regulation: to seek others. Consider the nursing mother and infant. During feeding, both are attuned to each other’s movements and are relaxed. The feeding becomes a time when the mother and child have the opportunity to be with each other, interacting calmly. If the mother was actively moving, the effectiveness of the feeding would be impossible. Just as an extremely depressed mother with poor awareness, due to her own preoccupation, may not notice the child struggling to latch on or sustain her milk flow effectively. Coordination is needed for this social dance to succeed.

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Play The parasympathetic system can also come into play when the child is actively utilizing the sympathetic system in cooperative play. When the sympathetic system is activated and heightens a child’s attention and energy in enjoyment, it can reach a crescendo and to not become overwhelmed, the attuned caregiver will reduce her vocalizations, drop eye gaze, slow her own movements, and allow the child to rest. This external shift assists the child to calm and reregulate. The child will also drop his/her eye gaze, look away, and become stiller and quieter. This attunement to each other, as previously mentioned in the attachment chapter is the way the other co-­ regulates the infant, and the infant can thus experience these changes and begin to internalize them into his/her own regulatory responses.

Sympathetic Circuit: Fight or Flight The second circuit, the sympathetic system, is the system many quote as the “flight– fight” responses. The body becomes activated and mobilization is paramount. Children’s behaviors are very noticeable in this phase and the diagnoses of Attention Deficit Disorder, Conduct Disorder, and Oppositional Defiant Disorders are frequently applied to these children. These are also the children who are repeatedly struggling with social relationships, learning, and attention challenges and are often “in trouble” with any perceived authority.

Dorsal Vagal Circuit: Shutting Down or “Playing Possum” The dorsal vagus is the most primitive circuit of the parasympathetic nervous system and provides the basic needs for survival. Some refer to this as the reptilian part of the brain because the dorsal vagal assists with the survival responses of withdrawal, freeze, and dissociation. One needs to recall the “dead possum” feigning when the possum is under stress. The animal lies motionless, tongue drooping to the side of its mouth and its breath so negligible, it is barely able to be perceived. This behavior defensively protects the animal when no chance of escape appears apparent. Predators will often avoid another dead animal and after some prodding will, with seeming confusion, walk away. Of course, we all know the possum reactivates when the threat is reduced and will rapidly disappear out of sight. When this system is engaged by a child, they appear to withdraw, have low mobilization, dropped eye gaze, and none or almost no conversation.

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Neuroception Versus Perception The traumatized child evaluates the risks in the environment and regulates the expression of adaptive behavior to match the perceptions of the surroundings (Dana, 2018; Porges, 2004). Porges describes neuroception as an unconscious scanning of our environment for cues of safety or threat by our autonomic nervous system. Our bodies react to these signals without conscious awareness. Porges distinguishes neuroception in this way from the perception, which has more conscious awareness. Most of us have experienced the hair standing up on the back of our neck when we sense our environment is incongruent. We instantly become more vigilant, attentive, and attempt to identify the threat. Cognition, problem-solving, and choices instantly disappear and survival kicks in.

“My Sweater Tried to Kill Me”: A Neglected 7-Year-Old Boy Background Mason had experienced extreme neglect as a child until the age of 4 when he was found wandering around an “abandoned” trailer home. The police, however, discovered that it was the residence of Mason and his mother. Mason’s mother was addicted to “crack.” There would be many occasions when Mason was left to fill his day without any supervision. Further investigations indicated that his mother had also been prostituting herself for funds and it had not been uncommon for the “visitors” to punish Mason for his presence. At other times, he would be placed outside and tethered to a post when these transactions were taking place to ensure he would not wander away.

Clinical Presentation I started seeing Mason when he was 7 and had been adopted by his foster parent. He was constantly in conflict at school and with his adoptive siblings. He was very vigilant, and could not stay focused on any task for more than 1–2 min. He did not want to be given any suggestions or ideas for proposed activities and would bolt, shouting his desire to be gone and the unfairness and injustice of the situation. This happened when he perceived he had lost control. Mason had, however, developed a strong attachment to his foster mother who was extremely attuned to his responses and he would go in search of her whenever this occurred.

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Therapy During the process of treatment, Mason began to trust me and started to be more flexible in the way he interacted. Eventually, there was even humor and laughter in the session. We were able to move from a smaller treatment room with less equipment choice to the larger room with more equipment. Mason was less dysregulated with novelty and although he would not try everything suggested, he did explore some alternatives without immediate rejection.

The Sweater Incident On one such occasion, we had been engaged in interactive familiar physical activities. Mason had spontaneously been laughing and tolerating his “not perfect” attempts at swinging and landing on a set determined spot on a mattress. After several attempts and improvement, he enquired about the use of swing, something he had previously enjoyed. It was agreed he could try this and because he had started to feel hot, he decided to take off his sweater. I began to attach the swing to the suspension point but out of the corner of my eye noticed Mason’s movement had started to become jerky and rapid. He had pulled his sweater up over his head, but was apparently “trapped” and this was becoming worse as he attempted to pull his arms free. A blood-curtly scream arose and he frantically fought to free himself, thrashing in every perceivable direction. But this reinforced the challenge of actually being able to do so. It was clear his sweater needed to be removed quickly or Mason would end up harming himself in despair. I kept touch to a minimum because this further triggered his fight response. I maintained simple clear directions and worked very consciously to keep myself regulated with my voice calm because he could see nothing. Mason eventually exploded free and fled at full force out of the room, in absolute terror. This body's memory of trauma had no words. What it did have was a powerful survival drive. His social engagement system was completely off-line and his fight/ flight was in full play!

Regression-Survival and Safety Perry (2004) describes this as “regression” elicited by less complex areas of the brain. For Mason, “regression” seems an understatement! But is clear, ontologically, Mason was responding at a far more primitive level of functioning where social engagement and cognition were not in the forefront. In situations where the child perceives a lack of safety, threat response behaviors may be triggered even if danger is not actually present. “Trauma compromises our ability to engage with

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others by replacing patterns of connection with patterns of protection” (Dana, 2018, p. xviii). For healthy adaptable functioning to occur, we need to be able to efficiently switch from defensive withdrawal or flight and fight states to a state where one can utilize social engagement strategies and experience internal calm. The primary influence on a child’s behavior is the child’s experience of safety. When safe and secure, a child can utilize this more advanced neural circuit and is able to be proactive in navigating the world (Porges, 2001). Without this, we are all at the will of our survival instincts.

The “Window of Tolerance” These states can be correlated/assimilated with the “Window of Tolerance.” This is a phrase coined by Dan Siegel (1999) and adapted by Pat Ogden and Minto (2000) in “The Modulation Model.” Both describe the optimal zone between extreme states of physiological hyper- and hypo-arousal. At this place, an individual can experience arousal as tolerable and they can integrate information in emotional, sensorimotor, and cognitive domains calmly. Within this window, there is an ebb and flow (ups and downs) of emotional experience at a present moment and over periods of time, but the modulation occurs spontaneously and naturally, and in no extremes. We all are aware of periods in the day when we are at a higher performance or tolerance level than other times. This oscillation of our body systems is the dynamic way our bodies continuously adapt to maintain regulation and homeostasis.

A World View I imagine the “window of tolerance” as a world globe (Fig. 4.3). We all fluctuate in our optimal zone around the equator. On occasion, we will become hyper- or hypo-­ aroused and peak toward the Tropics of Cancer or dip to the Tropic of Capricorn. We can return to a more regulated state by our own internal regulation strategies or with the assistance of others. This model functions on the premise we understand the sense of the equator and our regulated midpoint of balance. When given the context of many of the trauma children I have worked with, it is questionable if they are even aware of what “typical balance“ or “the equator” feels like. How often have you heard the request for a child “to calm down” and they dispute “I am!!!!!!” For those who have lived and experienced life predominantly in hyper- or hypo-arousal, asking a child to calm themselves is almost like asking someone to understand Norwegian if it has never been heard or even experienced. These children know chaos. This has been and continues to be experienced both internally and externally. The stable and secure foundation is absent or shaken between the states and may become the new norm after trauma (Ogden & Minto, 2000; Ogden & Fisher, 2015).

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Fig. 4.3  World view: The equator is at the midline and the tropics are at the extremes

Understanding physiology and the interplay of multiple systems on the “felt” experiences of these children will help to understand the challenge to these requests. Just as Alvarez (2016) describes the autistic child as “undrawn” versus “withdrawn,” the path we set may require the child to learn this completely new sensation in a safe context. Too often calmness has been “the calm before the storm” for these children and it has been truly something to be avoided!!!! In states of high arousal, however, there is excessive motility, hypervigilance, panic, anxiety, irritability, difficulty relaxing, sleeping, eating, and digesting food and emotions can escalate into rage or hostility. When states of hypo-arousal (low arousal) occur, the body can shut down, dissociate, experience extreme fatigue, numbness, flat affect, depression, etc., and the child can withdraw in order not to become overwhelmed (Grabbe & Miller-Karas, 2017). Adverse experiences can shrink our window of tolerance resulting in having less capacity to flow between arousal states and creating a tendency to become overwhelmed more quickly (Gill, 2017).

A Sensitized Alarm Response Perry describes the child as having a “sensitized alarm response” to association cues and hence has an altered baseline such that the internal state of calmness is rarely experienced (Perry, 2004). The intensity of the trauma response often disorganizes the individual’s cognitive capacities, interfering with the ability for cognitive processing and top-down regulation (LeDoux, 1996; van der Kolk & Fisler, 1994; Perry, 2004).

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The Polyvagal Ladder Deb Dana (2018), a colleague of Porges, has applied his Polyvagal Theory to a clinical practice for working with trauma survivors. She has created a visual image of a ladder. At the top of the ladder is the social engagement, ventral vagal system, and its associated characteristics. In the middle rungs is the flight or fight, sympathetic response. As you move further down the ladder the dysregulation comes into the withdrawal, dorsal state. In this manner, it is a way for the clinicians or carers to visually see the up and down movements of a child’s state. It is important to remember we all have movement along this continuum, however, a healthy individual will tend to stay toward the top of the “ladder” and socially reach out if feeling stressed. The children we work with have more difficulties on this higher rung.

Marianne Marianne, an adolescent, would move along this spectrum in both directions. Some days she would come in and report things had gone well and overall she was relaxed and less vigilant. Other days she would have been suspended from school because she had become so anxious she had run from the class and become combative when told she needed to return inside. She would slide further down the scale and retreat to her room and sleep for hours on end. As she started to improve, she would come out of her room and sit in the same room as her foster parents. She would place herself on the edge, not in the center, of the couch. Given more time, she would give feedback about the show to watch on TV and then join them for dinner, eating gradually more. Her interactions, or lack of them, were a clear indication of how she was managing her stress. We may also start the day on the higher rungs and feel socially engaged and proactive with our colleagues. But if an incident such as a medical emergency were to occur, we would find different responses from those people around us. For some, the sympathetic system would kick in, and they respond rapidly and efficiently to the medical needs. Others may become immobilized with anxiety and move toward the bottom of the ladder, withdrawing into the background. The recognition of the defensive strategies in a ladder hierarchy is a visual way of identifying the progress or regression of a child along the regulation continuum. It is not uncommon to demonstrate shifts up and down the ladder but under a higher degree of stress, predominant patterns can become more apparent.

Annie: Dorsal Vagal Response Annie had significant complex trauma exposures. She struggled with attachment due to the mental health challenges of her parents. Their parenting was inconsistent and unpredictable. She was frequently physically and emotionally neglected and

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was demeaned by them when she attempted to share any essence of success in her day. When under stress, whether that be a reminder of a traumatic memory or the novelty of a new challenge, Annie would withdraw to her bedroom for hours. She would ignore any further encouragement to join her adoptive family in activities. She struggled with poor endurance, low motivation, had difficulty with the skills of social engagement, became immobile, and would lie on bed scrolling aimlessly through social media. She did not feel or believe she had any impact on her world. This pattern of behavior continued to reinforce her belief of insignificance. It is, however, this type of withdrawal that can go unnoticed in school. If the child does not exhibit disruptive behaviors, manages to get minimum work done, does not interact with peers, and avoids conflicts, he/she may go quietly about the day, unable to attend to tasks for learning, and become more socially inept and isolated. These are the children where our own alarms need to be going off to ensure their safety. They are the ones that do need social engagement so they feel they exist in the world and that there are possibilities to learn new skills. Otherwise, their view of the world can become so restricted and limited, that they will lack exposure to other alternatives and the possibility for change may feel like it doesn’t exist. In addition, if they don’t orient to other people’s faces and attend to the non-verbal messages effectively, they can further shut down, vigilantly misinterpreting a threat.

David: Sympathetic Response: Fight and Flight David, on the other hand, was highly mobilized and utilized the sympathetic system when he became dysregulated. He had been referred for treatment following significant disruption and conflict at school. He would frequently be in fights with peers, challenges school rules, and become very dysregulated when he perceived staff were angry at him. He would dash through the school halls weaving away from staff attempting to constraint his escape, and then climb with marked agility, to the top of the television monitors high on the wall in the cafeteria. From there he experienced less threat. It always took some time for the staff to be able to get him down!!!

Fawning One has to remember children, in particular, are often in situations where they do not have an option to fight or flee. Another response that is not often drawn to people’s attention is called “fawning” (Walker, 2013). This can be a confusing behavior that an observer may find difficult to understand. The child attempts to appease the perpetrator of the abuse and attempts to win favor. This means that the child may deny allegations of abuse by the perpetrator when it has been drawn to outside attention or report on the behaviors of their mother or siblings to divert attention away from themselves. Brady and Shawn were brothers who commonly used strategy.

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They would “tell tales” on the other sibling and in doing would create a confrontation with the accused or reprimand from the mother. They succeed in diverting the attention away and their own “defiant” behavior would go unnoticed. This would provide at least short-term relief and a perceived sense of control in an often unpredictable or more volatile situation.

Allostatic Load Allostasis is the body’s way of managing stress and trying to find a balance. It is a sign of health and adaptability. When the system is working efficiently, the body can meet the short-term needs and the systems come back into balance. But, in a similar way to when the lid is off the poultry waterer, if there is loading on the system, it may not work as effectively and components can start to break down. This is referred to as the “allostatic load” and if extreme, the “allostatic overload.” Cortisol, on a short-term basis, is very effective in helping the body source the glucose it needs under stress. If the allostatic load is chronic and the body is constantly under stress producing excess cortisol, the body cannot effectively absorb it. The cortisol starts to damage the organs of the body and the systems become overloaded. Lester and Lagresse, 2010, in a review studies on children of addicted mothers, found evidence of the allostatic load leading to “impaired neuronal function in the hippocampus and medial prefrontal cortex regions responsible for executive function and adaption to stress” (p.  270). This overwhelming stress can be reflected physiologically with extreme responses. One allergist, I met, recalled common anaphylactic shock responses he had seen in doctoral defense candidates. The candidates level of stress would be so high their body became overwhelmed, and their stress response resulted in inflammation. This would become so extreme on some occasions that it would cause the airway to swell and start to close off! It needs to be acknowledged, however, that these responses with increased activity, vigilance, mobilization, and impulsiveness are often necessary when the threats of maltreatment are unexpected but frequent. It is important that the child can mobilize and also have an inflammatory response to prepare their body for possible injury. These are necessary adaptions and beneficial in the short term to manage the potential abuse! (Danese & McEwen, 2012).

Stress in Infancy Infants in the intensive care unit are also exposed to significant stressors. Prematurity itself can become a leading cause of death in these infants. The child’s body systems are underdeveloped and functioning at a less-than-optimal level. These infants, in addition to their poor development, have repeated exposure to stressors with numerous painful interventions each day, constant environmental stressors of noise, lights,

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and activity, and frequently low social regulatory possibilities due to the structure of the unit. Weber et  al. (2012) have recommended implementing the principles of Schore’s regulation theory to reduce the allostatic overload on these children who are already battling to find balance. Mothers are being educated on premature infant behaviors and needs, and encouraged to touch, hold, nurture, speak with, and feed their premature infants whenever possible. Neonatal Intensive Care Units (NICUs) are being encouraged to become aware of minimizing the environmental stressors with lowering lights, noise, creating less isolation, and using pain management for the necessary interventions. With this type of intervention, the mother’s stress levels subsequently reduced and their own regulation improved. This enabled them to more effectively co-regulate their infant using their own non-verbal body language.

Use Dependent Shifts Perry (2004) refers to traumatic stress changes as “use-dependent” shifts. With persistent, repeated activation of the stress response, multiple systems, brain areas, and the functions they mediate, are altered. The systems become “sensitized, over-­ reactive and dysfunctional. The developmental threat, then, creates a persisting fear state, “the state then becomes a trait” (p. 10). The response to the original threat thus becomes an ongoing response to experiences that are perceived or are the same, as the original traumatic event (Perry et al., 1995). With chronic activation of the endocrine system and increased allostatic load, there can be a blunting of the HPA axis stress response, as the body tries to downregulate the negative feedback system (Danese & McEwen, 2012). At this point, it is important to recognize that a trigger may not be easily perceived by an observer. Our sense of smell, for example, is primitive. A reminder of a past trauma could be a familiar smell of an abuser’s deodorant, perfume, and even clothing detergent. It can equally be the tone and lack of vocal prosody in a voice. I have had some children react because they have a male teacher, who happens to have a low-frequency, monotone voice. It could also be in response to the directness of your gaze. These triggers are very specific and not a more generalized response similar to those seen in sensory processing disorders. These are perceived as potential threats. The child becomes fearfully vigilant.

 he Adverse Childhood Experience (ACE) Study: T Childhood Matters Between 1995 and 1997, Kaiser Permanente and the Center for Disease Control and Prevention completed a study of approximately 17,000 adult volunteers and noted the presence or absence of Adverse Childhood Experiences (ACEs) within the

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population. Ten adverse childhood experiences were included in the survey questionnaire. These included physical, emotional and sexual abuse, physical and emotional neglect, household dysfunction with mental illness, history of mother being treated violently, divorce, an incarcerated relative, and/or substance abuse. The outcome revealed that ACEs are common and that nearly two-thirds of the adults reported at least one. They found if the participant had one, there was an 87% chance they would have two or more. The more ACEs the individuals had, the greater the risk for chronic disease, mental illness, violence, and being a victim of violence. The repercussions of the allostatic load are profound. Children who have experienced complex childhood trauma and the associated chronic stress are likely to be detrimentally impacted in their developmental, physiological, and behavioral realms, well into their adult lives (Chrousos, 1998; Felitti, et  al., 1998; Kain & Terrell, 2018).

Even Sleep! Once again I can only emphasize how intricately the body is interlinked. An imbalance in one area can have cascading effects on many other areas without the outward appearance being obvious. Studies by Kinlein and Karatsoreos (2020) studied the possible close connection between the HPA and the circadian rhythm. The circadian rhythm “allows organisms to anticipate daily changes in the environment, rather than merely respond to such changes” (p.  14) and concluded the normal rhythm of cortisol elevation and decrease in melatonin in the morning (with increased alertness) and reduction of cortisol and an increase in melatonin in the evening (increased drowsiness) was disrupted in these children. This leads to significant histories of sleep disturbance and a high potential for allostatic overload to future stresses (Gregory & Sadeh, 2016; Kajeepta et  al., 2015; Mohd Azmi et al., 2021). It is helpful at this point to reflect on your own experiences of sleep deprivation and the implications it had on your tolerance and behaviors. Events such as your kids making too much noise, or spilling a drink despite them having a concerted effort to prove their independence, can be your ultimate undoing. On exhausted days, your stress level has a small tolerance for disturbance. Many of our children with complex trauma backgrounds have disturbed sleep. Running on batteries almost empty or even completely depleted will be yet another chronic stressor and create an imbalance in the HPA axis functioning…or is it that the HPA axis functioning upsets the sleep? One needs to be aware of all these interconnections. One cannot simply address the behavior without considering the situation from many perspectives. One needs to dig deep to see these overlaps and tackle them even if it means progress feels too slow. Rushing in with a short-term fix will only be that. For a while, the behavior reward chart will possibly work. But when the child’s system has that additional stress, everything will all come cascading down again.

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The Effects of Stress on Genetics and Priming Resnick et al. (1995) found the women who had sustained sexual abuse as a child and had been raped in adulthood were more likely to develop Post Traumatic Stress Disorder (PTSD). They recorded a lower level of blood cortisol compared to the non-abused group. It was postulated that the low cortisol levels were a legacy of the child abuse and the failure of the body to mobilize effective levels of stress hormones in subsequent times of stress. Cloitre and Rosenbeg (2006) further examined the revictimization of sexual assault prevalence following a history of child sexual abuse. They concluded that dissociation reduced the women’s awareness of their surroundings and often inhibited the appropriate fight/flight response. The women also demonstrated poor risk assessment because their persistent hypervigilance often made the survivor lose trust in the accuracy of her own threat evaluation. Chronic stress related to childhood trauma appears to have an impact on the methylation of the FKBP5 gene in the hippocampus, hypothalamus, and in the blood. These changes have long-lasting effects on glucocorticoid responsivity and have been associated with anxiety behaviors and psychiatric disorders such as depression and PTSD. They are characterized by alterations in the HPA axis (Stephens & Wand, 2012; Weaver, 2009). Studies of holocaust survivors and their offspring have also been linked to changes in the FKBP5 gene (Yehuda & Lehrner, 2018). “Data supports an intergenerational epigenetic priming of the physiological response to stress in offspring of highly traumatized individuals. These changes may contribute to the increased risk for psychopathology in the first generation” (Yehuda et al., 2016, p. 379). A study by Radtke et al. (2011) studied the methylation of the NR3C1 gene in women who had been subjected to domestic violence before pregnancy or during pregnancy, and found changes in this gene in the children. They predicted, “the increased methylation of the NR3C1 gene could increase stress reactivity and could have a long-lasting effect on vulnerability to stress and trauma and chronic disease development” (Youssef et al., 2018). Meaney et al. (2007) concluded in their study on the epigenetic mechanisms of prenatal HPA programing, that the mother’s unique adversities and environmental challenges altered her own physiology and behavior. This in turn, impacted her infant’s HPA activity programing.” These researchers propose this adaption leads to the programing of gene expression in the direction of assisting the individual to adapt to heightened environmental adversity by increasing HPA responsiveness but at the expense of later metabolic and cardiovascular health-related vulnerability. Tarullo and Gunnar (2006) concluded in their research that adaptions in the functioning of the HPA axis by the child may initially be adaptive to a maltreating stress, but may later lead to “more vulnerability to future life stresses, developing a lower threshold of perceiving stress and an exaggerated stress response” (p. 367).

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Endogenous Opiate Response to Stress van der Kolk (1989) has brought to light the body’s endogenous opioid response in the face of trauma and its role in the repetition of trauma. The Brain Opioid Theory of Social Attachment (BOTSA) proposed by Nelson and Panksepp (1998) identified many similarities between intense social attachment and the behavior of individuals addicted to narcotics. When someone becomes socially isolated, there is evidence that their level of endogenous opioids decreases and this motivates the person to seek social interactions. There is a sense of reward and pleasure in creating this. However, if the reward of social contact is withdrawn, there is an element of dependence, which then needs to be remediated. Opioids have an analgesic effect on the perception of pain (Lanius et al., 2020; Nikbakhtzadeh et al., 2020; Valentino & Van Bockstaele, 2015). Self-destructive behaviors such as chronic interpersonal violence, self-harm, food-restricting behaviors, and violence to others may be used as an external stimulation for those who suffered neglect or abuse as children. These children did not have the more easily attained opioid effect from a nurturing relationship. This cycle of abuse or fear-inducing behaviors produces an altered state of self and numbing. It similarly provides relief to the euphoria of addiction. Tolerance habituation then occurs, so when there is withdrawal of the “attachment object,” the need for attachment becomes even more demanding. Thus the cycle of abuse can perpetuate without the strong, adaptive foundation of a secure relationship (Machin & Dunbar, 2011; Nelson & Panksepp, 1998; van der Kolk, 1989, 2000).

Oxytocin Oxytocin plays an important role in mother–infant bonding and is an important regulator of stress. The euphoria of birth, the forgetting of pain, and the intimate experience of bonding are elicited by this hormone (Buckley, 2015). A reduction in the oxytocin has been observed in studies of women and children following child maltreatment (Pollak, 2008).

Being Proactive In times of stress, the body prepares for response. It activates all the essential areas to help ensure its physical safety. When this occurs, the higher cortical areas and the cognitive functions can go offline. No matter how good the coping strategies are, no amount of appeal for reasoning will help if the mobilization system is in full swing. The horse has bolted! It is important to understand the need to be proactive, to be observant, and to realize the complexity of these multilayered, interconnected

References

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systems. So many times I am asked “what should I do when he is angry”….Really at this point….Regulate yourself, co-regulate the child, and keep him and others safe. Again, proactivity is the best. We should call “anger management,” “irritability management.” This would be far more helpful!!!! If you can intervene at the initial stages of dysregulation, cognition can still be on board. This may be difficult to understand but consider a time when you nearly hit a deer on the road.

Avoiding the Deer on the Road Remember, you did not take the opportunity to count to ten and evaluate other alternatives when you saw the deer. Your system kicked into action!!! You may have been in a wonderful conversation, but all becomes forgotten. Time stands still. All you can see is through a very narrow lens. Your awareness of others is a blur. It is not until a significant period of time has passed before your body slowly starts to calm. Your breathing again moves into a more regular rhythm. Your gaze broadens and you become aware of your surroundings. But language and time awareness are often the last items to return. Until that time, you may utter the same phrases over and over. A sequential dialogue is difficult to generate, let alone a return to your previous conversation. The system needs to calm before language and cognition come back online. This response is similar to a child who has been triggered. It may be the next day before you can get any verbal sense of what your child may have experienced. It still may be incomplete. This is a physiological response! Too often I have heard a child being “grilled” for their answers and expected to empathetically account to others for their behaviors. We, as carers, need to be more like a detective and this may be no easy matter. Gaining as much detail about the child’s trauma history as possible may help to elevate potential triggering situations and threats to the child’s perception of safety. With an increase and awareness of a child’s need for safety, new experiences can be facilitated and new pathways can start to be established. Safety brings stability and a growing sense of self. With this, the equator can be found and the ladder can be climbed.

References Alvarez, A. (2016). Impaired interactions triggering defense or exposing deficit: exploring the difference between the withdrawn and the “undrawn” autistic child. Commentary on “An integrative model of autism spectrum disorder: ASD as a neurobiological disorder of experienced environmental deprivation, early life stress, and allostatic overload” by William M. Singletary, M.D. Neuropsychoanalysis, 18(1), 3–7. https://doi.org/10.1080/15294145.2016.1151250 Bergland, C. (2013, January 22). Cortisol: Why “the stress hormone” is public enemy No.1. Psychology Today. https://www.psychologytoday.com/blog/the-­athletes-­way/201301/ cortisol-­why-­the-­stress-­hormone-­is-­public-­enemy-­no-­1

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Bremner, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445–461. Buckley, S. J. (2015). Executive summary of hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. The Journal of Perinatal Education, 24(3), 145–153. Chrousos, G. P. (1998). Stressors, stress, and neuroendocrine integration of the adaptive response: The 1997 Hans Selye Memorial Lecture. Annals New York Academy of Sciences, 851, 311–335. https://d1wqtxts1xzle7.cloudfront.net/42066218/Chrousos_GPStressors_stress_and_ neuroend20160204-23468-smwr1e-libre.pdf?1454610814=&response-contentdisposit ion=inline%3B+filename%3DStressors_Stress_and_Neuroendocrine_Inte.pdf&Expire s=1696393662&Signature=B1CkpXpv4hJacAY8Kz68JkrBLMTetY5Qept~8f0twgPEAsG OJVPnDXxJnDXd4A4GkHn~-J5WUPKoLEpCq3wY2a2LDrhqSslNtogwo19djY9FGDBail3yd5A38RHDUe3KndczncjakHBh-RUb6ntnrPZGTtIoVxB-YKdx~Dcw1yDyn59ziYbTftxypoWvxFBmW4IljLhngMpY7-436jr0BOrrbQJgeMGKFgvxsXu9S6tI3ZoeJ wCTTXXpqLjp~IjbkjOtUmHh-E3PF8hdTvmHrmWiauAISw3qX4VoL4homc9g dzR-DmYrlnjdbjX-XPQjzA4ipgezAGqA__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA Cloitre, M., & Rosenberg, A. (2006). Sexual revictimization: Risk factors and prevention. In V.  C. Follette & J.  I. Ruzek (Eds.), Cognitive-behavioral therapies for trauma (2nd ed., pp. 321–361). The Guilford Press. Dana, D. (2018). The polyvagal theory in therapy: Engaging the rhythm of regulation. W.W. Norton. Danese, A., & McEwen, B. S. (2012). Adverse childhood experiences, allostasis, allostatic load, and age related disease. Physiology and Behavior, 106, 29–39. https://doi.org/10.1016/j. physbeh.2011.08.019 De Bellis, M.  D., & Zisk, A. (2014). The biological effects of childhood trauma. Child and Adolescent Psychiatric Clinics of North America, 23(2), 185–222. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4), 245–258. Gill, L. (2017). Understanding and working with the window of tolerance. https://www. attachment-­a nd-­t rauma-­t reatment-­c entre-­f or-­h ealing.com/blogs/understanding-­a ndworking-­with-­the-­window-­of-­tolerance Grabbe, L., & Miller-Karas. (2017, December). The Trauma Resiliency Model: A “bottomup” intervention for trauma psychotherapy. Journal of the American Psychiatric Nurses ­ Association, 24(1), 1–9. https://doi.org/10.1177/1078390317745133 Gregory, A. M., & Sadeh, A. (2016). Annual research review: Sleep problems in childhood psychiatric disorders- A review of the latest science. Journal of Child Psychology and Psychiatry, 57(3), 296–317. Kajeepta, S., Gelaye, B., Jackson, C. L., & Williams, M. A. (2015). Adverse childhood experiences are associated with adult sleep disorders: a systemic review. Sleep Medicine, 16(3), 320–330. Kain, K. L., & Terrell, S. J. (2018). Nurturing resilience: Helping clients move forward from developmental trauma–An integrative somatic approach. North Atlantic Books. Khan, B., Sharif, A., & Qayyum, Z. (2021). Neuropsychiatric effects of in-utero substance exposure. Psychiatric Annals, 51(7), 331–337. Kinlein, S. A., & Karatsoreos, I. N. (2020). The hypothalamic-pituitary-adrenal axis as a substrate for stress resilience: Interactions with the circadian clock. Frontiers of Neuroendocrinology, 56. https://doi.org/10.1016/j.yfrne.2019.1009819 Lanius, R. A., Boyd, J. E., McKinnon, M. C., Nicolson, A. A., Frewen, P., Vermetten, E., Jetly, R., & Spiegel, D. (2020). A review of the neurobiological basis of trauma-related dissociation and its relation to cannabinoid-and opioid-mediated stress response: A transdiagnostic, translational approach. Current Psychiatry Reports, 201–214. https://doi.org/10.1007/s11920-­018-­0983-­y LeBouef, T., Yaker, Z., & Whited, L. (2020, January). Physiology, autonomic nervous system. [Updated 2020 Jun 1]. In: StatPearls [Internet]. StatPearls Publishing. Available from https:// www.ncbi.nlm.nih.gov/books/NBK538516/

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Resnick, H. S., Yehuda, R., Pitman, R. K., & Foy, D. W. (1995). Effect of previous trauma on acute plasma cortisol level following rape. The American Journal of Psychiatry, 152(11), 1675–1677. https://doi.org/10.1176/ajp.152.11.1675 Shore, A. N. (2017). All our sons: The developmental neurobiology and neuroendocrinology of boys at risk. Infant Mental Health Journal, 38, 15–52. https://doi.org/10.1002/imhj.21616 Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. The Guilford Press. Siegel, D. J. (2001). Towards an interpersonal neurology of the developing mind: Attachment relationships, “mindsight”, and neural integration. Infant Mental Health Journal, 22(1-2), 67–94. Smith, S. M., & Vale, W. W. (2006). The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine responses to stress. Dialogues in Clinical Neuroscience, 8(4), 383–395. Stephens, M. C., & Wand, G. (2012). Stress and the HPA Axis: Role of glucocorticoids in alcohol dependence. Alcohol Research: Current Reviews, 34(4), 468–483. Swales, D. A., Stout-Oswald, S. A., Glynn, L. M., Sandman, C., Wing, D. A., & Poggi Davis, E. (2018). Exposure to traumatic events in childhood predicts cortisol production among high risk pregnant women. Biological Psychology, 139, 186–192. https://doi.org/10.1016/j. biopsycho.2018.10.006 Tarullo, A.  R., & Gunnar, M.  R. (2006). Child maltreatment and the developing HPA axis. Hormones and Behavior, 50, 632–639. https://doi.org/10.1016/j.yhbeh.2006.06.010 Valentino, R. J., & Van Bockstaele, E. (2015). Endogenous opioids: The downside of opposing stress. Neurology of Stress, 1, 23–32. https://doi.org/10.1016/j.ynstr.2014.09.006 van der Kolk, B. A. (1989). The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatric Clinics of North America, 12(2), 389–411. van der Kolk, B. A. (2000). Posttraumatic stress disorder and the nature of trauma. Dialogues in Clinical Neuroscience, 2(1), 7–22. Van der Kolk, B. A., & Fisler, R. E. (1994). Childhood abuse and neglect and loss of self-­regulation. Bulletin of the Menninger Clinic, 58(2), 145–169. Walker, P. (2013). Complex PTSD: From surviving to thriving: A guide and a map for recovering from childhood trauma. An Azure Coyote Book. ISBN 1492871842. Weaver, I.  C. (2009). Epigenetic effects of glucocorticoids. Seminars in Fetal & Neonatal Medicine, 14(3), 143–150. Weber, A. M., Harrison, T. M., & Steward, D. K. (2012). Schore’s Regulation Theory: Maternal-­ infant interaction in the NICU as a mechanism for reducing the effects of allostatic load on neurodevelopment in premature infants. Biological Research for Nursing, 14(4), 375–386. https:// doi.org/10.1177/1099800412453760 Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: Putative role of epigenetic mechanisms. World Psychiatry, 17(3), 243–257. Yehuda, R., Daskalakis, N. P., Bierer, L. M., Bader, H. N., Klengel, T., Holsbooer, F., & Binder, E.  B. (2016). Holocaust exposure induced intergenerational effects on FKBP5 methylation. Biological Psychiatry, 80(5), 372–380. https://doi.org/10.1016/j.biopsch.2015.08.005 Youssef, N. A., Lockwood, L., Su, S., Hao, G., & Rutten, B. P. F. (2018). The effects of trauma, with or without PTSD, on the transgenerational DNA methylation alterations in human offsprings. Brain Sciences, 8(83), 1–7. https://doi.org/10.3390/brainsci805083

Chapter 5

The Child’s Managing Behaviors

Emotion regulation is our ability to respond to the ongoing demands of experiences with the range of emotions. They need to be socially tolerable and sufficiently flexible to permit spontaneous reactions, as well as the ability to delay reactions as needed (Cole et al., 1994). Just as infants respond to their environment, their emotions and behaviors can be powerful but not necessarily socially convenient! The attuned caregiver’s role can be to soothe the infant, and calm their distress or possibly to help the child upregulate and engage in activities such as play. By providing this co-regulation, the child neurosequentially can develop the ability to regulate themselves (Perry, 2004). The co-regulation is a mutual dance and sometimes the shifts between the mother and the infant are subtle and often hard to discern, but regulation gradually starts to become internalized. As we grow we continue to reach out to others to assist with this process (Porges, 2011), especially at times where we feel overwhelmed. Regulation supports the framework for higher cognition and executive functioning expansion. Under times of stress, when the thinking brain biochemically can go offline, the co-regulation facilitated by a safe other can create a secure base or a “bottom-up” approach that can bring arousal down rapidly and efficiently (Kain & Terrell, 2018; Perry, 2004).

Regulation in a Caring Environment Mikulincer et al. (2003) highlight the positive impact of healthy and reliable caregiving on the child’s development of regulation. If the stability is present, the child can consolidate positive regulation experiences and expand their own regulation skills into the realms of understanding other’s distress, and develop their own caregiving qualities. The caregiver’s resources/strategies become incorporated into the child’s own sense of self and this internalization increases their confidence and

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self-efficacy. The child develops a broader repertoire of ways to manage dysregulation and gradually learns to reach out if needing additional external support. Zimmer-Gembeck and Skinner (2011) evaluated 58 regulation studies and noted patterns in the age attainment of these skills. Preschool-aged children in healthy environments tended to utilize social supports from adults around them or exhibited very overt methods to achieve their desired outcome such as “standing their ground,’ or withdrawing physically from the situation. Middle childhood children gradually started to use additional or alternative supports other than their parents, turning to their teachers or peers. They also started to discriminate about who or where they would turn to, with more evaluation. The adolescent has an increase in internal reflection and uses both cognitive and behavioral skills in a more complex manner, matching adaptions on how to attain a particular objective. It is beneficial to have an awareness of this developmental sequence, when teaching new skills because the proposed alternate strategies can be more closely aligned to the child’s individual level of cognition and skill set. This can then provide the base to build a stronger repertoire of coping techniques. The challenge in the change process, however, is the child’s experience priming and their reactive physiology (Sroufe et al., 1999). Remember those pathways more frequently used will become rapidly engaged, particularly at times of stress. Triggers, even outside of the abusive environment, may be easily elicited and the more primitive or earlier strategies can come into play in a completely different setting.

Our View of the Managing Behaviors Matters Using strategies to attempt to create more balance in their own regulation process is important for the child. The child cannot remain in a state of chronic high arousal without the likelihood of detrimental impacts on the body. But what if a child lacks this kind of support to assist with developing flexible regulation? Teicher’s et al. (2016) questioned whether the neurological changes are damage or an adaption to trauma. This needs to be considered when evaluating a child’s behaviors. The child often has no other choice but to try to self-regulate within the repertoire of skills they have experienced. How we view these behaviors can have an impact on how a child may be judged and interacted with, or the type of interventions adopted. If a behavior is considered only as “good” or “bad,” then the options for remediation are limited. If a child’s behavior is seen as an adaptive attempt to achieve stability, then the behavior can possibly be interpreted as “resourceful” and through my eyes, “creative.” The child’s adaption to managing the situation, in the short term, may help the child experience some sense of control in a world where it often feels out of control. I describe here, the child’s behaviors as “managing behaviors” versus “defenses.” Managing a situation is associated with words such as “surviving,” “attaining,” “withstanding,” and “dealing with.” These are more proactive ­descriptions than defense. Defense is defined as “to protect,” ”deny,” or “resist.” This language reflects a reactive response and is less empowering. Yes, it is “only

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language,” but I truly see these children as full of resilience and am constantly amazed at the intricacy and ingenuity of these behaviors! Taking this perspective may mean you have to step back and again try to piece together the child’s possible experiences to gain a better understanding of why they have utilized their strategy. I understand that this may have people up in arms about the possibility of this approach supporting the child’s behaviors. But the reality is the child will likely continue to utilize the behaviors or their modification, in future times of stress, unless we, as carers, have a more proactive understanding of how these behaviors are being utilized by the child, to “help” him/her feel less overwhelmed.

Management and Understanding: Two Important Pillars Blake (personal communication, 2011) considers both the management of behaviors and understanding of their function as two very important pillars to be aware of when working or living with these children. Management without understanding can leave a child feeling misunderstood. Conversely, understanding the individual needs of the child, without management, can leave a child with only a limited repertoire of ways to cope and leave them feeling overwhelmed. It is important to find a balance. A child may learn to avoid interactions, to be inflexible in the ways they take part in an activity, or to focus only on the facts in a conversation versus engaging emotively, when this strategy will keep them safer. Becoming more emotional and assertive may increase the risks of threat for the child. Again, it is important to consider the how, when, where, and why of a behavior. And what function does it serve?

Resetting a Secure Base Redl and Wineman (1951) worked in a residential home for children with extreme conduct disorders. The children’s behaviors, learned from their life experiences, had become constrictive and lacked flexibility. This led to continuous and multiple conflicts. But, despite all their outward aggression, there were moments when these same children would demonstrate surprising compassion and concern for one another. Redl and Wineman described these glimpses as “islands” of ego strength. This can remind us of the vigilant adaptions children try to make when they are confronted with dealing with their experiences of an unsafe world. Based on our knowledge of experience-dependent development and brain plasticity, increasing our provision of more positive attachment experiences and the consistent modeling of alternative choices, it is hopeful that the reestablishing of a more secure base can be provided. This can “reset” the children’s perception of the world and allow these “islands” to expand.

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What Do Animals Do When Under Threat? Cantor (2009) considered the responses of animals in a hierarchy of defense strategies. These strategies include avoidance, attentive immobility, withdrawal, aggressive defense, appeasement, and tonic immobility. Anyone who has had a pet has likely seen this array being utilized when the animal perceives a threat risk or is in an unfamiliar situation. The avoidance strategy creates distance between the alerted animal and the potential threat/predator The threat is given full attention. In this way, the withdrawal or flight action away from the threat can eliminate or reduce the energy expenditure involved in a demanding fight response. It also poses less physical risk. Fighting becomes another option if unable to avoid, but the risks are heightened especially for animals with less physical stature and strength. If the risk is perceived as too high, behaviors that try to pacify, appease or even submit to the aggression, may have to be used. When escape is not possible, then tonic immobility can be utilized by the animal. But awareness is maintained, so escape can continue to be a possible alternative. The terms that have been adopted as trauma responses in people are very similar. They include flight, fight, fawn, and freeze.

The Experiential Canalization Theory Wadsworth (2015) proposed the coping strategies used by the child in a chronic stress situation, actually allow the child to grow and develop within that particular context. She suggests “reframing the maladaptive coping as functional adaption” for this reason (p. 96). I have witnessed this many times. Again, I emphasize questioning the function of a behavior. Too often, we want it to change. But, if it has adapted and is serving as a coping strategy, then taking it away before a safe alternative is created, may put the child at a higher short-term risk (Blair & Raver, 2012; Gottlieb, 1991). Using the canalization perspective of viewing behaviors as adaptions and not as deficits can assist with “understanding behavior within the context and the potential prospects and potential ‘trade-offs’ of large scale systematic efforts to bring about substantial change in individual developmental trajectories” (Blair & Raver, 2012, p. 13 pdf). Safety and survival will trump cognition; neurologically, physiologically, and behaviorally.

Secondary Strategies to Attachment It is necessary to consider the child’s surroundings and support systems. If the attachment figure is not available physically and/or emotionally, such that they are punitive, rejecting, overly anxious, or depressed themselves, the child may develop

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secondary attachment strategies to try to alleviate their attachment distress. The attachment insecurity of rejection, for example, can lead to avoidance behaviors, self-reliance, and deactivation of the “need” for attachment. Related to this is Bick’s idea of a second skin function (Bick, 1968). If the early attachment is not secure, the child may need to become “tough” or “tight.” They become muscular in their body and in their mind. Anxiety can become reinforced with messages and beliefs of helplessness and dependence. These children, in an effort to gain attachment, may attempt to increase their proximity seeking, often without being able to selectively perceive social or timing appropriateness. They will have a hyper-activation of attachment perception and be acutely attuned to any possibilities of attachment withdrawal. This anxious style of attachment is also frequently associated with negative self-esteem and emotions such as blame and guilt (Mikulincer et  al., 2003; Perlman et al., 2016).

Sonny Sonny, a 5-year-old, was raised for 4 years by his biological parents. However, they used substances and had a history of their own childhood trauma and mental health challenges. Their ability to give responsive, consistent caring for their son, was negligible. His older siblings were removed and placed in a different foster home than Sonny. He ultimately ended up being placed with his aunt and her children. Sonny was hyperactive and lacked the ability to sustain attention to any task. He would play briefly with a toy but would then leave it for another, when he had depleted his play options. He did not look at anyone when they spoke, was impulsive, and had marked difficulty understanding other’s needs for quiet time. He so desperately wanted to have physical contact, he would perceive even the most minimal signal of attachment as viable, and he would leap onto people’s laps, disrupt another child’s quiet play, and would move from one side of the room to the other to be with a person. Sonny would consistently bump and interrupt his foster siblings, despite their request to be separate. This would continuously lead to being rejected further, pushed away, or avoided and his needs being further compromised. The only time he was calm was when he was able to attain his aunt’s lap and she would rub his back. This hyperactive, distractible child would melt into her body. His attention would become internally focused and he became still and clearly soothed. He so desperately wanted attention but had difficulty understanding how to effectively attain it. This vicious cycle was repeated over and over with Sonny constantly struggling for attachment stability but unable to break the cycle of distressing cues (Perry, 2004; Van der Kolk, 1989).

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Anticipation of Threat: Sensory Vigilance A child’s chronic maltreatment is frequently associated with multiple forms or subtypes of abuse rather than a single subgroup (Warmingham et al., 2019). He/she has to adapt their ability to anticipate the type of threat and response. They develop vigilance and hyperactivity or if this is ineffective, the managing behaviors can progress into withdrawal and dissociation (Perry, 2006; van der Kolk, 2014; Ogden & Fisher, 2015; Walker, 2013). This swinging uncontrollably between the extreme states of arousal may become the new norm for the child after trauma (Ogden & Minto, 2000; Ogden & Fisher, 2015). The intensity of the trauma response, often disorganizes the child, interfering with the ability for them to cognitively process and utilize top-down regulation (LeDoux, 1996; van der Kolk & Fisler, 1994; Lambert, et al., 2017; Perry, 2004). Because of this difficulty with modulation, the children can become more vulnerable to future stressors and develop aggression (McCrory et al., 2011; Perry, 1997; Schore, 2002; van der Kolk & Fisler, 1994). Neurologically, due to the child’s experiences, the abnormal development of the cortical-limbic connection can interfere with the normal inhibition of rage responses and the child can cycle into this behavior (Solomon & Heide, 2005).

Attention Deficit Disorder Perry (1997) also aptly draws attention to the common diagnosis of Attention Deficit Disorder in these children. He highlights that the child who has experienced trauma does “not have a core abnormality of their capacity to attend to a given task, it is that they are hypervigilant” (p. 8). The child is constantly scanning their environment for signs of threat. Again, creating safety by attending to this perceived or real threat, considering the vigilance of the child and their individual life experiences, regulating yourself, and perhaps modifying the environment or demands can shift this inattention and increase their positive social engagement possibilities. This can then result in a rise in their internal calmness and experiences of alternate managing behaviors.

Visual Bias McLaughlin et al. (2015) illustrated the hypervigilance of chronic trauma in their study of adolescents aged 13–19 who had been physically and/or sexually abused. Using MRI, the researchers tracked the brain activity in response to viewing positive and negative facial expressions. The maltreated teens had a heightened response as compared to the non-maltreated group, in the regions of the amygdala, putamen,

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and anterior insula to the negative stimuli. In a similar study by Pollak et al. (2009), the researchers also found a close correlation between a child’s experience of parental anger and aggression and the speed and accuracy with which the children were able to recognize anger early in the formation of a facial expression. Multiple studies have correlated the rapid response of abused children to perceptions of threat. They found support that neglected children had more difficulty discriminating emotional expressions overall, but biased their responses to selecting sad faces. Whereas physically abused children were more likely to identify and react to negative emotions and affect (Hart & Rubia, 2012; Pollak & Sinha, 2002; Pollak & Tolley-Schell, 2003; Pears & Fisher, 2005; Pine et al., 2005; Wismer-Fries & Pollak, 2004; Vorria et al., 2006). There is evidence in studies that aggressive children can have marked bias to infer the hostile intent of another and over identify with this threat. The children feel more justified displaying a resolution using aggression, perceiving the insult to be intentional versus accidental (Weiner, 1993; Shackman et al., 2007; Shackman & Pollak 2014). Studies of older children have not shown these same impairments in the ability to discriminate between emotional expressions (Pine et al., 2005; Maheu et al., 2010). This suggests that emotional discrimination difficulties in maltreated children may normalize with age (Ochsner & Gross, 2005). It is also likely that the type of maltreatment a child has experienced may have a differing effect on a child’s emotional discrimination ability. Neglected and post-­ institutionalized children may be more likely to have difficulty discriminating emotions (Pollak et  al., 2000; Wismer-Fries & Pollak, 2004; Vorria et  al., 2006). Physically abused children, however, may be more likely to identify, rapidly orient to, and react to particular negative emotions, such as anger, fear, and pain. They are more likely to have witnessed anger and subsequent adversity (Pollak & Sinha, 2002; Pollak & Tolley-Schell, 2003; Pine et  al., 2005). Because of these experiences, there appears to be a close correlation with their delayed ability to disengage from the anger cues and their tendency to maintain vigilance to their surroundings (Pollak, 2008). Children exposed to severe early life stress and have experienced emotion regulation difficulties are thought to confer higher risks for later psychopathology (Lyons-Ruth, 2008; Tottenham et al., 2010).

Auditory Bias and Stress The human ear has evolved to be able to perceive both high and low-frequency sounds. The low-frequency sounds are frequent in predator alert and high-frequency sounds are similar to the melodic voice heard in lullabies, associated with calmness and rest (Porges, 2011). Exposure to chronic childhood stress appears to reduce a child’s ability to effectively attune to high-frequency sounds usually present in the human voice. When the sympathetic system activates, it has an effect on the blood flow to the cochlea and this appears to have the potential to reduce the ability to hear higher-frequency sounds (Tian & Zha, 2021). Porges (2011) has noted that the

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facial nerve that innervates the facial muscles used in social engagement and calming also innervates the stapedius muscle. This muscle impacts the ossicular chain and tightening of the ear drum. With a tight eardrum, the low frequency sounds become more dampened and high-frequency sounds rebound off the eardrum are transmitted for auditory processing. The hypervigilant child, with an activated sympathetic response, becomes instead attentive to detecting signs of threat and responds to low-frequency sounds with vigilance. This challenge with difficulty with high-­ frequency perception can then lead to complications for the child in perceiving the prosody in speech, particularly in a noisy background. The child can miss the nuances present in social conversations, leading to possible misinterpretations (Schore, 1994; Porges, 2021). I have observed this low-frequency reactivity in my clinic. The low-frequency sounds of the copy machine, footsteps, the furnace clicking on, or creaking floorboards can have some of the children I work with, completely disengage from the current conversation or activity. They narrow their focus and all their attention in the direction to the noise. They become very still, hold their breath, and appear to anticipate threats. It is not until I physically show and then explain to them the origin of the sound, they relax and again can attune to interactive conversation. This response obviously will have a significant impact on a child’s ability to engage cognitively in environments where there is a great deal of background noise, such as required in school and with academic learning. It also needs to be considered when a child has been triggered and people try to engage their attention using only verbal dialogue and reason. The focus would be more effective if they became more conscious of their non-verbal communication and focused instead on regulating themselves, so this would have a subliminal positive effect on the child.

Language Changes The brain hemispheres under healthy circumstances work together to provide coordinated integration of sensory and motor information. Under stress, however, van der Kolk (2014) describes “deactivation of the left hemisphere” and the ability to logically sequence experiences, and to translate these experiences into words becomes challenged. The Broca’s area, necessary for the verbalization goes offline. Without this ability to sequence and order experiences or language, “we can’t identify cause and effect, grasp the long-term effects of our actions, or create coherent plans for our future “(van der Kolk, 2014, p. 45). When I witness the “grilling” some parents or professionals give to children after they have “lost control” I am often dumbstruck myself. The questions go on and on. The lecture about empathy, sharing, and turn-taking comes barreling down at the child. The child is then demanded to explain their misconduct and when the answers are “not enough,” the barrage continues. No wonder some of these children “lie”! Knowing what we now know about neurology, physiology, and managing behaviors, it is no wonder they fill the verbal “void” with something. They have difficulty

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with sequencing, recall, finding words, and expressive language. What better way to have some reprieve than to say what they anticipate the questioner wants to hear. Of course, they pay the price later, but at least for a while there is some relief! Maybe later they will be able to recall more. Often these children’s experience of language has been directive versus descriptive, matter of fact versus expressive. Language has been used to control situations and to keep people at a distance. Again, the profound impact of physiological stress responses of the body can impact many systems and have ramifications across a child’s inner and outer world. Creating a sense of safety, (created by the child or an external co-regulator), can allow the child’s body to calm down and has the potential for the existing systems to come back online, broadening the options for future growth and development.

Managing the Stress Through Behaviors Avoiding, minimizing, and converting emotions can also be used to shift the internal conflict externally (Cole et al., 1994). Some children may laugh or act silly in stressful situations or swing to become disorderly and distractive. Both extremes allow the child to avoid the difficult problem but demonstrate the challenges of the dysregulation matching the appropriate emotion and the child being able to modulate it appropriately in context. Foley (2015) describes dysregulation as a “state of disequilibrium in arousal, reactivity, attention, action, affect which leads to a change toward a restoration of equilibrium …since all organisms tend to maintain the constancy of the internal conditions essential to their well-being” (p.  1). This is an important thought to consider when a child’s response appears confusing or “out of place” in relation to the context. Does hyperactivity, for example, lend itself to distraction from the conflict or threat? Does it allow a child to become so exhausted their body shuts down? Or does it help to maintain vigilance and hence perceived safety assisting in regulation? All or none are possibilities. Keep asking yourself why?

Aggression: Fight Hoffman (2015) suggests externalizing disruptive behaviors can be a way for the child to avoid painful emotions. Aggressive actions can serve to protect the child from feeling overwhelmed with shame, hurt, worry, or guilt. Aggression or controlling behaviors can also be a way of coping with inner turmoil and a sense of powerlessness and vulnerability. The aggression may be against one’s own self in self-harm behaviors or outwardly to others. A study examining aggression by Lahav et  al. (2022) profiled childhood abuse survivors and found that those that appeared to identify with the aggressor were more likely to use aggression against others. Through modeling and experience, the child may learn to control situations with

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violence and adopt a similar relationship to the one they had themselves experienced. A second perspective by Yates et al. (2008) considers self-harm may be used by the child to try to maintain a positive view of the abuser and he/she turns the abuse on to their own body, internalizing the negative beliefs about themselves (van der Kolk et al., 1991).

Dissociation: Freezing Dissociation appears to be activated following a history of childhood abuse and neglect. In this state, a child tends to experience numbing of their body and feelings/ emotions. They lose track of time and place with thoughts fogging and an altered perception of their surroundings. A child, when feeling totally overwhelmed, can use this managing behavior of dissociation to disengage from the stress they are experiencing externally and/or internally. This responsive pattern, however, can also have a blunting effect on the child’s other emotions and their memory recall may be narrow and limited because of this frequent state (Cole et  al., 1994). With the chronic nature of maltreatment, this mechanism can become less intentional and automatically triggered by stress. The child has difficulty being in the present moment and subsequently loses a track of time, continuity and will be inhibited with learning and attending to new tasks because she/he appears to be “spacing out.” The additional challenge of this dissociative response is the child may then become numb to real threats in their environment and become subjected to revictimization (Dawson et al., 2003; The National Child Traumatic Stress Network, 2020; van der Kolk et al., 2005).

Sandra Sandra is a 14-year-old who experienced severe neglect, physical abuse, and was witness to domestic violence. She was removed from her biological home as a 6-year-old, but until that time, learned to retreat from her experiences by withdrawing into the cupboard in her room. She would remain in this space until she fell asleep or perceived it was safe to come out. Her body would shift into a dissociative state as a way to manage her terror. As she entered into adolescence, despite being in a caring foster home, she would unconsciously use this dissociative “retreat” whenever she had communication with her birth parents and was again witness to their ongoing conflicts and reminders of her past. The spiral of triggers and dissociation and sense of “not belonging in this world” ultimately led to multiple suicide attempts. As Sandra became more aware of this pattern, she could sense the slide to dissociation and would self-harm with cutting or burning “to remember she was still

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alive” and to stop “the slide.” Gradually safe, socially engaging strategies were adopted earlier on in the separating process. Her foster parents would go to her room to speak with her after a certain period of time or a quiet evening activity together would be organized. Sandra became more aware of times when she was commonly triggered. She began to more effectively manage her dissociation with far lower incidences of self-harm, and an increasing receptiveness to reaching out to others.

Domestic Violence The impact of the chronic stress and the subsequent insecure safe place for the child has internalizing and externalizing impact on the child’s development. Zeitlin et al. (1999), in an article, examined the impact of maternal–child bonding following a history of prenatal domestic violence. They noted that mothers who had been abused during pregnancy, compared to non-abused mothers, had difficulty bonding with their infants. When the abuse was severe, the lack of bonding was more significant. Toddlers exposed to domestic violence can have difficulty expressing themselves and thus develop a range of behaviors such as depression, despondency, aggression, withdrawal, difficulty with attachment, and somatic issues such as headaches, stomach aches, enuresis, and sleeplessness (Lundy & Grossman, 2005; Martin, 2002). It appears that the children also become at risk for developing aggressive behaviors, have difficulty with developing trusting relationships, and may become bullies or be at risk for bullying. Aggressive behaviors may be a result of a child adapting to the exposure to emotionally high stress situations, where they have been subjected to abuse. Their need to respond and quickly evaluate situations means they may mistake gestures or comments as negative and respond with increased physical aggression toward others, transferring their aggression from their abuser into other settings (VanMeter et al., 2020).

Sexual Abuse In situations of sexual abuse, a child can turn the cards on themselves emotionally by using blame for their own part in the “abandonment,” shame, low self-esteem, fear, guilt, and somatic complaints. They may also become impulsive, aggressive, hyperactive, or have sexualized behaviors in an effort to have some control to their intolerable situation (Castro et al., 2019; Dawson et al. 2003; Noll, 2008; Nurcombe, 2000; van der Kolk, 1989).

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Neglect Children who have experienced neglect are likely to have an anxious attachment. The children are caught in an “irresolvable paradox” when the parent is meant to be a source of safety and protection but is unavailable to provide comfort and assist with modulating the negative experiences (Hess & Main, 2000). Research by Crittenden and Di Lalla (1988) found that preschoolers in the neglect group had difficulty with compliance in activities and being able to internalize their feelings. They tended to act out in anger while the physically abused children would be compliant frequently out of fear, suppressing their negative behavior. Children who are neglected also appear to have fewer opportunities for positive situations in their environment. This becomes reflected in their negative self-representation and low expectations of others, as rejecting or unavailable. They also demonstrated delays in their physical, cognitive, and language skills (Hildyard & Wolfe, 2002). Physically abused children, however, had the possibility of periods of being responded to ­positively, even rarely, and hence had the chance of some positive sense of self (Toth et al., 1997). The chronic lack of support modeling of effective modulation strategies can lead to a poor sense of predictability and personal control, and difficulty managing and adapting to any form of additional stress. Scott (2014) found children who had experienced neglect, particularly in their first 2 years of life, were likely to demonstrate aggression, show delays in social, cognitive, and emotional functioning, have low ego resiliency, poor self-esteem, low impulse control, and a more negative self-affect. Older children and adolescents were found to be more likely to engage in substance abuse, have violent or aggressive behaviors, and take part in more risky sexual activities.

 edical Procedures and the Neonatal Intensive Care M Unit (NICU) Perry (2007), a leading child trauma researcher, also includes a child experiences of many painful medical procedures and life-threatening medical procedures as medical trauma. In the neonatal intensive care units, Barker and Rutter (1995) reported that premature neonates undergo an average of 60 procedures every day, and although not all premature infants experience life threat, many have to endure painful medical procedures. Work by Whitfield et  al. (1997) examined the long-term follow-up on toddlers, post-NICU, and showed abnormal responses by these children to bumps and bruises. Maroney (2003) theorizes that the NICU infant may not be able, in later development, to distinguish between the here and now of a stressful event and the subconscious memory of the constant stress of NICU experiences.

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Dysregulated or Unregulated? Cole et al. (1994) argue the child’s emotions become dysregulated versus unregulated. The child is using responses to attempt to regulate but the process is occurring in a more dysfunctional way with over or under responses and poor modulation. They emphasize the behaviors and associated emotions, and serve to protect and communicate, even when they are interfering with the child’s ability to relate to others and to seek resolution. “… even the most dysregulated emotion serves some adaptive purpose” (p. 81). This communication needs to be recognized in a non-­ judgmental manner. If the foundations for managing stressors have not been experienced in a consistent manner, efficient strategies cannot be internalized and the child will choose from their limited repertoire which has, at least in the short term, helped them to survive. The child needs understanding and support to create a sense of safety, predictability, and attachment security, to be able to expand their secure base.

 Traumatized Child’s Managing Behaviors A in the School Setting Disruptive behaviors can also be a way of drawing attention away from frustrations experienced in the traditional school environment. In an extensive study by the Massachusetts Advocates for Children, 2005, the researchers found several noteworthy characteristics among the children who had experienced trauma. These significantly affected the children’s ability to learn and to conform to the social expectations in schools. As Katz (1997) so eloquently wrote, “Not realizing that children exposed to inescapable, overwhelming stress may act out their pain, that they may misbehave, not listen to us, or seek our attention in all the wrong way, can lead us to punish these children for their misbehavior. The behavior is so willful, so intentional. She controlled herself yesterday, so she can control herself today. If we only knew what happened last night, or this morning before she got to school, we would be shielding the same child we’re now reprimanding” (p. 7). The impact of chronic trauma on time sequencing, understanding cause and effect, the ability to communicate clearly, to problem solve, pay attention, take perspective, to learn and retrieve new information can be significant. The body highjacks the executive functions (Cole et al., 1994; LeDoux, 1996, Ogden & Fisher, 2015; Center on the Developing Child, 2021). When a child lives in environments where communication is directive, consequences are given inconsistently, time is perceived as unreliable and safety is constantly in question. These higher-level skills so essential to the learning process can be absent or compromised because the child’s focus and attention are on survival. With chaos in the home, the child’s

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organization skills are often lacking and “if the development of sequential memory is delayed and the ability to learn new information sequentially is impaired, traumatized children will have difficulty organizing and processing the content of academic lessons for later retrieval and application” (Massachusetts Advocates for Children, 2005, p. 26).

In the Classroom It can be no surprise, given this small sample of managing behaviors these children have learned to use, that school can be often very difficult. The child is expected to sit among a group of children, who they do not know well or who also have their own behavior challenges. They are then required to attend and focus on the learning process and to remain in place. If the foundation of safety is not firm, this in and of itself sets the stage for learning difficulties (Webster et al., 2009). Creedon (2004) reflects on the trauma “kindling” effect impacting the child’s memory, auditory processing, accurate interpretation of social and environmental cues, and the ability to manage impulsivity and follow directions. This primes the child for challenges in attainment of academic and IQ performance, and subsequent poor self-esteem, especially in a system that has low trauma-informed knowledge and implementation (Campbell et al., 2016; Tsavoussis et al., 2014). If the adults in the child’s life have modeled poor support and provision of safety and security, the child will have to anticipate and use managing behaviors to ensure this occurs. Better to be proactive, than to be “caught unaware!”, perceived or real (Christakou et  al., 2009; DePrince et al., 2009; Geier & Luna, 2009; Hart & Rubis, 2012; McGaugh, 2000; Rubia et al., 2006, 2007). To avoid the reminder of the trauma or emotions associated with their experiences, the child can use behaviors and strategies to consciously or unconsciously manage their feelings. Some children will sit quietly in class and become one of the few “unnoticed children.” These children can dissociate in response to the pressures of social interactions and academic expectations, and become vulnerable to bullying, missing large chucks of academic information, and fall further and further behind in their learning because they have no attention-seeking or disruptive behaviors (Chemtob & Carlson, 2004). Other children may dominate the room with their “out of control behavior.” In light of their experiences, however, they may be triggered by their vigilant view and interactions in the school environment. A comment or a remark made by a teacher, even to another child, reminds them of a threat or anger. This can be enough to elicit a response out of proportion to the situation and appear to “come out of nowhere!.” Given that many of the children have difficulty with social context and misinterpretation of the tone of voice and gesture, they can become aggressive with misinterpreting others’ cues. They may respond in “strike first” reactivity and misinterpret comments or actions responding with fear-based negativity. This leads to an increase

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in peer rejection and produces a subsequent rise again in the externalizing behaviors (Kim & Cicchetti, 2010). Some students “take control” of the classroom (Chanmugam & Teasley, 2014; David et al., 2015). The teacher then tries to regain control with giving directives, but this can further escalate the situation because of the similarities of the same style of communication in the child’s traumatic experience memory (Coster & Cicchetti, 1993). The child responds to the tone and facial expressions with adversity and increased anxiety. This can rapidly lead to feeling threatened and then terrified. Strategies such as perfectionism, however, can be a way of a child to attempt to placate an abuser. These children frequently internalize this need for perfection and when they have difficulty with schoolwork and attaining it. The child may engage in distractive behaviors in an attempt to avoid self-blame such as leaving the room or facilitating an argument with a peer.

Rewards and Consequences Charts, reward systems, and consequences are common behavioral management systems used in a classroom. They have the best of intent to create conformity and the motivation to improve behavior and academic performance. However, these systems are based on a child having experiences in their life that have been positively reinforcing when they have improved or achieved a goal. These systems work well for foundationally secure children. But for children who have difficulty with regulation, internalizing a positive sense of self-esteem, and self-worth, are hypervigilant, and have difficulties with memory retention and attention, I believe they do not need to have their “failings” pointed out by a chart posted in the class for all to see. What they need is a caring, attuned person, who can expand on their strengths and be proactive with providing security and the “just right challenge” for them as an individual. Desautels (2019) clearly summarizes these management systems. “Traditional discipline works best with children who need it the least, and works least with the children who need it the most” (p. 1). Children, for example, with poor impulse control are frequently experiencing redirection and consequently have a lower self-esteem. This can then cycle into an increase in the disruptive behaviors because they are constantly being redirected or reminded of their failing not only by the teacher but often in front of the class on “the chart.” The implication is that they should be in better control of themselves with sheer willpower (Sixrud & Johnson, 2019). The brain regions, however, which are connected for cognitive control and reward prediction, when already in a depleted state, have a decreased ability to be recruited. The child’s ability to resist temptation or to act on their desires is hindered (Danese & Baldwin, 2017; Marusak et al., 2015; Wagner et al., 2013; Wagner & Heatherton, 2013).

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Resilience When a child comes from an environment where things are unpredictable and their sensorimotor and caregiver modeling experiences are limited their understanding of cause and effect, which is necessary in the development of social interaction and empathy, can be compromised. Without consistency and predictability, it is difficult for these children to internalize having any sense of their own impact on the world. When their own feelings have been negated, or their own boundaries violated, it is difficult for them to understand taking another person’s perspective (Massachusetts Advocates for Children, 2005). Resilience and adaptability can come in many forms. Children who appear to over-control a situation, have rational, less emotive style of interaction may have developed such an approach to adapt to a stress-filled environment (Cicchetti & Rogosch, 2009).With this perspective, one can also view the bully who has ­frequently become the aggressor after experiencing his/her own bullying. Using an adaptive lens, the child has turned the table, creating a more predictable outcome by controlling peers in verbal and/or physical aggression (Ma, 2001; Perry et al., 1988).

Trying to Feel Safe All these children have incredible resilience. Their behaviors have a purpose. The behaviors are not elicited from an executive functioning place, but instead from a need for perceived survival. They are attempts to make themselves feel safe. Too often I hear that the “child is just trying to get attention” and rewards and consequences are put into place to mold the child in a more socially appropriate direction. However, if the foundations of trust and safety are not in place, the perceived need for survival and safety will trump social reasoning and appropriateness. We need to view them from an attachment perspective to meet the primary needs of safety, trust, and social connectedness. This can increase the possibility of new positive experiences being integrated. Incorporating more body-based, non-verbal interventions, accessing the body’s “felt “sense, versus using only cognition, is developmentally congruent. These children have had early attachment disruptions often before language has come on board. Bowlby (1973) perceptively concluded that …“children inevitably extract from their experiences expectations regarding likely behavior of others and themselves in relationships” (p.  202). Thankfully, with attuned and developmentally appropriate interactions and therapy, these early expectations are able to be modified or changed.

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Chapter 6

How Does the Modulating Caregiver Impact a Child’s Regulation?

In this chapter, I would like to highlight the common modulating characteristics of an attuned caregiver. The term, “caregiver” is a general term I will use to cover all who interact in a close relationship with the child. It can be, for example, the biological, adoptive, or foster parent, the child protection worker, the teacher, or the therapist. In the attuned relationship, these nonverbal modulating qualities are frequently present, but often not acknowledged. If we are to improve the child’s sense of security, these qualities are definitely worthy of note. In this chapter, I will identify these qualities in a general way and in the proceeding chapter, discuss them in more detail on ways they can be incorporated into interventions.

Attunement? Attuned caregiving provides the child a felt sense of safety and a secure base. The growth and development of a child’s regulation skills, and the flexibility and adaptiveness of a child’s responses are markedly impacted by this relationship. How does this attunement occur? What are the characteristics the caregiver ­provides that create this essence of “attunement”? How is it then conveyed to the child? To further investigate this, it is important to recognize the significant work that has been completed on mirror neurons and the synchronicity of nonverbal messages between individuals. An understanding of these modulating qualities can significantly impact a caregiver’s ability to assist and facilitate a child’s regulation development.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_6

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Mirror Neurons Mirror neurons are neurons that become activated in the brain of the person observing or hearing the actions or sounds of another person. This research was originally observed with macaque monkeys (Rizzolatti et al., 1988). It was noted that when the monkey watched an experimenter reach an object and then use it, similar areas in the monkey’s brain became activated. Areas of the brain previously thought to only be involved in recognizing an action were found to also be involved in the understanding of another’s intent. This is an experience we have all likely had. It can be witnessed when a mother is teaching her child to eat. She often will open her mouth as she moves the spoon toward the child and the child mirrors her action and opens theirs (Gallese et al., 2007; Iacoboni et al., 2020; Rajmohan & Mohandas, 2007). A strong association has also been found between hearing sounds and the person’s ability to understand the actions associated with them. This is indicative of the body’s ability to associate and connect sensory input from multiple sources and match the experience to an action, drawing from one’s reservoir of memories. During play, this association is commonly seen in play interactions. If the mother repeats a sound in play and has linked it in the past to an action, the child turns toward her and there is a clear buildup of tension in the child’s body. The child anticipates the tickle about to come (Kohler et al., 2002; Keysers & Gazzola, 2014). There are even implications beyond the repetition and mirroring of a movement. Witnessing the actions, feelings, and sensations of the primary caregiver activates the limbic centers in the child’s brain. These repeated experiences then have the potential to elicit empathy and associated feelings in the infant, similar to the emotions of the primary caregiver (Keysers & Gazzola, 2006, 2014; Carrillo et  al., 2019). When a mother introduces a friend, although a stranger to the child, her body language will be relaxed. She will clearly reflect comfort and happiness with their presence. Attuning to this, the child is more likely to also accept this new person (Feiring et  al., 1984). It appears … “this (neuron encoding) generates tension between bodies, and through this intentional attunement, it is possible to set the stage for regulating the inner subjective exchange of experience between two individuals” (Keysers & Gazzola, 2006, p. 375).

Feelings in the Body This information supports the experience-dependent learning processes of the child. If these experiences are repeated and are occurring at the time the brain and body’s physiology are also growing, the dynamics will be integrated into the child’s later regulation strategies. Positive attachment experiences will be internalized and “felt” in the body. They can become a resource to the child when his/her system is stressed. In contrast, if the interactions have become associated with inconsistencies in attunement, the child’s repertoire will likely reflect this in actions, sensations, and emotions.

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The Impact of How We Move and Respond: Kestenberg At this point, I would like to shift the focus slightly and highlight the work of Kestenberg. Kestenberg, a psychiatrist and psychoanalyst, examined this process of attunement and discord between the mother and child, from a detailed, observational perspective. She focused on identifying the micromovements of the mother and the child, during separation from one another and during interactions. She was well versed in movement notation methods associated with dance and performance, but she began to notice there were more subtle occurrences between a mother–child relationship than the actual action. She observed variations in the way the mother and child used their bodies to mold, “shape” around each other (shape flow), and how freely or tensely they moved (tension flow). She attributed the child’s sense of feeling understood and empathized with the caregiver’s ability to adjust her flow, facilitating a similar change in the child. A crying infant, for example, will be calmed more quickly if the intensity is initially matched by the mother and reflected back to the child (being understood). The tension is then gradually modified to become less intense and facilitates a state of calm. During this interactive exchange, there is a succession of changes in the body’s shapes. It may rhythmically “grow” (with expansion of the body), e.g., taking a deep breath in and “shrink” (narrow), e.g., exhaling. This regular predictable rhythm can create a sense of trust and safety, a promise of continuity. This is one of the reasons the process of breathing can be so important as an intervention when a person is dysregulated.

William: Regulating with a Sigh I was lucky to have trained with Kestenberg and often find myself using this information to help calm an angry, potentially aggressive child. William quickly comes to mind. Despite being a small child, he was in the throes of anger and lashing out at his mother on arrival at the clinic. He was beside himself. His mother was desperately trying to have him calm down by reasoning and appealing for order. It was clearly not working. To change the scenario dynamics, after signaling to the mother my intent, I quickly moved from the room with him. I replicated the strength and directness of his movements by moving briskly. William followed, stating emphatically how angry he was. His speech was rapid and in brief, staccato-like phrases. I matched his irritation by briefly using the same vocal intensity, affirming his comments about feeling mad. However, I shifted my focus away from the ongoing verbal content and started to pause after each exclamation. Then I would sigh. He did not become angrier. Instead, he lifted his head and looked at me. He also paused. There was a unity and attunement. I did not try to deny or oppose his sensations but clearly wanted to help him calm. I gradually slowed my walking pace. This I did slightly at first and then progressively more as we neared our destination. I stopped and paused at the bottom of the stairs and gave another big sigh. Then I rested

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momentarily. He mirrored this. He also stopped and again turned to look at me. By orienting to my face, he was able to see that I understood how he was feeling. We made our way into the room with the intensity of the situation markedly reduced. Later on, he was able to find the words to explain what had been going on.

The Elements of a Movement Kestenberg (Loman, 1998; Lewis & Loman, 1990) identified four essential elements in movement. A movement has an element of direction and space use, of weight, of time, and how it flows. Within each of these, she then notated a continuum of the intensity. 1. Space. When looking at the quality of space, this element looks at the direction of the movement. The direction of the movement is on the continuum of being very direct, such as moving from point A to point B in a straight line or perhaps on the other extreme, meandering all about the room, shifting its direction with an indirect quality. If, for example, a laser light was attached to the child’s body and you could turn the lights out, you could observe the laser moving perhaps directly to an object or creating many interconnecting pathways as the child changes his attention and moves to another activity. What you would be noticing is the pathway the child takes. For further clarification of this element and to remember fluctuations that naturally exist in a movement, one can describe an overall movement as: Direct – The child’s movement is from point A to point B, without deviating. Indirect – Their movement pathway meanders around the room without any clear direction. A child with a diagnosis of Attention Deficit Hyperactivity Disorder will enter a space and be like a whirlwind, darting from one activity or task to another, where everything needs to be experienced. This is a classic indirect use of space. The child’s path is constantly shifting. On the other hand, the child who has had enough of a session can surprisingly find the door without any hesitation. This is a very direct use of space! 2. Weight. This element focuses on the sense of weight in a person’s movements. The weight element spans from a heavy, weighted quality to a light one. Lightness – I have one client who has a history of Failure to Thrive. When she enters the clinic, she seemingly floats through the door making as little impact on anything, including the air surrounding her. She describes not feeling very significant and does not feel as though she has any impact on the world. This type of child drifts and seems almost weightless. Heavy  – Now consider the child diagnosed with Oppositional Defiance Disorder who wants to command the situation and is definitely not pleased “at having to come to therapy.” He/she makes their annoyance known by stomp-

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ing their way in and flopping down on a chair. This child’s movements have a sense of heaviness and a strong pull of gravity surrounding it. Their presence is definitely noticed. 3. Time. The variations in this element involve the polarities of a sustained/suspended movement or a quick movement. Sustained – This can be witnessed when a child says “I just want one more turn” and the child is “dragging their feet.” Everything takes a long time. Delays are predominant. It can also be noticed in the child who is detached and not socially engaged. There is a quality of timelessness in their presence and their actual movements. Quick – This is a child who is suddenly triggered in session and shifts rapidly “out of harm’s way” or becomes angry, maybe throws something or knocks over a chair. The movements are rapid and cut through the air. 4. Flow. This element is about the overall quality of the movement. Is the movement seamlessly changing or does it have a quality of tightness or control to it? The flow element visually appears to incorporate all the other above elements, but one in noticing how the movements link closely together in a seamless continuous movement or as controlled and held tightly in the “musculature” of the person’s body. Free – Classically this is the hyperactive child who moves with great flexibility without any sense of containment. Their movements are fluid, continuous, and appear to have an origin in the body core and to flow out to the ends of the extremities. Bound – When a child enters the room and is determined not to take part, you will notice they are holding their movement tightly and are demonstrating resistance or you may feel as if they have “the weight of the world is on their shoulders.” Detailed attention can be paid to these subtle shifts but it is important to note that these qualities rarely exist in isolation from each other. They tend to cluster in similar groups. An aggressive person, for example, when throwing a punch would use clustering of the more powerful elements. The punch would be sudden, heavy in weight, direct in action, and very controlled and bound. Conversely, a child with anxiety may demonstrate a likely cluster of gentler elements such as slowness, lightness, indecisiveness and endlessly moving and changing from one activity to another. The overall impact of these movement qualities elicits visceral responses in the observer, and the emotion can be more easily understood. When attuned, the caregiver, often on an unconscious level, modifies or shifts her responses and interactions with the child. This occurs by changing some of these elements in herself or the child. In addition, there can also be subtle changes in the shape our bodies make in the space around us or when interacting with another person. Wrapping our arms around a distressed friend and pulling them in close is an example of this space shift variation.

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We also use different movement planes such as horizontal, when we reach out; vertical, when we stand up, or sagittal, as we walk forward or back up. This has an impact on how a movement and its communication are interpreted. The same movement but with different elements can mean different things. Horizontally extending your arms forward can be used to reach out to another person in connection, for example, or can be done to keep someone away. The first has elements of sustainment and lightness; the second is quick and heavy. When a caregiver is attuned to the child, these elements are intuitively perceived and acted upon. We may not have had the language to describe them but they are present in all we do. Observing these qualities takes practice and training. I do not expect you to adopt these in detail. But by being more aware of their existence, you may be able to recall attuned or clashing experiences through a different lens and adjust your body and communication accordingly.

Pre-efforts There are times when we “just know something is about to happen.” Kestenberg identified these movements as pre-efforts. They are present when the body starts to engage with intent or in preparation to do a movement. For example, when a child is about to reach for something, there are subtle shifts in their body when they start to channel their attention to a focal point, and one can anticipate something is about to happen. This is a pre-effort. It can be seen in interactions between an attuned caregiver and their child. The carer suddenly “knows” her child is about to fall and reaches out as he/she starts to stumble and catches him/her before anyone else has even started to notice. Pre-efforts are precursors to movements. Some people are able to attune to these more rapidly than others. Perhaps this is intuition or an example of right-brain-to-­ right-brain communication (Schore, 2022). Maybe some people perceive changes in tension and shape, consciously or subconsciously more readily! Remaining aware, however, of these subtle shifts, the therapist and the carer have the potential to guide the child into feeling safer and feeling understood. You can be more proactive (Dell, 1970; Kestenberg & Sossin, 1979; Kestenberg Amighi et  al., 1999; Lewis & Loman, 1990). These subtle qualities can define the difference between an attuned interaction and a relationship/interaction that is simply being performed, mirrored, or copied. I have witnessed parents/therapists/teachers cognitively trying to incorporate different interaction suggestions with a child. Those without attunement, move through the steps like robots. Their actions occur purposely but the aliveness is absent. In these cases, the suggestions fall short of being “successful.”

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Genuine Attunement When a child snuggles into a carer’s shoulder after a distressing mishap, the way the mother’s arms wrap around the child, each inhalation and exhalation of her breath, the swaying of her body and being close enough to feel the sensation and beating of her heart, all subtly establish predictable rhythms and connectedness. The child becomes attuned and adopts the same states and calms. A sense of safety prevails. It is these subtle shifts that enable us to discern the difference between genuineness and falsehood. Clashes between these element qualities can alert us to the incongruences. Some people are more left-brain focused and have difficulty attuning to their own sensations. They may know the steps that need to be taken to establish safety, but they do not embody the qualities. Their efforts have minimal impact of a child who is starting to dysregulate. However, if the person with the more intuitive approach misreads the child, they are likely to be forgiven, because the genuineness is reflected in their body and is often unconsciously perceived. The body has its own discrete language.

Intersubjective Experiences Trevarthen (1993) a researcher of mother–infant interactions has identified the intersubjective nature of caregiver attunement. There is a sense of “self” and the “other.” The interactive communications between the caregiver and the infant includes exchanges of gaze, vocalizations, playful touch, and affectionate, emotional communication. This interaction is a two-way, synchronized interaction that facilitates resonance between the two. During this attunement between a mother and her infant, one cannot necessarily designate the initiator of an action, feeling, or thought. The leader and follower roles start to become blended in a dance together (Ammanti & Ferrari, 2013; Dumas, 2011; Ferrari & Gallese, 2006; Tortora, 2013). Conversations we have with close friends are similar. One topic or a particular feeling is expressed and leads to an adjustment. Another exchange, but something slightly different occurs. On and on, the conversation flows effortlessly. This interactive, dynamic, and spontaneous dance occurs in our bodies when we are in attunement with another person. All of us can recall the ease of being in this type of situation. The shifts happen without consciousness, or with only minimal effort. They flow naturally. Watching a mother and her new infant is like watching only one being. They are so in tune, where one starts and the other ends. It is a constant shifting, smooth, modulated flow. Their presence is a blend of each other (Winnicott, 1975).

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Right Brain to Right Brain This dyadic connection is described by Schore (1994, 2000, 2003a, b, 2009, 2011, 2017, 2022) as right-brain to-right-brain communication. The right brain is recognized as the nonverbal, emotive, and intuitive hemisphere. When the mother and child look at each other, their right brain processing attunes and synchronizes in a shared communication (Dumas et al., 2010). Recent studies by Hartikainen (2021) support this concept. She has identified the right temporoparietal junction and the right orbitofrontal regions are significantly involved in interpersonal, and nonverbal communication. Coordination between the two brains is a two-way path, adjusting and adapting to the other, so both feel “felt.” Misattunement and clashes can occur when the child is passionately expressing him/herself with right brain gestures and postures and the caregiver is trying to use left brain strategies with reasoning and a linear, logical language approach. No wonder they don’t connect. From right brain to right brain, the caregiver and child speak the same language. In this manner, the caregiver can assist with modulating her own body, and the child will likely be attuned. This attunement is, however, not always in the direction of calming. Play can be an up-regulator. Engagement from the caregiver may elicit excitement with an increase in movement intensity, heart rate, and vocalizations. If the play becomes too exciting, the child or the mother can then drop eye contact, pause and the partner notices the shift and allows the play to calm. This is attunement. A healthy attachment involves the ability to modulate and adjust to the other.

Neural Connections This inter-brain neural synchronization between mother and child has been witnessed in EEG studies (Dumas, 2011; Dumas et  al., 2010; Hasson et  al., 2012; Santamaria et  al., 2020). It was evident that the behavior of one influenced the behavior of the other and it was bidirectional. Positive emotions between the parent and the child revealed stronger neural connectivity than the negative emotions. This supports the process of regulation growth in healthy, positive modeled relationships. One that exists with a majority of negative affect will disengage the child’s attunement process, and the internalizing of modulation will become more difficult to attain. It is not uncommon for a traumatized child’s biological parent to have also experienced their own child trauma experiences and this can impact their perception and sensitivity to their child (Butti et  al., 2018; Montirosso & McGlone, 2020). When the parent becomes dysregulated, the child becomes dysregulated. On the moments of attunement, there is a degree of serenity in both.

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Interactive Slow Frame Movement Observations Beebe and Lachmann (1988) have played a significant part in the understanding of this interactive dance between a caregiver and their child. Using film and slowing or stopping the frame sequence of an interactive session between a mother and her baby, fleeting and subtle interactions were captured and analyzed. This revealed interactive movements between the two, which might have been missed with the naked eye. The movements were often so rapid it was likely they were partially or possibly completely out of conscious control. The films were observed on a split screen that enabled the viewers to observe both the mother and the child at the same time. Both the mother and the child were responsive to each other. One would adjust their head position, or open their mouth and the other would mirror the motion or effect. One would raise a hand, the other would raise a foot split seconds or just seconds later. This engagement was a moment-to-moment and a bidirectional, interactive exchange. There was also a rhythmic coordination between their vocalizations and movements. The mothers and infants would match each other in their pauses with similar durations and there was inverse matching with movement and holds (no movement). As one moved, the other paused and there was a dyadic interplay in their activity level. Each was participating with sensitivity to the timing of the other. This type of nonverbal interchange is demonstrative of the potential richness of the learning experiences that can be facilitated between a modulating caregiver and their child.

Social Engagement: Polyvagal Theory Porges (2011) emphasizes the importance of these social engagement skills with assisting a child’s regulation growth. Due to this intersubjective relationship, the caregiver can have a significant modulating impact on the child through their own regulation management (co-regulation). Because there is naturally a close relationship between a person’s heart and breathing rate, when a mother is feeling exasperated her increase in her heart rate will be reflected in her infant. The infant has less developed regulation adaptability and relies on the mother for the co-regulation. When the mother calms, her body will reflect the same and the child will regulate again. This frantic exchange can be observed in the sleep-deprived mother. “Nothing seems to calm the child!” When both the mother and the child are misattuned, they can fall into a rapid, negative spiral of clashing until another person steps in and the mother can rest and replenish herself. Social engagement allows the child to modify their regulation when their own strategies are challenged. Seeking or being in the presence of other people who are safe can assist with this regulation. The other person’s own facial expressions, eye gaze, voice prosody, touch, and attuned gestures can be shared through this synchronicity and be incorporated by the child as needed.

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On the Inpatient Unit When I was working as an inpatient therapist on an adult psychiatric unit, I was witness to this profound influence. I had been quietly writing up group notes when I heard yelling and angry shouting between a young woman and the nurse. The woman had walked out of the group and wanted to return to her room. The nurse demanded she should return to the group and reminded her this was the expectation on the unit. The scene rapidly became escalated. Neither were able to regulate. Their distress increased. On these occasions, where further escalation and safety were in question, staff were encouraged to step in and give the elevated staff member the option to leave the scene. Feigning her need to answer a telephone call, she left. The patient high-tailed into the far side of her room. Rather than pursuing her into the space, I stood at the door quietly. Regulating myself and watching the woman’s breathing start to slow. As this occurred, she slumped to the floor and held her arms around her legs, and rocked back and forward. I reflected on this change and emphasized her safety and her ability to know how to calm herself. Again I focused on quietness and slow regulated breathing and movements. After a significant pause, I asked if I could move closer. I designated the end of the bed in the middle of her room to provide clarity. She nodded and calmed further as I maintained the agreed-­ upon position and stopped. Again I confirmed her safety. It was amazing to watch her gradually regulate, to slow her breathing, to relax the grasp on her legs, to start to give eye contact and acknowledge my presence. It was powerful. Barely any words were used.

Synchronicity of Heart Rhythms Research by Feldman and colleagues (2011) has clearly demonstrated the interactive synchronicity between the bodies of attuned mother–infant dyads. In face-toface playful interactions that included eye gaze and vocalizations, the mother’s and the child’s heart rates raised and lowered within 1 second of each other. These positive, high-arousal social episodes are usually brief and happen throughout the day between a mother and child. It is proposed that this sets the landscape for this concordance. In situations where the mother was depressed, however, the face-to-face exchange was not matched with positive affect and the heart rhythms had less coordination (Trevarthen & Aitken, 2001). The tight relationship between heart rate and breath is worthy of note when trying to co-regulate a child. When the sympathetic nervous system is activated, the heart rate and breathing rate increase. When the parasympathetic system comes into play, the person’s heart rate and breathing rate corresponding become slower (Porges, 2003, 2004, 2011, 2015).

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Take a Breath Many of the children who come through my clinic have been taught breathing exercises. They usually compliantly complete a rapid series of deep breaths to demonstrate their skill and don’t calm! I have found if I approach the breathing rate from the breath aspect, the child becomes exasperated and cannot tolerate the focus required to slow their breathing further. Instead, if I introduce the experience with feeling their own heart, the focus shifts. Their heart is more tangible to feel and notice. There is also no associated anxiety experienced when focusing on breathing. This anxiety in and of itself can create further difficulty with their breathing. Instead, the process of locating their heart and quietening to feel its beat usually takes a few minutes I unhurriedly guide and assist as needed. During this lapse of time, I have been taking slow deep breaths and the child’s own breathing has become slower, without drawing specific attention to it. Porges (2011) has closely linked respiratory rate and heart rate to one another. We reflect on this change. The experience becomes more internally incorporated and understood.

Eye Gaze Eye gaze plays an important role in attunement. The face-to-face mirroring interaction between the mother and child creates a merger and can enhance their attachment bond because each feels understood. Ammaniti and Trentini (2009) describe eye gaze as….“the most intense form of interpersonal communication and the perception of facial expressions as one of the most salient channels of nonverbal communication” (p. 546). Schore (1994) proposes the gleam in the mother’s eyes as she engages with her infant, synchronizes the child to the mother’s internal affective state, and triggers the infant’s arousal. Socially engaged they share their internal states.

Pupil Dilation As a mother gazes at her infant, the hormone oxytocin is released, increasing pupil dilation. This dilation enhances and reflects the mother’s attention and interest in the child. And the child is attuned more (Leknes et al., 2013). Individuals in a study, with larger pupils, were found to elicit more smiles from infants, than those with smaller pupils. Larger pupils are also consistently strongly associated with positive affect interpretation. The converse is true for smaller pupils. Negative associations such as being “evasive,” “cold,” or “sneaky” are more frequent (Hess, 1975;

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Cheng et al., 2021). An attuned mother cradling her infant has direct and sustained eye contact. Both intently watch the other’s face and again, the facial gestures are replicated one to the other. Their gaze acts as a signal linking the two brains together.

Gaze Patterns and Dynamics As conversation shifts, gaze patterns also adjust. This dynamic shifting can elicit a sense of interest in the other person as direct eye-to-eye contact is made. Blake, reflected, “the issue of being interested is important in relation to attachment and regulation. A caregiver needs to show interest in a child’s mind or thinking. To be fascinated by how the child’s mind works -it is not just a dysregulated mess” (P. Blake, personal communication, June 6, 2023). As Alvarez suggests, saying things like “that’s really interesting you said that or noticed that” (Alvarez, 2012). This is especially helpful for an insecurely attached child who may feel they have had very little thinking about them and their mind (as opposed to their behaviour). In conversations where the content or vocalizations are of particular interest, the gaze can shift to the speaker’s mouth. When averted, the gaze can indicate disengagement or hesitance in continuing the interaction. Social signals create constant change (Canigueral & Hamilton, 2019; Grossman & Johnson, 2007). Gaze has also been observed when a mother cradles her child. There appears to be a left-side hold bias of cradling. This places the infant’s gaze to the left side of the mother’s face and the mother to the child’s left side. Neural activity increases in their right hemispheres, enhancing the right-brain-to-right-brain connection (Hasson et al., 2012; Malatesta et al., 2020; Schore, 2022).

Increasing Self Control Gaze interaction, with the moments of synchronicity and those of missed coordination, is also considered important components in the development of self-control. In an attuned relationship, an infant learns that he/she can drop their eye gaze to facilitate calming. He/she can raise or sustain their eye gaze to maintain or continue an interaction. Because these gaze fluctuations are part of healthy attuned interactions, when there is a disproportionate use of one strategy over another, it can be an important indicator of possible at-risk relationships (Feldman et  al., 1999; Levy et  al., 2017, Gianino & Tronick, 1988). It is also helpful for the caregiver to be aware of this shifting of eye gaze. It could be an indicator that the child is experiencing a change in feeling safe. The present interaction the two are engaged in may have become overwhelming in intensity and the dynamics may need to be modified to restore the dance balance between the two.

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Motherese Prosody of the human voice can calm or alert a child. This is the natural fluctuation heard in rhythm, tone, and stress in a person’s voice. Motherese is a speech register used by adults with infants and younger children. It can be used to personify an object and to also increase alertness and engagement with the infant. It is simple in structure and higher pitch with exaggerated intonation than adult conversation. The pitch ranges in variability and is often repeated. It has a singing quality. This speech pattern allows the child to engage in social turn-taking, provides varied auditory stimulation, and is more easily processed and remembered by the infant (Fernald, 1985; Fernald & Kuhl, 1987; Fancourt & Perkins, 2018). As the child listens to the vocalizations of the mother’s voice, her state of calm elicits signals of safety. This has a calming effect on the vagal input to the heart, the facial muscles, and breathing, enabling social engagement to occur between the mother and her child. Similar prosody elements of pitch and rhythm can be found in lullabies and melodies of songs resulting in their calming effect on listeners (Cirelli et al., 2019; Porges, 2015, 2022). Motherese is more commonly used early in an infant’s life when vision has not yet developed to the same extent as the auditory processing. When combined with facial expressions, eye gaze, and the gestures of the caregiver, emotional content can be conveyed to each other. “This is the crucial language of infancy. While infancy means literally ‘without words’, this does not mean there is not a forceful communication occurring between the caregiver and the child during this period. From the perspective of future emotional development and regulation, this is perhaps the most important language a person can learn” (P. Blake, personal communication, June 6, 2023). As the infant’s ability to convey more positive emotional signals increases, he/ she also can impact the caregiver and have an influence on their speech patterns, facial and postural shifts. Prosody is a key component utilized in the modulation of the social interactions (Kolacz, et  al., 2022). A play session may, for example, become arousing with the higher pitch, faster speech rate, and a wide-eyed gaze exchanges. And the play is continued. Equally, with a different allocation of pitch and rate and associated eye gaze and postural shifts can have the ability to convey caution or elicit relaxation and the interactive dance will adjust correspondingly between the caregiver and child (Cooper et al., 1997; Trainor et al., 2000).

Womb Security and Rhythm Mothers instinctually replicate the qualities found in the security of the womb to help calm and regulate their infants (Morris, 1971). The mother cradles her child in her arms with all-surround physical containment and usually pulls the child’s ear close to her left breast where the child can hear the rhythmical beat of her heart,

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whether she is left or right handed (Bourne & Todd, 2004). She rocks the child in rhythm that is similar to the rate of her heartbeat at 60–70 beats per minute. Mothers across cultures rock their children with the same frequency (Hatfield & Rapson, 1993). When the child is distressed and holding is not enough to calm the child, she will get up and walk but at a slower rate than a casual walk. To enhance the rhythm, she will coo and vocalize with rhythmic breaths close to the child’s ears and face. Positional changes similar to those seen of fetuses in utero by ultrasounds can also calm a distressed baby. By crossing the baby’s arms across its chest, holding it at a 45-degree angle and rhythmically rocking, you can recreate a similar position the infant has experienced in utero and rapidly calm the child (Hamilton & Collings, 2018). Swaddling has also been used for decades to increase a child’s sense of security. It replicates the contained space of the womb. The snug wrapping increases the child’s sense of security and decreases the disturbing startle reflex. This has a calming effect. Feldman (2007) noted the mother’s arms are a place of touch and contact. It is the place where the infant experiences rhythmic patterns, such as cooing, sucking, rocking, and experiences the “burst-pause” pattern of typical face-to-face play. Reite and Capitano (1985) surmise from their studies on attachment that this development of rhythmicity between mother and infant is a major feature in the development of attachment bonding. As we grow older we incorporate and utilize swings, rocking chairs, porch rockers, and hammocks to elicit our own regulation. When under stress, we can also observe people chewing gum, clicking a pen off and on, rocking their legs or stroking their hair in these rhythmic attempts to assist with self-regulation. They are repeating these familiar internalized, early movement patterns. “Rhythm is a promise of continuity. It is a promise that what is happening now will happen again and that nothing will shatter the chain” (Shevrin & Toussieng, 1962, p. 570).

Biochemistry Welch and Ludwig (2017) highlight in the Calming Cycle Theory, the close connection between the mother and infant autonomic systems and their emotional relationship with each other. Biochemical changes occur in the attuned relationship between the mother and the infant. In the mother–infant dyad, emotional behavior is modulated through an open feedback loop system between the two autonomic nervous systems. When there is an emotional connection, there is an increase in oxytocin levels in both the mother and the infant. The oxytocin increase triggers positive behaviors such as increased eye contact and positive facial and vocal communication, in the mother and in the child. The sensory contact signals the vagal system. There is a lowering in heart rate, an increase in the vagal tone, and a corresponding increase in the dyad’s social connectedness (Porges, 2011).

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Oxytocin is also attributed to increases in the use of tactile contact between mother and child, the increase in nurturing behaviors, and the promotion of love and attachment experiences (Abraham et al., 2019; Hatfield & Rapson, 1993).

Touch Communicates Support and Protection The early studies on touch and its impact on the infant were explored by Harlow and Zimmermann (1959) with monkeys. Infant monkeys were removed from their mothers and paired with inanimate wire surrogates. One surrogate was simply wire but provided a food source. The other surrogate was covered in cloth and provided no food. It became apparent that the monkeys preferred the cloth surrogate. They would briefly interact with the wire monkey for food, but return to the cloth surrogate for comfort, especially at times when there was a perceived threat. It appeared that without this touch contact, the monkeys had a weak attachment formation and heightened stress levels. Touch, by the infant’s primary caregiver, is instrumental in multiple domains (Barnett, 2005; Blackwell, 2000; Prescott, 1975). It provides sensory stimulation to enhance neural connectivity. It has an effect on a child’s autonomic regulation, assists with lowering stress reactivity (Aguirre et  al. 2019; Nguyen et  al., 2021; Porges, 2011, 2015; Schore, 2000, 2003b, 2017) and it can provide warmth and comfort, especially in infancy when the young child has difficulty with maintaining their own body temperature (Hofer, 2006; Fotopoulou et  al., 2022). Touch also enhances oxytocin release which strengthens social behavior and bonding. Affectionate touch increases dopamine and opioid release and further reinforces the positive elements of the interaction. This in turn influences the motivation and the reward-based learning regions of the brain (Carozza & Leong, 2021; Duhn, 2010; Fotopoulou et al., 2022). This positive, affectionate touch has a marked impact on the child’s ability to regulate and to engage in social behaviors. The engagement cycle between the mother and the child becomes reinforced with positive eye gaze, facial expressions, and vocalization with each other. The child couples these nurturing and positive effects with the experience of being touched. These experiences become integrated and provide the child with the comfort and motivation to reach out to others and to engage further in their world (Browne, 2000; Della Longa et al., 2019; Montirosso & McGlone, 2020; Morrison et al., 2010).

Aliveness All of these modulating characteristics, however, do not occur in isolation from each other. They are dynamically interlinked. There is an element of “aliveness” (Fogel & Garvey, 2007) and almost a continuous flow of movement and intent. The

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mother–infant interactions are not static. During the enjoyment of the interaction, there are postural shifts, changes in eye contact, facial expressions, vocal prosody, and gestures. “The very core of aliveness is something that is never completely at rest, never fully defined, never satisfactorily contained within categories….we need this concept, if only as a guiding metaphor, to frame the deeper human meaning of the infinite possibilities hidden within our everyday communicative encounters” (p. 256). This aliveness is essential for the child’s ongoing development (Alvarez, 1992). The moments of attunement, the ebb and flow of the interactions, model and help to integrate the elements essential for regulation modulation. It is clear that “felt” understanding and attunement are communicated through our, often unconscious, body language. Even when there are times of misattunement, if they are incorporated with honesty and respect, the clashes can also become an opportunity for growth, for both the child and the caregiver.

Putting These Elements Together Charlene: I Don’t Want to Be Here. I Was Forced to Come! Charlene did not want to be here with mother. Sudden, direct strong toss of her chin, chest caved, punchy voice, very low eye contact…but followed her mother’s quiet suggestion to wait upstairs. I walk in and give direct eye contact. I sincerely apologize for keeping her waiting. She pauses. I casually compliment on her pink fleece pants and ask if they are nice and warm. Again she appeared knocked off balance and surprised. I am not engaging with her irritation. She checks me out. She slows her movements, pauses, and takes a breath. It is apparent, with her stillness, she is listening to my interchange with her mother about the different intake forms. She keeps her eye contact low to reduce the likelihood I will notice. She disengages and looks at her phone, stumping in her posture. Have I forgotten her? She re-engages me with an announcement she will be bringing her soda with her to the clinic space. I agreed but designated she could drink in on breaks and she could not use it on the equipment due to soiling the material if it spilled. She was ready for a fight for bringing the soda but was now caught off guard because I moved quickly with little head turn indicating I had a full expectation she would accept those conditions. She was Surprised, paused again and followed. I walked ahead of her instead of matching her delay tactic of slowness. If I matched her pace she would likely slow further and link the slowness with an increase in her resistance again. Instead, she tried to draw my attention to her resistance by complaining about the stairs and the distance to the clinic room. “I hate stairs!” Then she questioned why I had pictures of children from different countries on the corridor walls. Why are they there and implied it was a ridiculous choice! I

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smiled to myself and instead of battling and justifying, I introduced her to my two large goldfish. They floated effortlessly in the water, Calm and regulated. I shared my amazement and relayed a story to her of the color change I had witnessed with my fish. This caught her attention and she shared her knowledge about fish. Her confidence increased and her body began to relax. Almost aware she had dropped her guard, she again began questioning why she had to complete some tabletop tests and how long it would take. I calmly agreed it would be nice to get up and move about. She begrudgingly commented that the place looked like it had stuff in it that could be fun and smiled. Again she when asked if she wore glasses, she snapped a response and stated she didn’t want to wear her glasses and didn’t care about them. Grumpiness reappeared. It was a familiar state. It gave her a sense of control and a brief burst of energy. It could easily be interpreted as resistance and taken negatively because her tone and overall effect were minimal. When not “resisting,” she lacked “aliveness.” She held her head down and had a collapsed, exhausted posture. She appeared burdened and stated in various forms how it “doesn’t matter” and that she had no control over her future. “I hate school.” “I am not good at anything.” She continues her monologue about her “failures” and poor health. She has extremely poor vision but has adapted well with using foot taps on the stairs to perceive their depth, refuses to jump because she can’t judge the height and prepare for the descent with safety. I focus on her skill at understanding how to keep herself safe and her attuned adaptions. She announced she hated gym but did enjoy wrestling. Again, she had chosen a sport which was low to the ground and was highly reliant on touch, a strength she did have, versus the speed and agility associated with many other sports. I agreed wrestling was a good choice because it was close to floor, did not require the eye precision she found challenging and she was strong. She had announced she liked to fight. “I am always angry!” At this point, I reflected on a similar adrenaline surge associated with fear. She had raised many concerns for her safety. Her body then significantly relaxed. Her breathing became easier, her eye contact softened, she watched me in surprise and tilted her head. I was not countering her experiences, but agreed her own knowledge of herself was sound and she was justified in feeling angry given her life experiences and the expectations that were constantly placed on her. We sat quietly. Her resistance was gone for the moment. She calmly walked back upstairs and her mother’s jaw dropped open because the resistance had “dissolved.”

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Kestenberg Amighi, J., Loman, S., & Lewis, P. (1999). The meaning of movement: Developmental and clinical perspectives of the Kestenberg Movement Profile. Taylor and Francis. Kestenberg, J., & Sossin, M. (1979). The role of movement patterns in development 2. Dance Notation Bureau Press. Keysers, C., & Gazzola, V. (2006). Towards a unifying neural theory of social cognition. In Anders, Ende, Junghofer, Kissler, & Wildgruber (Eds.), Progress in brain research (Vol. 156, pp. 383–406). Elsevier B. V. ISSN 0079-6123. Keysers, C., & Gazzola, V. (2014). Hebbian learning and predictive mirror neurons for actions, sensations and emotions. Philosophical Transactions of the Royal Society, B: Biological Sciences, 369(1644), 20130175. Kohler, E., Keyers, C., Umilta, M. A., Fogassi, L., Gallese, V., & Rizzolatti, G. (2002). Hearing sounds, understanding actions: Action representations in mirror neurons. Science, 297, 846–848. Kolacz, J., daSilva, E. B., Lewis, G. F., Bertenthal, B. I., & Porges, S. W. (2022). Associations between acoustic features of maternal speech and infants’ emotion regulation following a social stressor. Infancy, 27(1), 135–158. Leknes, S., Wessberg, J., Ellingsen, D. M., Chelnokova, O., Olausson, H., & Laeng, B. (2013). Oxytocin enhances pupil dilation and sensitivity to ‘hidden’ emotional expressions. Social Cognitive and Affective Neuroscience, 8(7), 741–749. https://doi.org/10.1093/scan/nss062 Levy, J., Goldstein, A., & Feldman, R. (2017). Perception of social synchrony induces mother-­ child gamma coupling in the social brain. Social Cognitive and Affective Neuroscience, 12(7), 1036–1046. Lewis, P. W., & Loman, S. E., (Eds.). (1990). The Kestenberg Movement profile: Its past, present applications and future directions. Antioch New England Graduate School. Loman, S. (1998). Employing a developmental model of movement patterns in dance/movement therapy with young children and their families. American Journal of Dance Therapy, 20(2), 101–115. Malatesta, G., Marzoli, D., Apicella, F., Abiuso, C., Muratori, F., Forrester, G. S., Vallortigara, G., Scattoni, M. L., & Tommasi, L. (2020). Received cradling bias during the first year of life: A retrospective study on children with typical and atypical development. Frontiers in Psychiatry, 11, Article 91. https://doi.org/10.3389/fpsyt.2020.00091 Montirosso, R., & McGlone, F. (2020). The body comes first. Embodied reparation and the co-­ creation of infant bodily-self. Neuroscience & Biobehavioral Reviews, 113, 77–87. Morris, D. (1971). Intimate behavior: A zoologist’s classic study of human intimacy. Kodansha International. Morrison, I., Loken, L. S., & Olausson, H. (2010). The skin as a social organ. Experimental Brain Research, 204, 305–314. Nguyen, T., Abney, D. H., Salamander, D., Bertenthal, B. I., & Hoehl, S. (2021). Proximity and touch are associated with neural but not physiological synchrony in naturalistic mother-infant interactions. NeuroImage, 244. https://doi.org/10.1016/j.neuroimage.2021.118599 Porges, S. W. (2003). “Social engagement and attachment” A phylogeneticperspective: Roots of mental illness in children. Annals of the New York Academy of Sciences, 1008, 31–47. Porges, S. W. (2004). Neuroception: A subconscious system for detecting threat and safety. Zero to Three: Bulletin of the National Center for Clinical Infant Programs, 24(5), 19–24. Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological foundations of emotions, attachment, communication, self-regulation. W.W. Norton & Company, Inc. Porges, S. W. (2015). Making the world safe for our children: Down-regulating defence and up-­ regulating social engagement to “optimize” the human experience. Children Australia, 40(2), 114–123. https://doi.org/10.1017/cha.2015.12 Porges, S. W. (2022). Polyvagal Theory: A science of safety. Frontiers in Integrative Neuroscience, 16, 871227. https://doi.org/10.3389/fnint.2022.871227 Prescott, J. (1975). Body pleasure and the origins of violence. Bulletin of the Atomic Scientists, 31(9), 10–20. https://doi.org/10.1080/00963402.1975.11458292

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Rajmohan, V., & Mohandas, E. (2007). Mirror neuron system. Indian Journal of Psychiatry, 49(1), 66–69. Reite, M., & Capitanio, J. P. (1985). On the nature of social separation and attachment. In M. Reite & T. Field (Eds.), The psychobiology of attachment and separation. Academic. Rizzolatti, G., Camarda, R., Fogassi, L., Gentilucci, M., Luppino, G., & Matelli, M. (1988). Functional organization of inferior area 6 in the macaque monkey: II. Area F5 and the control of distal movements. Experimental Brain Research, 71, 491–507. Santamaria, L., Noreika, V., Georgieva, S., Clackson, K., Wass, S., & Leong, V. (2020, February) Emotional Valence modulates the topology of the parent-infant interbrain network. NeuroImage, 207(15). https://doi.org/10.1016/j.neuroimage.2019.116341 Schore, A.  N. (1994). Affect regulation and the origins of self: The neurobiology of emotional development. Lawrence Erlbaum Associates. Schore, A.  N. (2000). Attachment and the regulation of the right brain. Attachment & Human Development, 2(1), 23–47. Schore, A. N. (2003a). The human unconscious: The development of the right brain and its role in early emotional life. In V. Green (Ed.), Emotional development in psychoanalysis, attachment theory and neuroscience: Making connections. Brunner-Routledge. Schore, A. N. (2003b). Affect dysregulation and disorders of the self. W.W. Norton & Company, Inc. Schore, A. N. (2009). Relational trauma and the developing right brain: An interface of psychoanalytic self psychology and neuroscience. Self and Systems: Annals of New York Academy of Sciences, xxxx, 1–15. https://doi.org/10.1111/j.1749-­6632.2009.04474.x Schore, A. N. (2011). The right brain implicit self lies at the core of psychoanalysis. Psychoanalytic Dialogues, 21(1), 75–100. Schore, A.  N. (2017). Early right brain regulation and the relational origins of emotional wellbeing. Plenary address, Australian Childhood Foundation Conference Childhood Trauma. Children Australia, 40(2), 104–113. Schore, A. (2022). Right brain-to-right-brain psychotherapy: Recent scientific and clinical advances. Annals of General Psychiatry, 21(46), 1–12. https://doi.org/10.1186/s12991-­022-­00420-­3 Shevrin, H., & Toussieng, p. w. (1962). Conflict over tactile experiences in emotionally disturbed children. Journal of the American Academy of Child Psychiatry, 1(4), 564–590. Tortora, S. (2013). The essential role of the body in the parent-infant relationship: Nonverbal analysis of attachment. In J. E. Bettmann & D. D. Friedman (Eds.), Attachment-based clinical work with children and adolescents (Essential Clinical Social Work Series). https://doi. org/10.1007/978-­1-­4614-­4848-­8_7 Trainor, L. J., Austin, C. M., & Desjardins, R. N. (2000). Is infant-directed speech prosody a result of the vocal expression of emotion. Psychological Science, 11(3), 188–195. Trevarthen, C. (1993). The self born in intersubjectivity: The psychology of an infant communicating. In U. Neisser (Ed.), The perceived self: Ecological and interpersonal sources of self-­ knowledge (pp. 121–173). Cambridge University Press. Trevarthen, C., & Aitken, K. (2001). Infant intersubjectivity: Research, theory, and clinical applications. Journal of Child Psychology and Psychiatry, 42(1), 3–48. Welch, M.  G., & Ludwig, R.  J. (2017). Calming Cycle Theory and co-regulation of oxytocin. Psychodynamic Psychiatry, 45(4), 519–541. Winnicott, D. W. (1975). Lecture delivered at the Royal Children’s Hospital, Sydney, Australia.

Part II

Intervention: The Body-Based and Attachment Approach to Complex Trauma Regulation in Children

Love was a flower of slow nurture, justice was a fruit of vigilant cultivation. The flower would wither and the fruit would drop under the hands of a shiftless gardener. (Morris West)

Chapter 7

Safety and Attunement

Throughout the preceding chapters, the use of the terms safety and attunement have been referenced multiple times and have been implicated as essential elements in the development of regulation. They are also frequently identified as basic components in interventions, and necessary in the process of establishing a therapeutic relationship. These terms are recognized and acknowledged as important, but their interpretation or implementation appears to be variable and often vague. How does one create a sense of safety? How does one use oneself to facilitate the secure base in the therapeutic relationship? I propose, if regulation and growth are naturally facilitated in the frame of a healthy relationship, then using the modulating caregiver qualities as a framework can give us a firmer working foundation. Given that the vast majority of these children have had their attachment relationships challenged, providing these essential elements can re-establish the foundation of felt safety and provide the secure base from which the child can move forward along the regulation, attachment continuum. To do this, I will shift the cognitive use of the word “safety” and move it into the realm of the being “felt” and internalized. I suggest doing this by “recreating” the qualities and experiences of a healthy modulated relationship for the dysregulated child. The impact of these qualities on a child’s regulation development has been well established and supported, through multiple experiential and research domains. We don’t need to reinvent the wheel. The pathway to improving regulation is right in front of us.

Secure Base Bowlby’s concept of the secure base is established within the relationship between the primary caregiver and the child. From a secure base (the attachment figure), the child can explore out into the world, knowing for sure that they will be comforted © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_7

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and “nourished physically and emotionally.” If stressed, the caregiver will be there to respond and comfort or help them, “only actively intervening if clearly necessary” (Bowlby, 1988, p. 11). Woodhouse et al. (2019) examined this secure base concept and questioned its importance in the attachment of the child in comparison to the importance of a caregiver’s degree of sensitivity. They concluded the infant’s attachment in a secure base construct was eight times larger in effect than maternal sensitivity. The parents responded to providing comfort by holding the infant in a chest-to-chest soothing position to regulate crying, but there was less focus on the sensitivity of the baby’s state and moods. They found that the provision of safe place from which the child can explore and then return to was a strong precursor to attachment security. Certainly, the provision of moment-to-moment adjustments was not determined as unnecessary, but the safety was paramount for the child to feel secure enough to venture out into the world. A child’s exploration and play occurs when a child feels safe.

Mabel Mabel was a 24-month-old who had been subjected to sexual abuse by her mother’s boyfriend. She would be left for hours in her playpen with minimal play items and no social interaction. One day when left in the care of the boyfriend, she was sexually assaulted. She had sustained significant internal injuries and was removed from her home due to the mother’s reluctance to leave her boyfriend, believing it must have been someone else. Mabel was a shy child who tentatively entered the space. She scanned the play items but did not move toward them. She froze in place. She turned to her foster mother and attempted to climb into her lap, appearing to want comfort, but then quickly climbed out again. She stood by herself, uncertain. Her foster mother reported at home that she had started to be less tentative with them and was engaging in some brief, interactive play but lacked affect or playfulness. When stressed, she wanted to be in their laps, but had difficulty calming, and would leave quickly, appearing frightened. She wanted security but was ambivalent. In repeating this cycle of attachment and then dis-attachment, she kept reinforcing the unpredictability of the adults in her life providing continuity and safety. Being physically wrapped in their arms appeared to trigger her need to leave them, despite her body language screaming she wanted to feel safe. I suggested trying to wear an on-hip sling (similar to sarongs used in many Asian and African countries). This sling wrapped over the parent’s one shoulder and Mabel could be lifted in and straddle their opposing hip. During activities in the day, she was placed in the sling that was secure but not confining. Her arms were free. This was implemented during times when her regulation was not at the stress point. She was removed while still regulated, successfully concluding an enjoyable “ride.”

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Her foster parents were encouraged to express their happiness to have done this with her. She began to enjoy these secure experiences. Eventually, she was secure in this way of being held. This enabled her foster parents to place her in the sling during times when she started to become dysregulated. She was now able to tolerate being “held in safety.” Her parents would walk around the house or outside in the yard if the weather was permitting, adding the predictability of the rhythm in their sway, their breathing, their warmth, and the consistency of their heartbeat. The sling became Mabel’s secure base. She was able to use her foster parents for comfort. Because she now had the secure base to return to when stressed, she began to explore and became more “alive” when playing. It is a reminder again, if the physical environment is not safe, or perceived as not safe, the child will not be able to shift their attention away from vigilance to socially engage (Porges, 2011).

“Being Contained” and “Being Held” Many of the children who are seeking services with dysregulation have challenges in their attachment security. The concepts of “being contained” (Bion, 1962) or “being held” (Winnicott, 1971), which are both physically and psychically established, can be incorporated into the facilitation of a “secure base” and a sense of safety (Bowlby, 1988). This “containment” or sense of “being held” can be recreated by restructuring the environmental and the person-to-person interactive experiences. This container/holding can be the actual space the child is physically in, literal holding, such as being held in a caregiver’s lap. Or it can be perceived and “felt” as a sense of security. A form of being internalized so the child feels held from within themselves (Duggan, 1978; Kestenberg Amighi et al., 1999; Wipple, 1984). Both exist at the same time. They are not separate. One can reinforce, or can change, the other. I will, however, try to make a distinction between managing the literal environment and the “therapeutic use of self to simplify their discussion.” Even while the attachment relationship is still developing, providing external supports can facilitate a sense of security and in turn, reinforce the modulating regulating qualities of the caregiver. But, it really is the chicken or the egg scenario…which comes first? Try not to view them separately in real situations; each needs the other.

References Bion, W.R. (1962). A theory of thinking. In E.  Bott Spillius (Ed.), Melanie Klein today: Developments in theory and practice. Volume 1: Mainly theory. 1988. Routledge. Bowlby, J. (1988). A secure base; Parent-child attachment and healthy human development. Basic Books. Duggan, D. (1978). Goals and methods in dance therapy with severely multiply-handicapped children. American Journal of Dance Therapy, 2(1), 31–34.

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Kestenberg Amighi, J., Loman, S., & Lewis, P. (1999). The meaning of movement: Developmental and clinical perspectives of the Kestenberg Movement Profile. Taylor and Francis. Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological foundations of emotions, attachment, communication, self-regulation. W.W. Norton & Company, Inc. West, M. (1961). Daughters of silence. Heinemann Ltd. Winnicott, D. W. (1971). Playing and reality. Tavistock Publications. Wipple, H. (1984). The use of movement containment structures in facilitating the development of basic trust in pre-schoolers who are at risk. Unpublished Master’s thesis. Antioch/New England Graduate School. Woodhouse, S. S., Scott, J. R., Hepworth, A. D., & Cassidy, J. (2019). Secure base provision: A new approach to examining links between maternal caregiving and infant attachment. Child Development, 91(1), e249–e265. https://doi.org/10.1111/cdev.13224. Epub 2019 Feb 11. PMID: 30740649.

Chapter 8

The Assessment of the Child with a Complex Trauma History

The Start of the Assessment Process Whether in a home situation, clinic, or school, the more you know about a child’s history, the experiences they had, or the challenges they currently have, the less likely you will stumble on a major trigger. The information can help you put together the pieces of the puzzle and consider the source or missing elements. Understanding the possible reasons a child needs to use a managing behavior can help you navigate the potential skills that may need to be developed, reestablished, or integrated. If the child is able to feel more secure, they will be less resistant to release or modify their managing behaviors and new experiences will have a greater chance of being adopted.

Occupational Therapy I have been an occupational therapy clinician for a number of years. A great deal of emphasis has always fallen on the use of standardized assessments as an integral part of the evaluation. They are scored and become the body of the report. This sadly is also not uncommon across many other professions. However, we have a very valuable tool to utilize when assessing this particular group of children and adolescents…the power of observation. I have found this possibly more valuable than most of the standardized tests. We are not seeing a standardized child. Dysregulation is frequently present following complex trauma experiences, the child is challenged in their ability to use executive functions and to socially engage. When a child sits down to complete in a standardized assessment, are we really getting a true picture of the child’s level of functioning? Their behaviors may impede their performance. For example, when a child is hyperactive and © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_8

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constantly on the move, their balance or coordination skills may score lower than expected. But the child is also being vigilant to their new surroundings. The child has likely been reminded many times “they can’t do things well anyway!” But their ability to attend and focus is impaired. How can they do well on a test?

Observations I believe observing the child in different settings, watching their interactions with their caregivers and siblings, and the information in the reports and background history, are important in providing a more comprehensive picture of the child. The standardized tests do provide an objective baseline on specific skills and indicate how the child is functioning compared to the same-aged peers, but I feel the results need to take a less dominant role in the report, especially in light of their dysregulation and consideration needs to be equally placed on the value of observation.

Questionnaires For example, in my search for a reliable regulation assessment tool, I evaluated over forty emotion regulation questionnaires. What became very apparent was the challenge the children would experience in understanding or tolerating the verbal questions. Again…they’re coming to us because of dysregulation. If they could so intractably recognize their own challenges and use a Likert scale to rate them, then they probably wouldn’t be seeking treatment. Even when I thought I had found one that was less complex, all I got was impulsive responses, but the boxes were checked! The second issue I have frequently noticed is the likely bias, usually unconscious, that comes as a result of the child’s biological parents own childhood trauma experiences. The parent’s expectations and their interpretation of why a child is behaving in a particular way can become distorted because of their own ways of managing their past (Newman et al., 2011; Slade et al., 2005). On the other hand, when a foster parent attempts to provide information, they often don’t have an extensive background or history of the child’s trauma. The child may have just been placed with them. The child’s behaviors may be dampened while they are evaluating their new environment and its security or maybe escalated in an attempt to remain vigilant and to have a sense of control. When taking histories and selecting the standardized assessments, it is worthwhile pondering further on these issues.

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The Telephone Intake My assessment process starts when I make my initial contact with the parents or caregivers. I believe it is important to take note of the information that is shared spontaneously about their child, the tone of caregiver’s voice, their level of prioritizing their child, and even their ability to recognize areas that need to be addressed. I have had some caregivers give so much detail I am searching for paper to document all the information they are sharing. And others are yelling at their children to change behaviors as I am on the phone with them. They then have to stop the call because they have other things they need to do! These interactions are important to consider when planning for future treatment strategies in the child’s home. It also yields information about the type and amount of trauma psychoeducation that may need to be shared when assisting the caregiver in understanding the impacts of complex trauma on their child.

Other Sources of Information Other information and history about the child can come from a variety of outside sources. It may be a doctor’s order faxed over to the clinic or a case worker from the county wanting to make a referral. Again, as much information the referring providers can share will help develop a greater understanding of the child being referred. I generally will ask the identifying details of the child, the challenges they are experiencing, and if there has been any history of trauma, citing examples of what might be considered…domestic violence, school bullying, abuse, neglect, etc. It cannot be assumed the caregiver or even the service provider understands what events in the child’s life can be recognized as trauma. In gathering this information, it is extremely important to be nonjudgmental. Intergenerational trauma is not uncommon. Care needs to be taken to avoid implying blame on the caregiver for creating these issues. It is valuable to have the caregiver’s own understanding of the child’s challenging behaviors and their potential source because they experience the potential triggers and repercussions on a daily basis. A prescriber may not have as much detail for this reason. I understand the time constraints that can be imposed on the length of this type of telephone intake, but if these observations become an integral part of your evaluation, you will be able to increase the quality and likely positive outcome of your treatment because you have a greater understanding of the child. Each child is an individual. Even with similar trauma experiences among siblings, one child may be significantly impacted and the other able to function with less or no impairment. The age, the frequency of exposure, the support systems and resources a child has and the different safety issues are all components that can affect the child’s level of resiliency.

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This is a reason I have major aversions to curriculum-based approaches because the individual child is lost in the process of meeting the structure of the curriculum. The suggested steps may have been completed, and frequently contain very useful information, but these children are very unique in their own experiences, adaptability, and utilization of specific defenses. Some essential foundation skills such as safety, may be absent or diminished in the child and they may not be able to integrate the information in the sequence or rate expected. As clinicians, we need to find a balance between these constraints and consider the type and quality of treatment we can and want to offer.

The Waiting Room I have often been asked to recount the type of observations I make when I meet a child. Because I place a great deal of importance on observations, here is my process. It involves constantly asking questions to myself. As I am walking to the waiting room, I am listening for the type of activity I can or can’t hear. As I step into the room I quickly scan the room… Are the caregiver and child waiting quietly? Is there a sense of containment created by the adult or the child? Are there constant redirections? Are the parent and/or the child on their phone, paying little attention to their surroundings? Is the child running around the space? Has the adult brought any activities with them in anticipation of a possible wait? Are they seated on separate chairs, or on the couch together? Is one sitting in the winged upright chair and the other sprawled on the couch…shoes and all? Where in the room have they selected to wait? Are they close to the door or on the far side of the room? Are they near other parents and children in the room, or as far away as possible? How much orientating to each other are they doing? Does the parent maintain eye contact with their child or myself? How is their use of the space around them? Are they retreating, preoccupied, or verbally or physically dominating the space? How is the caregiver’s responding? Are they holding their bodies rigid and irritable or appearing unaware of any mayhem? Is there any touch going on between the caregiver and their child? Are the caregiver’s comments all negative or directive? Is there any negotiating, bargaining, or plans to do something after the assessment if “they comply”? Are the caregiver and child clashing with each other or do they make adjustments? Again, all of these observations are fluid and dynamic. I find my attention narrowing and flaring, then perhaps narrowing and flaring again. The questions constantly shift. If there is chaos or a lack of cohesiveness when I get to the waiting area, I create a smaller space by pulling up a chair and walking directly over to the child. I introduce myself and assess how the child is reacting to my proximity. Do they pause, offer their hand, or carry on with what they were doing without anything but a brief visual contact? How does the parent respond? Are they conscious of the impact they or the children are having on other people in the space? Does the parent acknowledge or watch their child as they negotiate the shared space with other children?

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If the parent is dysregulated, I immediately engage in co-regulating them. They too need to feel safe and heard. Is this what I am witnessing similar to home? I start immediately on creating or reinforcing regulations and the caregiver’s place in the child’s life as a potential place of safety. I take deep slow breaths and relax my body and allow my eye contact to be gentle but reflect interest. If the parent is not paying attention and is on a passionate tirade about their child, I may make a comment about their child to reengage the parent’s frontal cortex, so they can again remember their caregiving role. I see how they respond. Is there a cascade of directives and no physical movement or change? Or do they drop their eye contact with me and demonstrate little expectation of follow-through on the part of the child or themselves?

Transitions The child and a primary caregiver are present for the initial assessment. An intake packet is shared with the caregiver ahead of time. If it is not possible for them to print the packet at home, it is mailed or completed at the time of the interview. I feel it is important to introduce myself to the child and explain what will be involved in the assessment and ask if they have any questions. If the child is hesitant to move to the clinic space, the parent is encouraged to also view the room. I tend, however, depending of course on the age of the child and the nature of the trauma, to have the parent wait separately from the child. This tends to give more clarity of who is the overseer of the space, and the child has the opportunity to engage in a new relationship dynamic versus bringing their behavioral “history” in with the caregiver. How do the child and the caregiver react to the prospect of being separated? Does the caregiver give any encouragement or need to console the child? Is a compromise established? Is bribery present? Does the child appear concerned or unconcerned with this idea? Does the child give a fleeting glance back to their caregiver as they leave? Do they even make eye contact? Does the child engage in conversation as they walk to the space? Is the child wanting to dash ahead, or lagging behind? Is the child listening, initiating conversation, or is the child distracted the entire way to the room? What happens when he/she encounters someone else on the way? Do they react differently if it is another child or an adult?

Entering the Clinic Room I will walk around the clinic space with the child to orient them. It is a gym-like space with suspended equipment and karate mats over the whole floor. How does the child react when they see the room? Do they wait for guidance, “take over,” or exclaim “Way cool!” The playful environment frequently puts the child at ease. It is a far cry from the traditional office space.

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If the child leaps ahead into the room, I will always draw them back to the entrance to model a pause and introduce the fish swimming in their tank near the doorway. Can they hold their attention to the slow movements of the fish swimming or do they show interest in knowing more about them? If the child does not pause and naturally slow on this encounter, then I am more aware of their level of distractibility and interest in social engagement. I always have melodic music quietly playing in the background. The subliminal nature of the rhythm can assist with creating a sense of safety. After all background music is used in shopping centers to put us at ease and to keep us shopping. It is a helpful resource to utilize. It helps to break any lapses in conversation and muffles any low-frequency sounds such as to the furnace clicking on, the telephone ringing, or even the door banging outside the room. Does the child charge into the space and impulsively jump onto the large, inflated air mattress in the center of the room without checking it first for safety? Do they immediately try to climb the ladder to the loft? Are they randomly moving all over the room? Can they visually orient to me? Are they moving confidently, hesitantly to touch anything, or, immobilized and expressionless? Can they attend to and follow directions? Are they close by my side and aware of the table where items are laid out in preparation for the evaluation? Are they preparing to sit or are they unaware or simply not interested? All this information helps me determine how I will proceed with the assessment. I may need to focus on containment quickly by walking directly to the assessment area, giving them time to familiarize with the space, or even having them transition to a quiet area first. If you insist on presenting test items without considering these observations, you may rapidly find the child cannot focus and you will be playing “catch up” with the child as they dart from one piece of equipment to another. This does not create the “secure base.” Being observant does not have to take extra time. Use your transitions well. They yield information, and if used, will often determine how willing the child is to complete any testing.

The Formal Set-Up of Assessments I usually present the tabletop activities first. This allows side-by-side quiet time and I can quickly assess the child’s level of frustration and proximity tolerance. All the items are laid out to ensure minimal transition between one item and the next. I try to keep any transition as brief and rapid as possible. Gaps can feel like black holes to the traumatized child. I lay out the items as I need to use them, preopen bags and sharpen pencils ahead of time. This means I can reach for one item as another is being put away. Often I ask the child to help in this process. This helps to maintain their interest and lets them demonstrate responsibility and competence. If they are restless, I give them a definite time frame by telling them the remaining number of items to complete and let them know the next activities will be more active. This is usually enough to keep them on task.

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For the very young children, activities are usually presented on the floor (to keep them grounded) and again given in quick succession. It is advisable to be familiar with the test you are administering to reduce the opportunities for the child to become distracted or frustrated. The process does not happen necessarily with exaggerated speed, because it is efficient. The child does not need to sense they are being hurried.

Safety First Even during the assessment period, I establish the safety rules of the room. The child needs to ask and check in before using equipment so they can stay safe. After I have stated this, I always pause, and I wait giving them time to process and acknowledge the information. It is important when establishing these “rules” that your body language is not tense and authoritarian. It is merely an expectation for everyone because safety is what you are going to provide. If the child cannot manage their impulsivity, then sometimes removing equipment calmly and putting it aside may be necessary. When removing the equipment, it is important it be done with a neutral approach and safety again verbalized. Otherwise, the child may misinterpret the action as a punishment. Establishing these ground rules without a caregiver present is easier because the child is clear who is in charge of maintaining their safety and I can manage how the information is presented in calm, regulated manner creating less opportunity for conflict. Remember these children will seek the familiar if the parent is present. If they don’t attend at home, the mere presence of the parent can elicit the same response and be something else you will need to manage.

Keeping Predictability I always have any equipment previously used packed away and the space tidy before a child comes in. You also won’t find yourself or the child being distracted trying to relocate a particular piece of equipment or activity. I believe when I am working on establishing safety and familiarity, order is essential. This is not a rigid rule, but when a space is looking disordered, it can feel chaotic and lead more rapidly to chaos! Open shelves or cupboards are challenging to ignore. Doors or curtains can reduce impulsive children’s desire to grab an item when they see it. Again, it is one less element to contend with. This allows more of my attention to be with the child and equally theirs to be on me. As mentioned before, the quiet melodic music is always playing in the background, unless on very rare occasions, a child wants none. If this is the case, I am instantly alerted to a high possibility of reactivity already present in the child. I will accompany this type of request with a quick evaluation of a space that may need to be less visually stimulating and more containing.

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Because these children are often vigilant, I may or may not close the door. Some need to know it is slightly ajar to reduce their perception of being trapped, while others like it closed for privacy. If there is a need for their caregiver to be close at hand, I have a small adjoining room where they can sit and be available to their child when they need check-in. If the parent is in the room, I ask they sit to one side, slightly out of the direct visual field, so the primary focus for the child is on me. Some may find this caregiver arrangement strange, given that attachment is my primary focus, but these children have already come to the clinic with challenges in their attachment relationship. I want to provide a secure base first and then when the child is modulated in session with me, I can bring the caregiver back in. The relationship and security I have then established will be stronger and can help with co-regulating the child, if the caregivers react or trigger them again. I become a new stable base from which their relationship can be reestablished. Both need to feel secure. Otherwise, I find the known dance that has existed between the caregiver and child will keep being repeated. And in this scenario, each is likely to be primed for reactivity because of their history together, and then less able to tolerate new ways of interacting and listening.

Verbal Processing or Modeling I am attentive to how much information the child appears to be able to process. Do directions need to be one step? Does proximity control need to occur to assist the child to attend? Does their eye contact drop or are they scanning the environment? How do I improve or change “the container” (environment) for this child, so he/she has a greater chance of attending? Maybe the room needs to be simplified and equipment moved out of sight. Again, I want to structure the environment to assist the child in gaining a better focus before even starting the formal assessment. I also pay attention to what I am wearing. Am I comfortable? Can I move easily to demonstrate the motor skills I would like the child to try? I chose clothing that is visually simple without bold colors or large patterns. I wear no jewelry. A child may want to detach it from my body. I am also aware of any perfumes, deodorants, and even detergent smells because these can be potential triggers for a child. Neutral is better. These children are perceptive. The mere presence of a new person and the nature of the evaluation will already have their vigilance on a higher level. Is it likely these factors alone will determine the completion or ease of an assessment? Probably not, but they are aspects of the child’s environment we can control. An accumulation of many small triggers, however, maybe just enough to make the session challenging for all.

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Formal Assessment Tools Every clinic or setting uses different assessment tools and varying time constraints to complete the evaluation. Using observations, from the first moment, however, can save time. In my clinic, the primary caregiver completes an intake packet. The packet consists of identifying information including a history of the child’s gestation, previous or current providers, trauma type and age of exposure, behaviors at home (with siblings and with peers), functioning at school and in the community, and any identified triggers. I also explore sleep and play histories and their level of self-care functioning in dressing, hygiene, and eating. It is interesting that Blake (2021) nominates similar areas of sleeping, eating, toileting, general health, peer relationships, and play as important indicators of emotional functioning. Meanwhile, the therapist completes a motor skills developmental assessment and all the previously stated observations. These are combined together, with the intake and any further outside provider child histories, to complete the formal assessment process.

The Puzzle This process attempts to gain a broad view of the child’s level of functioning in the various domains of his/her life. They are all scored when required but are then placed out like a puzzle. What known trauma experiences has the child had? What age and for how long? Who was the perpetrator? Are they safe and in a stable place now? Are there any patterns? Do certain conditions elicit particular behaviors? Has the child been through multiple evaluations and treatment programs? What are the child’s areas of strength? How did they handle the novelty of the assessment process? Did they act safely? Did the child socially engage with the therapist or anyone during the assessment period? Even with the assessment completed, the caregiver, (no matter their title or role), needs to continue to non-judgmentally question the “why” of any behavior. They need to keep recalling the history and expanding their knowledge about the child. This may be by seeking additional history, asking new questions, or watching and listening to their child more intently. The process is ongoing, even if goals have been established. As the child feels safer, they will venture out into the world and take greater risks into the unknown. Their picture and our understanding can continue to expand.

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References Blake, P. (2021). Child and adolescent psychotherapy: Making the conscious unconscious (3rd ed.). Routledge. Newman, L. K., Harris, M., & Allen, J. (2011). Neurobiological basis of parenting disturbance. Australian and New Zealand Journal of Psychiatry, 45, 109–122. Slade, A., Sadler, L., Dios-Kenn, C.  D., Webb, D., Currier-Ezepchick, J., & Mayes, L. (2005). Minding the baby: A reflective parenting program. Psychoanalytic Study of the Child, 60, 74–100.

Chapter 9

The Environmental “Container”

Primary Safety A primary importance when working with a dysregulated child is establishing that the child is safe in their present life situation. If the trauma is ongoing and the child is unsafe, then changing the strategies can put the child under potential threat. Creating a sense of safety requires managing behaviors to become modified or released as the trauma is being resolved. This may reduce the child’s defenses. For some, this appears to be plain common sense. However, paying attention to this fact can be overlooked if the surroundings, such as the school setting or clinic, are assumed to be “safe.” Safety at home or in the child’s outside life can sometimes be presumed to be present and to have been accounted for. This may not be the case. If the child is not safe, this is the first issue to address. This may require Child Protective Services to be called to complete a home visit or another outside agency to interview the child at length. Two factors in particular need to be considered in this interview situation. If the child is not feeling safe, then (1) language goes offline and (2) if novelty, in and of itself, creates further uncertainty, it is possible that the child will make attempts to avoid change, despite the possible risks entailed. The interview process in itself may make the child feel unsafe. If verbal language goes offline under stress, the child’s verbal responses may be minimalized, in poor sequence, and/or lack accurate time frame elements. The validation of abuse or risk is then difficult to obtain. For this reason alone, using strategies wherever possible during the interview process, which can help the child “feel” safe will have a significant effect on the outcome. The child may anticipate removal. This in and of itself can be a trigger for the child. They will possibly feel torn between their biological desire to be with their parent, despite the evidence that it would not be in their best interests, and a threat that a prospective new placement “may be just like it is here anyway.” Uncertainty © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_9

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will dysregulate. They may try to win favor from their abuser, by denying events, given their past poor experience of assistance and help. They may fabricate information about the relationship or circumstance being better than they actually are, to simply get the interviewer to leave. The longer the interview lasts or the frequency of reassessments continues, then this will dysregulate the accused abuser. This can further increase the child’s risk of more abuse. Playing the odds of the “known” for the child may feel safer than the “unknown” of being removed and potentially “being safer.” I have had child protection workers ask how they are supposed to change an environment when they are going into someone else’s home. It is a good question. It may not be ideal, but you can work with what you have. If you have been delegated to the living room and there is a constant flow of people in and out, I suggest finding a corner on the floor. Maybe you can move a chair slightly to the side and create a smaller or perceived smaller space with the walls and the chair, developing the illusion of a safer area.

The Surrounding Physical Space Does Matter If you have an option to move somewhere else, a place with less traffic is ideal. Sometimes, this can actually be the laundry room. There, however, needs to be options open for the child to not feel trapped. Ensure your body does not block access to the doorway. Generally, the less movement around the child, the less attention they will need to pay to feeling safe, and the more can be on you. I recommend also utilizing and adopting some of the modulating caregiver strategies to assist the child with further regulation. We need the child to be less vigilant, so the evaluation can be more effective and reduce the child being at further risk.

It Takes Time Regulation interventions need to incorporate a “good enough” safe place, the development of a secure base, a safe haven, and sensitive attunement. I wish I could say it is an immediate fix. Implementation of healthy attunement qualities will definitely make an impact on the “felt” sense of safety for the child. But for this to be fully realized, the relationship needs to strengthen and there be consistency and stability over time. Remember regulation development and the associated neurological and physiological growth happen over several years and are constantly being modified throughout our life experiences. We can all provide the quick fix to prevent a meltdown. But helping to sustain regulated behavior is far more advantageous for the child if they are able to be internalized. They can be available in their repertoire for future challenges.

What Is the Child Selecting?

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Let’s Look at the “Physical” Container Porges (2011) concept of neuroception is present in our daily lives. When we enter an unfamiliar space, we scan its features and listen to our “gut feeling” concerning the safety of the space. This is not necessarily happening at a conscious level, although for some it is. For most of us, we enter the space and place ourselves in the area which “feels” the most comfortable. It may be by people we know, by the door, or by the snacks that have been made available. We find a place where we feel the most secure. Even architects are now considering the visceral impact of building design, to create a similar sense of safety and comfort in hospital and care facilities (Farhangi, 2020; Gesler et al., 2004). The impact of the space around us is real.

Maybe This Room Is Too Large! When working and engaging with these children, the space size can also impact the effectiveness of an intervention. It is the first thing I address wherever I am. For some children, a wide open space will have the child bouncing off the walls and every object in the room as if they are attempting to find a definite boundary. I frequently get the image of a ball in a pinball machine. This type of vigilance does not elicit a secure base feeling! For this reason, providing a smaller space, though not a restrictive space, can reduce the amount of hypervigilance required by the child particularly until the child is more familiar with you. This is a common challenge that can easily be averted.

What Is the Child Selecting? In a classroom, I have had reports of children being reprimanded for crawling under a desk or table. But they are creating their own container…less movement, less chance of being bumped, less visual, and often less noise. They are telling you loud and clear they are overwhelmed. Follow their cues. If it is not socially convenient, then try to find a space that does adopt the qualities of the space they have chosen. I recall a 10-year-old bolting out of a group with staff in pursuit and he dove under the cushions of the waiting room couch. The staff wanted him out of the waiting area. But no one else was in the room. I intervened and requested that he is able to stay there for a while until he calmed down. He had found a soft, warm, dark, muffled place to hide. My boss stepped in due to the commotion. He understood and had any pending visitors use another space. The child calmed down with no aggression towards the staff. He had commonly resorted to physical violence to people in the past.

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Again try to watch what the child is seeking. I do not suggest a room designated for “that type of behavior,” e.g., a time-out room. The time-out room can have a cascade of threat elements attached. It may be safe for the staff, but for a child, it can be sheer terror. Remember, we were not cut from the same cookie cutter. We all have different foundations of safety and attachment experiences. For these children, a sense of safety is more often than not, dubious.

Small Can Be Good On occasion, I have resorted to changing to smaller room, particularly when the child I am working with is particularly vigilant. In the smaller setting, I can remove a great deal of the equipment I have in there, not as a punishment, but to help the child orient consistently to one choice of equipment or myself. If the child comments on the reduction of choices, I let them know it is to help them concentrate on how to use a piece of equipment safely, or I emphasize the positive aspect of wanting to be able to “get to know them better.” Again, I do not want the simplified space to be misinterpreted as a punishment. It is more typical for change to be interpreted as negative without explanation. It is amazing how this is easily accepted when the presentation is genuine and supportive.

Now Let’s Talk About Open Spaces There are, however, adolescents or younger children who actually benefit from having more space. All of you can recall the adolescent who comes into a room and flops down on the couch with monotone responses. When I have this type of child, I want their world to feel broader, to get them moving. I barely let them sit before they are back on their feet or I won’t even let them sit at all. I will sometimes head straight outside and amble along on a walk making comments about the surroundings. Once we have steadily walked and they are more activated, I make frequent stops sometimes to notice a bird, a plant, or even the shape of the clouds and share my amazement with them. Sometimes, I am sure they question my level of sanity, but it broadens their perspective of being part of a larger world of choices and they don’t just end up grunting from the couch! I help them “move up the ladder” into social engagement by changing their surroundings to a calm environment until they regulate enough to become more socially engaged.

The Guided Use of the Equipment and Physical Safety

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Consistency in Space Use The consistency of the space and equipment use is another element to consider in creating a secure base. If the child knows what is expected of them when they enter the room, they don’t have to come through the door as vigilant. For example, I have one piece of equipment that consists of several layers of lycra fabric. It is suspended from four corners like a hammock. This is where I direct all the children and adolescents at the start of almost every session. Initially, especially the hyperactive, vigilant children question why they have to climb into the hammock again. I simply state that I want to ensure they are safe. When they demonstrate this skill and can change down between the layers of fabric, following directions, they can shift to another choice. After that first or maybe second challenge, they are drawn like magnets into the routine. Some become so comfortable they immediately regulate. I even use the entry into the room in a consistent way. Initially, I had the children remove their shoes to keep the mats and equipment cleaner but I began to notice that it allowed the children to pause before entering. They would take a deep breath! Bending the rules for children with obvious triggers can be done, but when they begin to remove their shoes without prompting it becomes a clear indication they have progressed along the safety and trust continuum! To manage vigilance or dissociative responses to unexpected noises, I will familiarize the children with their whereabouts should they arise. We may wander upstairs and visit the waiting room of another clinic and experiment with the squeaking floorboard ourselves. If the child is new to the space, I include these potential sounds on the “tour” and familiarize them. It is very clear when these triggers occur. I have had children freeze mid-conversation and become wide-eyed and very still.

The Guided Use of the Equipment and Physical Safety With every activity, I will make no sudden movements or surprises unless the child is calm and able to make this request. It is so easy for most of these children to dash from one activity to another or to make feeble attempts at an activity and leave it if they anticipate they will not succeed to the level they want. I will guide the child to equipment that will assist with their regulation from an attachment continuum and not from a sensory perspective such as vestibular or proprioceptive needs. The reason why I do this is because these children avoid novelty like the plague. They will repeat what is familiar, e.g., spinning around and around in a swing, jumping into pillows from a great height, shifting rapidly from one piece of equipment to another, and replicating their known chaos and adrenaline rushes. If the session is totally child-led, then the familiar patterns of engagement will continue. I seek to broaden their base and guide them to less familiar experiences of consistency, rhythm, a safe sense of sustained containment, regular rhythmical breathing, and exploration that is contingent of reducing impulsivity and fleeting experiences.

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The “Just Enough” Challenge Safety is paramount. This does not mean I am like a “helicopter parent,” hovering around the child, protecting them from danger. I am providing the secure base from which they can explore with an understanding of their limitations and tendencies. I provide new opportunities, but they are safe enough for the child’s current regulation level. I am being proactive, not reactive. This is similar to the caregiver providing the “just enough” challenge to facilitate growth. This provides a little tolerable frustration, but not enough for the child to dysregulate. If I feel a child is not ready for an activity they have spied, such as the rock climbing wall, I will say no. I will remind them that when they can safely follow instructions and can focus on directions for a successful climb, then I will naturally allow their request to be fulfilled. They look at me in surprise but know they are not at that point in their regulation skills yet and accept an alternative. I will ensure when these children have attained the skills I have described, that they then do have the opportunity to climb even if they appear to have forgotten their previous request.

Equipment: Containment Qualities I am lucky enough to have the availability of space to create a sensory type of gym. In the room, I have several suspension points I can hook or clip equipment to and then be able to adjust their height as needed. For example, I have had one child, aged 7, refuse to get into the lyrca hammock because it was “too high and hard to climb into.” His primary fear had actually been “what if I fall out?” I lowered the material to a foot off the floor and with delight he tumbled in. We gradually raised the height and incorporated into its use, the “fun” of rolling out onto the “bouncy” foam mattress below. This activity was presented as a playful choice. With a twinkle in my eye and prosody in my voice, I would ask, “I wonder whether you can roll out of this layer?” His eyes would light up with confidence and mischievousness and he would take his deep breath. I would feign his apprehension reflecting it back to him. He would giggle again and proudly tumble out! I would squeal in delight and he would laugh and laugh. He was no longer concerned with the unknown of what it was like to fall out! This level of game is usually associated with a much younger child. I matched his developmental needs so he could be challenged “just enough” to expand his ability to experience his world without fear. Listen to what the child is saying. I would have been in a constant battle with him about the hammock use if I had not adapted it to his needs. Instead, it became a playful opportunity. Something he had not had a great deal of in his life.

Michael

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What Are Other Container Choices in a Room? In each treatment room, there are options for spaces which are for “quiet time or play.” I have created a loft where children can climb, but underneath is a play house area. The space is open but creates an illusion of being its own little world. It has baby dolls, a kitchenette with “all the food and cooking needs,” a doll bed, a small table, and chairs. It is amazing how this small space can help a child focus, feel safe, and start to play and interact while the larger space filled them with apprehension.

The Ball Pit Even a ball pit filled 2/3 way with colorful plastic crush-proof balls can create a container! It is how it is used that makes the difference. Let me give an example. Most children have experienced ball pits as a play to jump, spin in, throw balls in and out off, and generally create playful chaos. I want a place of safety and a sense of containment, calmness, and a child’s focus! This is at the opposite end of the movement spectrum. I structure the play according to these elements. How do I do this? I will explain in the next section where I discuss the use of self to elicit the preferred outcome, but for now, I want to recall an adolescent I have worked with and the effectiveness of the ball pit as his container and place of safety.

Michael Michael was a 17-year-old, very inactive, overweight, and had marked difficulty with motivation. As a 6-year-old, he had witnessed his mother being brutally beaten and killed. Since she had been his primary caregiver, he was placed in the foster system and lived in multiple homes until settling in one for the four years before coming to the clinic. He struggled with school and academic learning and had many bouts of aggression with school staff. He had difficulty making friends and would often be irritable at home. He shared his home with his foster parents and three foster siblings. The household was active and often felt overwhelming. He did not share many details of his trauma with his counselor, despite it being “so close to the surface” and affecting his life on many levels. I had worked with Michael for several weeks. Michael lacked being touched or held at home and was hesitant to receive it now. I directed him toward the ball pit. The balls would provide the tactile touch components and the additional prompt for playfulness. He climbed in. He lay down, moved his arms back and forth and his ever-present level of “irritability” started to melt away. He slowed his movements and lay supported in the bed of balls. He smiled. He then experimented with hiding below the

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surface and reappearing. He began to cautiously play, and his “aliveness” started to appear. Then in a playful way, he disappeared below the surface and a small young voice sounded from the depth of the ball pit. He introduced himself by the nickname his mother had given to him and began to share some of his childhood experiences, positive and negative. All the while he lay beneath the surface and used the young voice. He later explained that when he was hidden from view, and surrounded by the balls, he felt safe and contained. From this place of perceived security, he was freer to begin to share the unshareable!

Ground With the Ground! Another technique to assist with regulation is to use the floor and the ground. The therapist can literally provide a stable container for a child and help the child feel more “grounded.” If the child is racing around the room and unable to focus, bring the activity to the floor. Then lie on the floor yourself and invite the child. The child will mirror this. By having them lay on the floor with as much of their body in contact as they can tolerate, the child will literally feel the support and grounding effect of the ground. It will slow them down. By modeling this “comfort,” adjusting your own body posture, coming to the child’s level, and demonstrating relaxation, the child has the potential to start to attune to the less familiar sensation of stillness, and experience some calmness instead in their own body.

Even Cardboard Blocks Can Create a Secure Base Most of us have experienced building the cubby house/fort. Whatever it was made of, it was “a place to call home.” Blankets would be pulled from all corners of the house, chairs away from the table, and clothes pins or books would keep everything in their place (hopefully). This activity is often associated with childhood memories, but many of the children I have worked with have not experienced this activity.

Adam Adam, a petite 6-year-old was one of them. Despite his physical demeanor, he could become a destructive whirlwind when feeling unsafe. He would try to climb on or above all the equipment which generally replicated this approach all day long. He seemed to be on a continuous search for “his” place to “just be,” a place of safety and security he owned!

How Much? Which Swing?

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I sensed that he needed to be the engineer of this created space and pointed in the direction of the pile of large cardboard blocks. He was hesitant. What was he supposed to do with them? I started to place them on the floor, suggesting he could perhaps build his own cubby house. He stepped forward but actually stayed still. It was clear he had never done this activity before. He lacked experience on how to layer the blocks on top of each other and had difficulty with planning more than one block ahead. But gradually with some assistance, a container started to appear. He would experiment with stepping back and forth over his single block wall and each time pause and look around his “room.” It never occurred to him to build a door! He, however, was very diligent in creating a bed, a toilet, “which flushed” and a refrigerator. The door was added but was able to be closed. And there he sat “king of his castle,” surrounded in his own place, calm, proud, and still. Building up this external home was helping him to symbolize the concept of a home. This is an important transitional experience on the way to developing the idea of an “internal home.”

How Much? Which Swing? Some children, however, need more activity and input from equipment to experience this sense of calmness. By adding the swinging component and incorporating the rhythm and predictability of the back-and-forth motion, I have witnessed child after child transforms from a bristling exterior to nesting and finding stillness and relaxation. Given their trauma experiences, some children feel more vulnerable and a potential target for abuse when still. I began to notice the individual children wanted or needed different degrees of containment. Some wanted to be “held” but also wanted to be able to easily “escape” if they felt too overwhelmed. Others wanted to be completely cocooned in a swing enclosure. I reflected on the attachment continuum. Children venture and begin to explore in small increments. They experiment and return back and forth between the new experience and the security of their caregiver. I considered the all-surround container of a caregiver’s arms with the child fully supported, to the child reaching away from close body contact as they straddle a mother’s hip, to experimenting with alternately crawling and sitting on the floor, to cruising along low furniture and then to stepping out into the world. I have now created a variety of “container” choices in an attempt to meet the wide range of individual needs. I have open, semi-open, and enclosed swings. These can be matched specifically to each child’s unique needs. Again this is not a curriculum. What may work with one child may vary with another or even for the same child within a session. By having this progressive selection of swings, graded in their attachment qualities, I can also have a concrete assessment of a child’s progression. What type of swing can they now use on the continuum and relax in?

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 ut Isn’t This Like the Sensory Integration or Sensory B Processing Approach? Yes, there are sensations experienced by the child. This is how we perceive our surrounding world and develop our own sense of self. We learn through our sense of touch, our position, and the movements of our body, through the forces exerted on our joints and muscles, and the multiple other senses of vision, sound, and even taste. This approach I am proposing, however, is not from a sensory integration framework. It follows the developmental sequences of attachment and regulation. It is both a physical and a psychological approach. It is sensory and symbolic. The “whole” child, mind, and body are considered. The equipment and the space look similar to a sensory gym; however, the equipment and the therapists use of self are utilized to assist the child along these continuums. The goal is to reach a place of security with regulation and age-appropriate social engagement.

“Stability Before Mobility”….“I Am, I Do” As an occupational therapist trained in sensory integration, I pay homage to the work of Jean Ayres and her increasing focus and awareness of the importance of sensory input and processing (Ayres, 1973). Her work has had a major impact on the work of pediatric occupational therapy. Clinics have incorporated suspension and playful equipment that actively engages the child and provides sensory input from multiple sources. Occupational therapists are in a wonderful position to utilize these facilities when working with children who have a history of complex trauma. However, the sensory integration approach was intended for work with learning-­ disabled children. I believe that the trauma child does not have a sensory processing problem. When these children are hyperactive or dissociative, the behaviors serve a defensive purpose and have helped the child survive their trauma issues. The remediation and treatment needs to take into consideration the function of the behavior through a trauma lens, rather than through the traditional sensory processing lens. I understand so often the behaviors these children present do not appear to provide a useful outcome, but they do serve a purpose and we need to keep asking why! Given the previously discussed research, one can see that these children are usually avoidant of novelty and will seek activities and behaviors that are familiar. Too often I have witnessed well-intentioned therapist spin and spin a trauma child or follow the child around the room in a child-led session. Given the information, we now have available about the avoidance of novelty, the familiarity of a chaotic spin will likely be chosen by a child. It replicates what he/she knows and is familiar with. The “calm before the storm” principle may drive these children to seek familiarity even if it further disorganizes them or at least maintains them in a disorganized familiar place.

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These children are not necessarily missing sensory information but have selected attention to those aspects of their environment that can ensure their safety. They notice and react to particular smells, not all smells in a group of smells (Warner et  al., 2013). They freeze when they hear a low-frequency sound, out of a fear response. They narrow their focus. They anticipate anger from a facial expression or tone of voice over the possibility the person may be surprised or shocked. Or they keep moving to remain vigilant. The sensory integration model is primarily child-­ led. When working with trauma children, I believe we need to guide from a secure base. To let the child experiment, the therapist needs to introduce new experiences that have the “just enough” challenge to expand their repertoire and reset the foundation for trust. For these children, I acknowledge the fun of spinning but calmly explain that for the time being, I will introduce something new to them and explain the predictability and calmness of rocking. Sustaining this position can be challenging for the child. Because they worry about the “calm before the storm,” I will give the child something quiet to do or watch as they swing such as small oscillating lights, a purring, vibrating toy cat, or even watching the fish swim in the window sill tank to help maintain their focus. These props add additional movement qualities of sustainment and can help the child remain in the swing longer, allowing time to assist with further relaxation. Then their eye contact improves and often is accompanied with comments about their experiences and feelings. I am not debating the success or non-success of useful sensory strategies and view many environmental changes in a positive light, such as giving a child the option to move to a quieter space or wear headphones. However, these strategies rarely become internalized for the child. They act more peripherally on the child’s hand or ears rather than “felt and experienced to the core” of their body. Long-term remediation occurs when there is an improvement in the child’s sense of safety and trust. They then regulate, relate, and can reason (Perry, 2020). One of the therapists recounted a conversation she had with a county worker who had called requesting a letter to be able to purchase “a weighted blanket or at least a vest” for a child with a history of significant poor attachment. His mother has a history of ongoing depression and anxiety and did not touch or hold her child. She was constantly “busy doing other things.” The therapist did not discourage the purchase but was able to explain to the worker that the need of the child was to feel noticed and bonded with his mother. She strongly encouraged opportunities instead, to focus on the long-term improvement of the bond between the child and mother. The child would then internalize this and experience less anxiety without any additional external supports. The focus of trauma treatment has moved over the past decade and recognizes the need for body-focused approaches. Sensorimotor psychotherapy (Ogden & Fisher, 2015) and somatic psychotherapy (Levine, 1997) are such approaches. They source the visceral, internal sensations one experiences and use this information to assist the client in processing trauma information. Acknowledgment is given to the body’s memory of traumatic events and the challenge of “finding” the words for their experiences and responses. These models do not view the sensory challenges

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as deficits in processing but rather as a resource to facilitate the individual to a broader awareness of how the body can retain these memories and impact many facets of their life even years after the event. That is they help people learn the language of their body. One of the tools I have used in the assessment process is the sensory profile by Dunn (1999); however, I encourage it to be used to create a broader lens to view these children and be utilized to define them!!! Champagne and Stromberg (2004) have implemented sensory rooms in mental health facilities. They have demonstrated a reduction in seclusions and restraint at the facilities where this approach has been implemented. However, these facilities are not long-term options. Once discharged, many return to a familiar chaotic environment. I reflect on the therapist's mantra of “stability before mobility.” If the client has the opportunity to broaden their experiences with repetition, repetition, repetition, then their body memory of their sensations can become more familiar and considered in sensorimotor psychotherapy terms as “procedural” and happen below the level of consciousness. Kaplan et al. (1993) studied data on 96 learning-disabled children and they concluded that there was no favorable impact of sensory integration therapy (SIT) over other therapy interventions. What they did find, however, were two important conclusions. (1) The parents and caregivers perceived the treatment was working. Kaplan proposed that this was due to the intense bond between the child and therapist and (2) the sensory integration model provided a basis for the carers to change their perspective on the child’s misbehavior, non-compliance, etc., and provide engagement from an alternative theory base. Children work well in environments that allow them to move or engage in a playful manner. The sensory room is such a place. It is also a time when the therapist is closely interacting with the child and the child as their primary focus. This is not such a familiar experience for the child with a trauma history. The interactions provide more nonverbal opportunities for physical engagement versus verbal dialogue. It is here that occupational therapists are at an advantage when working with these children, but I don’t believe we should have exclusive access to these regulation principles. I envision, with training, the strategies being utilized and incorporated into offices, schools, residential facilities, homes, and wherever there is a need. Even a child-sized rocking chair in an office, a pile of large pillows to bury into or a soft mat on the floor can shift a child’s regulation to a calmer state if utilized in an individual manner considering and remembering the child’s own history. Knowledge and training are necessary when working with these children. To work on regulation, one needs to build a stronger safety and trust foundation. The qualities of touch, proprioception, and vestibular input are all incorporated in this model. However, here again, these children do not have a general processing issue. Their triggers are specific. For example, proprioception has physiological calming components but the choice of activity or equipment must consider the individual trauma experiences of the children before being used. For example, facilitating crawling under heavy pillows that generally facilitates a calming experience may

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trigger a child who has been held down and abused. Instead of calming it can elicit a strong fight/flight reaction. Similarly, tactile brushing for a sexually abused child may elicit defensive reactions and cause a child to dissociate. Bouncing on a trampoline may elicit a flight response and increase physiological anxiety, because the aerial component (lack of groundedness) increases the child’s heart and breathing rate similar to the adrenaline surge of abuse (Eichinger et al., 2022). Even general sensory activities that are available online are often too broad for these children. An example of this is the often recommended wall push-ups to calm. Given the nature of most children, but in particular these children, their tendency will be to do the designated number as fast as they can. They are often done with very little focus on completing the full range of the push. If this is to have a greater calming effect, this type of activity needs to encourage the sustainment and the extended length of each push-up. The activity should focus from the beginning to the end of the pushing movement. The total number should not become the main focal point. This same activity, if done in a slower, more focused complete manner, will elicit a slower heart rate, and slower breathing and incorporate resistive proprioceptive qualities, which can then be beneficial. Left in the hands of the child, this activity will only produce fatigue, not the internalization of regulation which they need in the long term.

Triggers It can be surprising even what an assessment item can elicit in a child. I have had a handful of children pale and express extreme resistance with the push-ups or wall squat items on a standardized developmental motor skills assessment. Some caregivers use these as methods of punishment for their children. Once again I emphasize, please do not assume a child’s resistance is simply about compliance. It can be a way they can maintain some control if they are feeling unsafe and a potential way of avoiding triggering from past experiences.

Now How Can We Use the Swing Differently? The swing is chosen for its containment qualities and the individual need for a “felt” sense of security. It can be adapted to the child’s regulation state from session to session as needed. Again my selection of the swing or equipment is not from the perspective of providing vestibular stimulation, but to match the “container” needs of the child. The modulating caregiver naturally rocks their child when he/she is distressed. Similarly, the rhythmic sway is used with the choice of swing. I step back and consider where the child is along their attachment, secure base continuum.

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What are their needs for a sense of containment? Do they need to physically “feel” safe? How much do they want to be “seen,” or how much do they need to see others? Some children want to be calmed in a swing but don’t want to be pushed, or don’t want to feel confined. Some need to be woken up with playfulness! The type of swing is matched to these needs. Again one size does not fit all. I want the children to embody these experiences. Cognition can come later.

 wings and Matching Them to the Child’s Attachment S “Container” Needs The Basket Swing  Some children are very hesitant to climb into a closed space. They want to feel held but not confined. They want to be close, but not too close. There are platform swings and bolster swings available, but these don’t provide the curved container, the “holding” qualities of a carer’s arms. Instead, the child always seems to be on the brink of falling off the swing. The basket swing is like a nest (Fig. 9.1). It is open, curved, and large. A therapist can even push the swing gently without having to touch the child or to get too close. The child is surrounded in the soft pillow and the rigid frame of the swing firmly supports the child. It is suspended 4–6 inches off the floor. It can be easily climbed out if the child starts to feel overwhelmed and is a wonderful starting place when a child is feeling apprehensive. The neglected child can still be watchful in the swing because of its openness but at the same time experience needed comfort and support.

Fig. 9.1  A basket swing

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Fred Fred had experienced severe neglect. He had been found as a 4-year-old locked in a room among layers of his own and animal feces. He had been fed but there was evidence of only snack wrappers and fast food. When he arrived at our clinic, he quickly became overwhelmed in the large room and even in the small space with a great deal of the equipment removed, he would dart from one area to another. He did not want to be directed to particular activities. He barely noticed they were options. His vigilance ruled but he needed a place to settle. He did not want to be confined in an enclosed style of swing or “container.” One day I brought in the basket swing. He had previously been playing with a stuffed animal and I placed this in the swing and gave it a push. After several repetitions, he noticed and paused. He came closer and then attempted to push the swing himself. I placed more stuffed animals in the swing and he again pushed them becoming more enticed by the activity. I invited him to climb in and he tentatively did. I let the swing naturally sway without adding any additional momentum. He sat. I asked if he would like me to gently push it. He made eye contact and nodded. I did once. He smiled and then climbed out. He continued to explore the room but his range was closer to the swing and he would pause and look over. I again invited him and he moved away. I continued to rock the swing using prosody in my voice to animate the interaction I was having with the animals. He came over and climbed back in. He let me rock him, one leg hanging slightly over the edge, just in case. His upper body began to relax despite his lower body being ready to “go into action.” It was the first time he stayed in the room without checking the location of his adopted mother for longer than 10 min! When he did leave again, he told her about the swing and dragged her by the hand to see the “animals” and demonstrated how he could push them gently. Lycra Hammock  This hammock is several layers of thick lycra fabric attached at the corners to a carabiner and suspended approximately 2½–3 feet from the floor (Fig. 9.2). Underneath I have a soft foam “crash pad” mattress. I use this hammock as a consistent entry point activity to the clinic space because I can rapidly assess the child’s focus by their ability to keep themselves safe, centered, and to take on new challenges. Fig. 9.2  A lycra hammock

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The innate quality of the lycra can be used to advantage or disadvantage. It can provide a womb-like container or can send a child bouncing into hyperactivity. This is where again, this approach is one which is more guided than the child lead. This does not mean you prevent children from being playful, but you need to decide why you are using a piece of equipment and the goal you are trying to attain. If I want a child to slow down, I encourage them to keep stopping and check they are safely in the middle of each layer. I will pose questions as they go down or redirect their attention to the small window that has naturally been created by the fabric layers and ask them to watch the fish swimming within their view. These pauses place the emphasis on containment and sustainment. If I have a child, on the other hand, who is withdrawn and tentative, the rebound quality of the fabric can naturally be used to elicit “aliveness” while still safely containing the child. The stretch of the fabric can be utilized and playfully bounce the child to touch the foam mattress under them and then up to see the fish! The intensity can be easily adapted.

Find Me! Pod Swing  This swing is excellent for smaller children (Fig.  9.3). It is mostly enclosed, but the type of fabric allows the child to still see the outline of surrounding objects or people through the side walls. The front is open. If the child is sitting cross-legged inside, they can view out of their “window” and orient easily to your face. They can move toward you and then practice “being away,” while still having you in their visual field. This is an activity where facial animation and the playfulness of the caregiver interacting with his/her infant is so clearly replicated. If a peek-­ a-­boo game was a swing, this would be it!

Fig. 9.3  A pod swing

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Phillip Phillip was found abandoned in a car when he was one. During this short time with his biological parents, they were in and out of his life. His father had beaten his older sibling and mother so badly that they were both hospitalized and he was subsequently imprisoned. His mother had addiction challenges and was inconsistent with providing care. He bounced between various family members’ homes. Finally, he was placed with a pre-adoptive family, who at the county’s recommendation brought him to the clinic. They had “run out of options?” Phillip was constantly “in trouble” and was prone to aggressive outbursts. He ran away regularly from school, but his foster parents were very consistent and it was clear they cared for him deeply. Phillip often arrived dysregulated. He was impulsive and would push his foster sibling roughly aside to distract his foster parents from his next endeavor. He was drawn to chaos. He wanted to desperately spin and spin, fall off equipment, and rapidly move from one thing to another. All I can recall is that I definitely needed to find a playful way to contain him. I didn’t want to terrify him by confinement but needed to keep him orienting to me so I could assist with co-regulating him. The pod swing came into my line of vision. He climbed in at my suggestion. I confirmed he was snug and safe and started swinging him with some speed back and forth until he realized he was still moving, but somebody else was doing it. He snuggled down. Knowing the back and forth was not likely to be successful for long because of his restlessness, I started to slow the swing down and it turned away from me. He saw me through the side of the swing and said “I can see you!” I turned him back around and said “I see you!” and smiled a genuine big smile. Over and over Phillip wanted this repeated. His focus and engagement were wonderful. From then on, the standard question was “Are we going to play the where’s Phillip game?” It became a regular activity, filled with laughter and positive experiences for both of us. It is interesting to reflect back on the similarity this game had to his own life. Except this time, he was always found with delight! Phillip has now been adopted. He continues to have counseling and play therapy, but takes the risk to engage and interact with others. His “outbursts” have reduced significantly from multiple a day, to one, which lasts minutes versus hours. Occasionally, he will drop by and with an impish smile ask, “Where’s Phillip?” Open Swing Chair  This style of chair is readily available on the market (Fig. 9.4). It is an indoor or outdoor seat made of canvas, with fabric sides and curves around the person who is seated. It is a socially acceptable option for adolescents or older children. Again, the fabric is supportive but not restrictive. When a child is seated, it curves around their body and contains them more than a traditional chair. The swinging can be initiated by the child by pushing off the floor. The power of these swings is incredible. I have had children who defy needing any friends and who proudly share they are very tough, melt into the folds. Their tough exterior dissolves and they can be the child that does need support and a safe place to be.

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Fig. 9.4  An open swing chair

Fig. 9.5  A lycra swing

Lycra Swing  This swing is made of heavy lycra and when opened and fully stretched can hold a large child or small adolescent in a lying position (Fig. 9.5). If a child sits in the swing, the sides naturally close but the child can have the option of them staying closed or easily open the sides if they want to see out. The heavy-­ duty fabric provides all-surround pressure on the child and is strong enough to lean upon and change position within. The fabric is dark and when closed shuts out 90% of the light. This swing is helpful when a child is feeling overwhelmed with too much going on and allows them to “close off” the extra input and calm. It has the potential to spin; however, this is rarely something I do. Spinning leaves the child dizzy and “off balance.” That is too similar to chaos. I discourage any movement other than rocking if I am using it to calm a child and explain to the children why. If they are agitated and restless, but clearly need to be able to screen out the outside

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world, I will place some oscillating lights in with them. The child can become spellbound as they watch the slow, rhythmic changes of color. I let them know I would keep the swing gently rocking and be consistent where I push, keeping the speed consistent. I want no unpredictable input for the child which could trigger a fear response, particularly when their vision is obscured. The lycra swings can also be used in eliciting joy, activation, and playfulness.

Susan Susan was recommended to come to the clinic after several suicide attempts. She was 14 years old and had been born with a physical condition that challenged her balance and made it hard to dance, a passion she desperately desired to be able to do. She was struggling at school and felt isolated watching her friends engage successfully in gymnastics and team sports. She arrived at the clinic and took one look at the gym and wanted to turn around. I encouraged her to stay and she began to realize the equipment provided her gravity-­free options for movement. Remembering her joy of dancing, history of poor standing balance but upper body strength, I asked her to select a favorite piece of dance music. I hung up the swing and demonstrated to her how she could move within and on the swing in multiple and varied ways. Her smile broadened. I turned the music up, loud enough to surround us with its beat and she began to dance in the swing. It was like watching this girl come alive. She spun, hung, and climbed all over the swing in time to the music. She then requested we repeat the process over and over and then asked if I could record “her performance.” Although physically tired by the end of the session, she excitedly carried my phone upstairs, sat close to her mother, and proudly shared her success. There was no difficulty selecting the equipment and activities for Susan because many of the children who come to us have balance issues. I have found, I do not always have to directly address this skill for it to improve. Based on Schmahmann’s cerebellar theory (2004), “the cerebellum not only coordinates movement but also emotions and feelings.” I come from the other end of the balance challenge and instead, address the child’s regulation. The balance often improves as the child becomes more regulated!

Past Reflections Please let me emphasize this knowledge did not just come from theory. As a graduate dance movement therapy student in both a school and residential-based setting, I realized if I didn’t figure out how to keep the children engaged and contained, I would be chasing an entire group around the playground or clinic. I had many close

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encounters! It was not the ideal situation when I was being evaluated and trying to make a good impression. I scrambled to notice the features of an activity that were helpful and the others that I needed to avoid like the plague. Hence the equipment and activities I am sharing are based on many hours of experience. You too can start to look at the space surrounding you and your various choices. Think about how you want to engage the child. There will be successes and failures, but learning and growth for both you and your child can come from these misattunements. Don’t worry! Just get in there and start. And keep asking the question “why?” Welcome to this path of discovery!

Out of the Clinic This containment work is the basis of the regulation work I find myself doing with the children, particularly early in their attendance to therapy. As I have already mentioned, I have the wonderful opportunity to use a variety of equipment….so what if that option is not available? Generally, the child will seek the containment he/she needs. This is their attempt to regulate from within their repertoire. And again, if it is not socially convenient look around and see what could meet their needs. Ensure they and others are safe. In the home, respecting the child’s own space is ideal. Their bedroom, for example, can become a safe haven. It needs to be a place to go for safety, not punishment. It potentially then allows their belongings to also be respected. But again, this is the perfect scenario because siblings exist! Often I hear parents complain about their child’s lack of empathy and ability to share. But frequently the child has not had respect from others for their own things, and thus does not want to share them. This is why, creating and reinforcing a safe space where the child can go is important in a household. Sometimes again creating the illusion of their own space with a screen, or a curtain can meet these needs. Pulling a child’s bed a foot away from the wall can create a safe place stuffed with pillows. They can retreat headfirst and have less chance of being disturbed. I have also had parents in a multi-child household purchase a bed tent. This can fit onto a child’s bed. The child can zip it up for privacy or claim an area that is theirs more effectively. If even this is not possible, it is important to find opportunities for the child to play undisturbed. This can be facilitated by engaging the other children in another activity or at a different time of day. Give them their own sense of space. Equipment that calms and is better suited to family living can be introduced into the home. Examples include a rocking chair, a porch swing, a hammock outdoors, or an indoor style with a frame that can be installed and available as the child needs regulation assistance. I do not, however, prescribe the same swing or even a swing to every child. I assess their need for a safe base and recommend the design and form accordingly.

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When Does the Felt Sense of Safety Start? I recall a conversation I had with a much-respected colleague trained in Eye Movement Desensitization and Reprocessing (EMDR) and a fabulous clinician. She pondered the question of safety and identified she would invite her client to focus on creating a safe place in their mind and would support this creation often with sound or scent from candles. She paused and reflected that the sense of safety must have started earlier on in the session. She then concluded where she sat created this sense of security. She recalled she always sat off to one side of the client and pondered that it was like a “heart-to-­ heart” connection. Again, she stopped and reconsidered her office space. She realized where she sat also allowed the client to have free access to the door should they need it. This reduced any sensation of feeling her clients were feeling trapped. I encouraged her to further consider the structure and her use of the room. How were the chairs placed? How did she enter the room? What was the consistency of her approach and structure of the sessions? She realized the sense of safety started long before the client was cognitively invited to create a safe place in her mind! Yes. This container is literal and “felt.” The interactive web of safety does not consist of just one element but a combination of large and minute shifts, a dance of attunement. Too often, in this world of cognition and constant training, I notice one can become absorbed in sharing and applying techniques, and the foundation of security is lost from our attention. Some clinicians just “seem to miss the mark” when working with clients because their focus is on the psychoeducation or technique. Instead, if they remain quiet and watch in the way an attuned mother does with her infant, they would learn a great deal. They would notice subtle shifts of position, eye gaze, breath, and attention and be able to reflect and attune in such a way the client would feel “felt” and “held.” It is difficult for language and logic to override the body’s visceral, gut-felt responses to perceived safety.

Can I Take the Risk? These children, who too frequently have experienced insecure attachment, need to experience a sense of safety to reestablish or create new foundations and perceptions of their world. This “secure base” is essential for them to consider adopting different coping strategies, and to dare to step their foot onto the threshold of exploring their past trauma experiences. Consider your own trepidation of sharing a vulnerable moment with someone. You too, pay close attention to the other person’s nonverbal cues and their attunement to you. You would unlikely share a personal experience, without this felt sense of safety. It is not enough to simply state it is a safe place. It needs to be “felt” to the core!

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References Ayres, J. (1973). Sensory integration and learning disorders. Western Psychological Services. Champagne, T., & Stromberg, N. (2004). Sensory approaches in inpatient psychiatric settings: Innovative alternatives to seclusion and restraint. Journal of Psychosocial Nursing, 42, 35–44. Dunn, W. (1999). Sensory profile. Pearson Assessments. Eichinger, I., Schreier, M., & van Osselaer, S.  M. J. (2022). Connecting to place, people, and past: How products make us feel grounded. Journal of Marketing, 86(4), 1–16. https://doi. org/10.1177/00222429211027469 Farhangi, D. (2020). Designing spaces to help people feel emotionally safe in the workplace. Home/Research and Insight/Blog/Designing spaces to help people feel emotionally safe in the workspace. Gesler, W., Bell, M., Curtis, S., Hubbard, & Francis, S. (2004). Therapy by design: Evaluating the UK hospital building program. Health and Place, 117–128. Kaplan, B. J., Polatajko, H. J., Wilson, B. N., & Faris, P. D. (1993). Reexamination of sensory integration treatment: A combination of two efficacy studies. Journal of Learning Disabilities, 26(5), 342–347. Levine, P. (1997). Waking the Tiger-Healing Trauma. North Atlantic Books. Ogden, P., & Fisher, J. (2015). Sensorimotor psychotherapy. W.W. Norton & Company, Inc. Perry, B. (2020). 4. Regulate, relate, reason ( Sequence of engagement) [video]. Neurosequential Network Stress and Trauma Series. Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological foundations of emotions, attachment, communication, self-regulation. W.W. Norton & Company, Inc. Schmahmann, J.  D. (2004). Disorders of the cerebellum: Ataxia, dysmetria of thought, and the cerebellar cognitive affective syndrome. The Journal of Neuropsychiatry and Clinical Neuroscience, 16(3), 367–378. Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence. https://doi.org/10.1007/s10896-­013-­9535-­8

Chapter 10

Safety and the Therapeutic Management Strategies for Carers and Therapists The Therapeutic Use of Self

…I believe we feel safest when we go inside ourselves and find home, a place where we belong… (Maya Angelou, 2009)

This term, “therapeutic use of self,” is taught in therapy training, and to a broad spectrum of other service providers (Health and Care Professional Council, 2013; Taylor, 2008; Knight, 2012; Dewane, 2007; Sleater & Scheiner, 2019). But what is it? The Medical Dictionary (2009) defines the therapeutic use of self as “a health care provider’s use of verbal and nonverbal communication, emotional exchange, and other aspects of his or her personality to establish a relationship with the patient that promotes cooperation and healing.” Abson (2019) furthers this definition to include processes such as (a) attunement – being present with the client, (b) using unconditional regard – supporting the client with where they are and respecting their beliefs, (c) self-disclosure  – reflecting on how something in session has made you feel and/or sharing a personal experience and (d) balancing the power differential  – empowering the client and respecting their cultural beliefs. She emphasized the need for the therapist to consider their nonverbal communication in establishing a positive therapist–client relationship and quoted Carl Beuhner (Evans, 1971), “they may forget what you have said - but they will never forget how you made them feel” (p. 244). The majority of the therapists in Taylor, Lee, Kielhofner, and Ketkar’s study (2009) felt they had not received sufficient training in identifying the use of self. They expressed that the specific qualities of the therapeutic use of self were difficult to pinpoint, and the discussions frequently became embedded instead in the qualities of a therapeutic relationship. Solman and Clouston (2016) are in agreement and described the therapeutic use of self as “an elusive aspect of practice.” The term seems to encompass all that one does. But that may not be therapeutic! In more general terms, it is implied a person will use their qualities to create an environment of safety, through the use of themselves. But again, it does not define

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0_10

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how this is done. We have a general concept of verbal and nonverbal body language but this is not enough. I have seen some workers/parents/therapists use their body language and it did not create a sense of safety! A sense of safety and security is created within the healthy relationship between the primary caregiver and the child. The caregiver provides the external environmental safety needs of the child but the attuned caregiver also creates a perceived and internal experience of safety in the child, through her interactions and use of her body language. If we are then describing the therapeutic use of self to create safety in a therapeutic setting, I propose these are the qualities that can be applied to help reestablish the firm secure base the child has not fully experienced.

Mirrors and Reflections Understanding the impact of mirror neurons and our use of neuroception is important when entering a session or being with a child who has regulation challenges. If you regulate yourself before engaging them, your calmness will have a subliminal effect. This can be with just a pause. A few deep exhales and the vagus nerve effect will come into play and you will feel calmer. Even when a child is agitated, this is a powerful ally. The mirror neurons are not only engaged in mirroring of movement but also the intention. They affect the synchronicity between two people. If you are calm, this will have an impact on the child. When a child is dysregulated and become angry, they are often met with equal anger or a demand for redirection of their feelings. This provides the child with something to push their anger against. Each person in the interaction gets angrier. But if you are relaxed and calm, there is no counter “energy” and the child has nothing to push against. It can be a new experience for them. I am not saying fold under the pressure of outbursts, but by pausing and regulating yourself, your perceptual lens will become clearer. It will allow you to feel the emotion under the surface of the outburst and not be detoured so easily. Listen to your own attunement. Try to stay out of your head with interpretations. Adding judgment, or demanding the “child pull themselves together” sends the message they have done something “wrong,” or perhaps they are a “bad kid.” The therapist’s role is likened to that of a mother who provides her child with a secure base from which to explore. “This means, first and foremost, that he accepts and respects, his patient, warts and all….” (Bowlby, 1988, p. 152). This can be difficult. Always be aware of your own safety options, but under aggression, there is often sadness or even anxiety about the child’s own perceived sense of being unsafe. Acknowledging its existence will create different options and choices. Instead of standing rigid, you bend and acknowledge their feelings, replicating the modulating caregivers with moment-to-moment attunement. It is surprising the path that then maybe traveled if the child feels heard. On more than one occasion, the less said with the mouth and more said with the empathic nonverbal

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language, the greater the shift internally in the child. Remember if the child “feels” safe, their managing strategies will not need to be engaged and they will feel secure to explore new options or interactions.

What Can We Notice? This level of understanding can be layers deep. Just as the attuned caregiver appraises their child, there are shifts and modification dances that are continually occurring during every interaction. Here again, Kestenberg’s work can continue to play a significant role in the use of self to help with a child’s regulation (Kestenberg, 1967; Kestenberg & Weinstein, 1978; Kestenberg & Sossin, 1979; Kestenberg Amighi et al., 1999).

Body Language Let me explain further. It may become more complex than you expect, but I will try to summarize some of the main concepts to increase your understanding of body language, its interactive elements, and how you can use the information. My purpose here is not to turn you into a dance/movement therapist or to become a movement analyst, but to expand your appreciation of the complexity of nonverbal communication and to understand “a movement” or an “action” is not one thing…it is created from multiple and subtle adjustment which occur in unison. They convey the nonverbal message the child or you are trying to impart. This may help to explain the confusion I hear when a caregiver says…“I only reached out towards him and he lost it!” The real issue is….how this reaching out was done? Some people become concerned that this level of observation will make the child “feel as if they are being watched.” It is certainly not done with a notebook present! This observation does not always occur on a conscious level, sometimes it is visceral but it may be what you are “noticing.” You can become more astute to the movement qualities and shifts when trained to do so. The dance of attunement and social engagement also tightly link to the other modulating qualities of the healthy attachment figure such as voice prosody, eye gaze, and facial expressions. These are the cues most of us observe more readily. I do believe, however, that some people are attuned at a deeper level and viscerally perceive these shifts. They are often described as being more intuitive (Stanton, 2016). This is something that is more recently examined in intersubjective psychotherapy (Buirski et al., 2020; Haugvik & Mossige, 2017; Liljenfors & Lundh, 2015). Maybe this is so, or maybe not! One of my parents once said to me with a big smile on her face (thankfully), “ I don’t know what you do, but you have a witchy way of doing things!”

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Fig. 10.1 In synchronicity: Mother cradling and “containing” her infant in her arms

Literal “Holding” Our sense of neuroception can detect if someone we are interacting with is safe or unsafe. One of these markers of detection is the shaping and flow quality the “caretaker” is creating in their body. The yin and yang symbols are demonstrative of this shaping. As an infant is held by their primary caregiver, (for now I will designate the mother), she cradles the infant in her arms, shaping her body around the contours of the child’s body (Fig.  10.1). The child nestles into this container shape and is relaxed. As the mother breathes, her body accommodates this expansion and shrinking shape change, and the child reciprocates. When attuned they do not clash in their movements. If the mother is holding the child stiffly, as the child breathes their bodies will minutely push against each other, and the child will feel the misattunement and may then push away. This pushing against the mother’s body causes the attuned mother to readjust and they again fit together like pieces of a puzzle (Kestenberg Amighi et al., 1999).

Primary Caregiver Holding Given the limited parameters of professionals holding a child and because there are other ways for a child to “feel held” by a therapist, without actually holding them, I would like to focus first on holding in the primary caregiver relationship. As simple as this may seem, it is something I often notice is difficult, particularly for a

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biological parent who may have gone through their own trauma in childhood. The crying or disruptive behavior of the child can trigger the parent to their own trauma recall or attachment disruptions. They can distance themselves from these memories and feelings and then reflect this back with their own repeated disengaged interactions with their own child (Berthelot et al., 2015; Dozio et al., 2020). Many of these parents need to be shown and modeled experiences of compassionate containment. I do not mean “just” holding their child, there needs to be aliveness in the hold. This coaching and modeling can be made through eye contact, touch, positioning, gestures, and facial expressions, and accompanying explanations. I suggest it occur in small repeated increments so it can be processed and not become overwhelming. I often ask the parent to try to recall a positive holding experience they have had. I ask them to notice the accompanying visceral sensations in their own body and to draw on these when interacting with their own child. Sometimes I simply remind the parent to breathe, they often laugh and there is almost instant relaxation in their body.

The Therapist The therapist or other caregiver can facilitate a modified “holding” by sitting or reclining on the floor with the child and curving their body next to them, partially containing them as they play or talk. Even sitting with the child on a very soft surface like a large foam-filled pillow, or in lycra hammock together, can elicit shaping into each other. They both become surrounded and supported by the foam and fabric and the container is created. I have been known to climb into the lycra hammock with a child and playfully push and bump up against them, as I try to make myself “comfortable.” Every time one of us moves, we slide into the other and contour our bodies in accommodation. I am very watchful during this process, but generally, the child shares the space in laughter. The container is established by the hammock and holds us both. This is a new experience for some children. They are used to standing on their own. Playfulness can remove some of the negative associations the child may have established about being “held.”

 erceived Holding and Creating a Sense of Safety: Shaping P and Response When we are in synchronicity with clients, the subtle change of our actual bodies shaping around each other in space, without even having physical contact, also exists. If one watches for it, it can be seen. But it is more often “felt” at a visceral level. When someone, for example, steps in front of you as you are walking, they

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interrupt your path and you feel an abrupt clash as if someone has stepped into “your bubble.” You stop or shift your body in another direction and curve away from them despite no actual physical contact. This is “shaping in space.” Ueshiba, the founder of aikido, describes this shaping shift from the perspective of a person’s response to aggression. “If your opponent strikes with fire, counter with water, becoming fluid and free flowing. Water, by its nature, never collides with or breaks against anything. On the contrary, it swallows up any attack harmlessly” (Stevens & Krenner, 1999, p. 127). When we go in with an agenda to do a particular activity or to impart a certain concept, that is not the same as the child’s agenda, a clash occurs. How we approach and respond to each “parry” will impact the outcome. Going in with “rigidity”(mentally or physically) creates a boundary to push against. Moving with a plan, but having a flexible response, is a completely different scenario. Kestenberg (1985) describes this shape flow …as a conveyor of trust in the environment and …the foremost vehicle of relatedness to other…(p. 143). When a mother holds her child and is disconnected or disengaged physically or psychically from her child, the child senses the disconnection, there is no firm “container” being provided. Mothers who themselves have had childhood experiences of limited holding, tend to hold their infants in a similar pattern. The infant embodies this “shrinking” and they can develop feelings of “self-doubt and distrust” (Kestenberg Amighi et al., 1999, p. 123). It is important, as a therapist or a caregiver, when interacting with the child to remember to provide stability not only in the equipment being used but also in your own presence.

Proximity Safety can also be elicited by proximity. Recall the watchful eye of the mother in the attachment process as her child explores and plays from their secure base. She is nearby and within reach of her child. The caregiver and therapist can be proactive and provide safety by just being close. This modulating effect can be particularly helpful in a busy environment like a waiting room, grocery store, or even a classroom. The caregiver does not hover, but is close enough should any assistance with co-regulation be needed. This security is simple and can help a child be less vigilant, allowing them to attune to other experiences. Too often, this needs to be demonstrated. Over and over I hear expectations being loudly spoken from the seat of a couch. The child just ignores them. The caregiver needs to get up and move closer to the child. Their voice will then be softer and less triggering for the child. In this world which is so language-oriented, and now digitally minded, this element of merely being present can get lost. It is also important to remember that many of the children are not functioning socially at the age level. They need to have the experience of younger level skills to be able to integrate them and move on in their social and interactive development.

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Postures and Gestures Creating a presence can be elicited with an awareness of your posture. Postural movements encompass your whole body and there is not a separation from the peripheral movements. Your whole body is vested in the movement. An example can be seen when a child walks confidently into the clinic. They have had a happy and successful time and everything nonverbally reflects this. On the other hand, the child who is slumped over the assessment table with their head bent and making limited movement can reflect disengagement and possible depression. Their whole body tells the message. Gestures, on the other hand, tend to be limited to a part or periphery of our body. A light flick of our hand, the brushing away of our hair, or the quick shrug of our shoulders are examples of gestures. They emanate less commitment to the movement. When people are being genuine, we “feel” and notice it. The person is grounded, their whole body is engaged and they feel very present. When someone is less committed, their body will reflect this lack of importance and their movements will be segmented and further from their trunk.

Posture: Full Body Involvement Being present with a client involves a postural presence; being wholly engaged and not distracted. These qualities are the reason I have a challenge when I hear “fidgets” being given to children who are restless. Fidgets are objects such as stretchy toys, squishable balls, or puzzles that are manipulated in a child’s hands. Because they are used by the child so peripherally, they will distract him/her and keep them busy, but the child is not able to embody the calmness into the core of their body. Their effectiveness is usually short-lived and forgotten because of this. Engaging the child in postural full-body movement instead will develop a more sustained level of regulation. It is felt to the core!

Stillness These do not have to be heavy proprioceptive activities. One of my all-time favorites is a small plastic bird a child balances on the tip of their finger. Once balanced, I have the child walk a circuit in the room or down the hallway. Stillness and calmness need to be throughout their whole body for this to be successful. If the child is only attentive to maintaining stiffness in their finger, and not stabilizing in the core trunk of their body, the bird will fall. It is not about telling the child to be calm, they realize by making shifts in their body, what is required. Some will need coaching, but when they integrate it, they are up for more challenges.

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Here Are Those Elements Again: Weight, Time, and Direction As I had previously mentioned, the elements of weight, time, and direction are in every movement. Weight moves along the continuum of heavy to light, time from sudden to sustained, and direction from direct to indirect. Since these elements tend to group together with similar qualities, this knowledge can be utilized at a more conscious level to redirect behaviors to become more socially appropriate to the situation.

Playing With Equipment Adjustments By looking at the space and the equipment choices, you can add elements you would like to have the child use and expand their repertoire without them necessarily having to consciously elicit them. This is similar to the attuned parent who gives the “just enough” frustration tolerance to the child by adding or withdrawing elements to encourage the child to expand their skill sets. If, for example, I want to shift a child’s qualities away from increasing aggression, I change one element at a time and the others will follow. Frequently, these children are expected to stop what they are doing completely. This requires them to stop a strong combination of elements (strength, directness, and suddenness) and shift it to the extreme opposite of lightness indirectness and slowness. They will tell you in no short terms, what they think of that idea and won’t. The shift is too hard to do! Recall when you were feeling angry, how hard it was to turn things off when you were already on your rant. Instead, I change the element of time. I add slowness to my speech, with pauses, deep exhales, and slowness in my own movements. I start to co-regulate the child through the mirror action, synchronicity, and the effects of attunement. The time component will slow and the other elements of directness and weight will gradually shift in accompaniment. The child can calm down more easily. You can alternatively add a piece of equipment that has slowness as its dominant quality, such as doing a big push off the wall with a swing. The bigger the push is, the longer the wait for the next exertion. The pause is naturally incorporated and the elements of indirectness and lightness will link together. Walking outside can calm children again because it lets them stomp. It is difficult to stomp quickly if you want to make “your point” that you are annoyed. They have to slow down. They will simply run out of energy. Then you can add in additional pauses to notice the surroundings. The child becomes aware of things other than themselves and you can then engage them even briefly. But they will notice you are there. Nature and the surroundings will emulate slowness. The plants won’t grow any faster even if the child insists.

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Get Out of Your Head and Into Your Body This is not voodoo. These are ways to redirect behaviors using the modulation qualities of the healthy relationship. I have simply extracted the micro-qualities of the movements. Some of you will do this naturally without being able to label what it is you are doing which is more effective. Follow your intuition. Get out of your head and into your body. Our bodies are wiser than we give them credit.

The Pre-effort Elements Finally, I would like to discuss the pre-effort elements further. These give you the ability to anticipate something, a potential derailment before it happens. The child when about to do something will momentarily quieten, be still and focus in the direction of their “plan.” This could be a matter of a second or even part thereof. When a parent says “my child always runs from me when we transition,” you can pay attention to the child’s preefforts. You can pay attention to the child’s pre-efforts. You will notice the minute movement shifts. Instead of the child then bolting down the corridor, as they are “winding up” to run (this happens sometimes in microsecond) and can catch their attention with a simple statement such as “I love your jacket,” or calmly step between them and the door while walking out with the parent casually blocking their way. It is easy to see the channeling if you are watching for it. Again be proactive instead of reactive! It is so much easier!

Eye Gaze and Orienting A parent can sometimes just give “that look” and the child knows there will be trouble if they follow through with what they are planning or doing. A parent can also convey excitement with “the twinkle in their eyes” and playfulness follows (Fig. 10.2). Both parent and child can drop eye gaze to rest from an interaction, or to reduce its intensity. Gaze can be powerful. When we look toward someone, we notice their facial expressions. It provides us with prime information about the other person’s emotions and intent. Many of the children I have worked with have learned to drop their eye gaze. It may serve as a protection to not be seen seeing things, to avoid confrontation, to “become invisible,” or to avoid a direction or demand. There are many purposes. In doing so, however, they continue to miss also witnessing joy and caring which can so eloquently be captured in a person’s eyes. Orienting toward a person is an early developmental skill a child learns in their relationship with their caregiver. This opportunity to be seen and acknowledged facilitates an increase in the child’s own self-image and internalized sense of security and stability.

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Fig. 10.2  Mother with her baby securely held on her lap. Their eye gaze is connected and filled with joy and attunement

If their attachment relationship has not provided these experiences, the child learns to be vigilant, misinterprets expressions, and has difficulty learning new skills because they are not looking at them being modeled. They have more difficulty co-regulating with another person and have challenges socializing successfully because they are missing the essential nonverbal cues. So many positive experiences can be missed. I have seen many therapists interacting with a child, but they have not paid attention to this important component of social engagement and regulation. The child then tends to do the same activities and is almost oblivious to the therapist in the same room. Because there are many reasons why the child is disengaged visually, it is not something you demand. This actually may be repeating the trigger that has him/her avoiding eye contact in the first place. I usually try to position myself in a way the child can see me during a playful activity such as the “Where’s Phillip?” game or as the child changes layers in the hammock and I peek in “to see if they are still comfortable?”

Samuel Samuel, a 5-year-old with a significant history of physical and emotional abuse, was particularly averse to looking at an adult’s face. Instead of demanding eye contact, I simply positioned myself at the end of the slide and lowered to a squat. The child had little choice but to see me. I grinned and expressed my joy. He noticed me! A

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child who has experienced trauma and neglect can easily feel negated. One way of managing this is to negate others, especially caregivers. They avoid eye contact. Although this is a way of coping, it can impede relationships. These are times when it is helpful to catch their eye.

Brian Brian was 7 years old was found wandering the street at night. His parents were involved with a known drug cartel. He had witnessed both domestic violence and street violence. He had been removed and placed in multiple foster homes. One of which was also abusive. He had many reasons to avoid eye contact! When starting to reestablish safety in a gaze, I only briefly looked directly at Brian. Instead, I shifted my gaze to his temple or slightly off center. These brief encounters were more easily tolerated and were then perceived as less threatening. (Anyone who has worked with fearful animals will know this type of eye contact is universal.) I then positioned myself at eye level, by sitting on adjoining mats as he moved through the lycra hammock. He could see me, again without the gaze being direct. I would occasionally ask him to look to something like the fish, or a tree outside the window. Almost in a rebound, he would look at the suggestion and then look back at me. Whenever he did this, I was conscious of being very present and smiling back gently. Because I was at eye level, he had the opportunity to catch additional glimpses of me without any demands attached. If I was demonstrating a new activity and I noticed he had dropped his eye gaze, I would pause in my conversation, and he would reconnect his gaze wondering why I had stopped. Again each new eye contact would be greeted with pleasure. I selected visual activities such as using a lighted kaleidoscope for him to view. We would then share “the best colors” by transferring the kaleidoscope between each other. I would also roll balls or toy cars through a fabric tunnel, placing him at one end and me at the other. Although the cars and balls were “the focus,” the narrow opening meant we saw each other’s faces each time one was sent cruising through. Using playful activities meant every time he made eye contact or looked toward my face, it was in fun. On other occasions, I would have him quietly track a laser light. We did this in unison. The game would vary with us trying to guess letters the other had written on the wall, or “catch” a cat toy laser spot on the floor as the other person moved the pointer. I also coached his foster parents to avoid demanding his eye gaze when being reprimanded. He needed more positive experiences repeated and repeated. When he came in one day and shared a simple joke with me I nearly fell over. He looked at me spontaneously the whole time and beamed when I responded with a laugh. And then exclaimed, “You’re funny!?”

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Voice Prosody The quality of prosody can be introduced in many different ways to elicit a perception of safety. Singing has been used for generations and studies have found when a mother sang to her child, there was greater positive effect, closeness, and social bonding between the mother and her child. The researchers also noted that there were physiological changes in measures associated with reduced anxiety (Fancourt & Perkins, 2018; Loewy, 2015). Singing can be incorporated in a treatment session or encouraged at home. It increases the opportunity to positively interact, particularly with a younger child. It is hard to sing without being regulated because you have to take deep breaths. This alone is a good reason to sing. Remember in the attuned relationship, prosody is not in isolation from eye contact and facial expressions. If you consider adding a tilt to your head, it will take away the element of directness and inferred confrontation, and convey an element of listening and interest. But, pay attention to any drop in the child's visual focus toward you as you speak. It is often indicative of too many words being used. Remember language goes offline when a child feels overwhelmed or stressed. A monotone voice can come across as threatening. If your voice is naturally limited in its range, then add in gentleness to your gestures and eye gaze to help with the “partaking” of communication. I had a child who became very dysregulated in a class. It was confusing because he had always managed at school. When I enquired, I discovered the school had switched his female teacher to a male teacher. The teacher was not an intimidating person but he had a very low voice. I suggested the school use the female aide in his class to assist with giving directions and assistance. She helped to co-regulate the child by the prosody of her voice and he was triggered less. The child’s behavior turned around! Remember prosody of the mother’s voice usually occurs while there are back-­ and-­forth exchanges of movement or playfulness with her infant or child. By engaging in an enjoyable playful activity, the prosody can become linked viscerally and biochemically to the positive social experience and is likely to be remembered in the child’s body. However, vocal prosody does not translate into marked animation. Nothing has me cringing more than an adult overly emphasizing and pretending to enjoy an activity. Their body language often says otherwise. There will be a clash, misattunement, and a potential decrease in trust and safety. The child will notice the nonverbal messages above all else. Matching body language and your voice is essential. It is not the content of what you are saying, it is how it is communicated (Kykyri et al., 2016).

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Rhythm The caregiver’s use of rhythm provides the predictability of continuity and also elicits a sense of safety. It is present in the mother’s heartbeat and her breath. It is replicated in the forward and back movement of the child to and from the secure base during exploration. It is present as a child learns to crawl and rocks back and forth on all fours and in the rhythm of walking. Sucking is the simplest of these rhythms (Kestenberg, 1967). As the child grows, their repertoire of rhythms also expands and varies. But in times of stress, we all fall back on the continuity of the earliest repetitive back-and-forth movements, to calm ourselves. The attuned caregiver spontaneously walks and rocks her child when he/she is crying or agitated. Its calming qualities are incorporated into the porch swing, the rocking chair, and the child’s cradle. Rocking intervention outcomes can be influenced by the direction and the speed of movement. When a child is held in a vertical position and rocked, it tends not only to calm them but can also alert them. When the child is held in a horizontal position, the effect is more sedentary. The rate of rocking was found in a study to be 30 cycles per minute (Bryne & Horowitz, 1981). Interestingly, another study continuous rocking versus intermittent rocking was more soothing (Brackbill, 1973). We can use these rhythms and positions in regulating interventions and replicate them for the child with the various pieces of play equipment. It is viscerally linked and associated in our body memory as relaxing. Advertisers have the images of hammocks strung between the trees when trying to sell a vacation spot. We generally associate swaying with comfort and security and feel this internally.

Music When I select music, it is usually about 60–80 beats per minute, similar to the rocking rhythm and also the mother’s heartbeat. I chose quiet, instrumental pieces. Lyrics tend to become more quickly associated with memories and distract the child from “being in the present moment.” Music acts as a valuable bridge when the room is quiet. Rhythm is regulating. It is a key element in creating a sense of safety. It is playing constantly throughout the day.

Touch And here we are at touch. Touch assists with modulation. It is an important element for the development of a child’s body image and self-esteem. Sadly, touch for children with complex trauma backgrounds may have been largely absent or associated

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with negative experiences. In the therapy setting, because of the legal liability issues that are associated with touch and the child’s history of abuse, direct touch is often not possible. Clinicians, however, can still give touch experiences through equipment and activity selection. The previously mentioned swings are one example. Experiences that engage the “whole” child such as being in a ball pit, or snuggling into a warm sleeping bag will provide more positive input at one time. But again, watching the child’s responses is essential. This can be too much for some and an activity that is more peripheral such as applying skin lotion, brushing their own hair, or using play putty will be more tolerable.

Heidi I recall one adolescent, Heidi, who was diagnosed as an infant with failure to thrive. She had been left isolated and given minimal attention for the first year of her life. She was rarely touched or rocked and would lie unstimulated in her crib for hours. She rarely cried as a young child. She had learned no-one would come anyway. If she expressed her needs, they were frequently unmet. She shrunk inside of herself. It was safer. Although Heidi had been placed with a caring family, these memories continued and she managed her life in a similar manner despite her age. When she arrived in the room, she would come in quietly and barely parted the air around herself. She would drift into and through activities and conversations. It was as if she had no “container,” not even the boundary of her own skin. She would draw away from any direct physical touch almost like an amoeba from a noxious stimulus. But, she needed touch to know where and who she was. She had tried on several occasions to commit suicide believing “no-one would notice her disappearance.” I incorporated activities such as the lycra hammock because of the natural rebound from movement in the fabric. Sometimes, she needed to just lie in the hammock quietly and feel supported. I would quietly talk with her to reduce her tendency to dissociate and to keep her socially engaged. After a period of time, when I sensed she was starting to “inhabit” her body and would be safer, I’d ask her to start moving up and down through the layers of fabric. Each time she did, because of its innate instability, she would have to focus on constantly readjusting her body. If she didn’t, she would fall out onto the soft foam mattress below, getting deep sensory input, and have to exert herself to climb back in. This type of activity activated her awareness of her own body, and her body in relation to her surroundings. She would slowly start to be “present” and I would see some weight almost pouring into her arms, legs, and body. She would become more “grounded” and “notice” me in the same room.

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Brushing There are many activities that can incorporate touch and be provided for a child. But some children need more directness. I have been lucky to train and experience several body-focused approaches to healing. Where ever the origin of the technique, the emphasis on providing effective treatment was always on truly “being present.” Anyone who has had a massage or bodywork will understand the difference between someone who is attuned and someone who is merely going through the steps. It is night and day. One can relax and the other creates more tension. Keep this in mind. When deciding whether or not to do some brushing, it is important you understand the child’s trauma background. I am extremely reticent to use brushing if a child has had any sexual abuse or has been held down in any way. Triggers can be elicited too easily, especially if a secure relationship has not already been established. I will always share with the caregiver information about the brushing and have them watch and learn how to do it if the child has been able to tolerate it well and calms. Removing “secrecy” element is important to help the child associate touch as a positive and more socially acceptable experience. I have developed my style of brushing based on the more eastern body works I have experienced. It is different from the more familiar Wilbarger’s Brushing protocol, used by many occupational therapists. The goal of the brushing is to calm, not to activate. The brushing is slow and repetitive. I repeat the same process each time it is done with a child, but will always stop if the child wants to move away. I will extend the activity, if they are requesting it or have calmed significantly from their previous high activity but need it to be continued for further regulation.

The Brush I use a soft sensory brush and let the child feel it and brush themselves. If he/she shrugs away from the brush during the introduction, I suggest waiting for another time until the child is less vigilant and can tolerate the touch without withdrawing in their body. If they are not averse to the brush, I will ask if they would like me to brush them. Again this permission is important. Too many times these children have had their bodies violated without ever giving permission. The children, who have experienced the brushing before, will rarely deny the opportunity and will rapidly flop down on the soft mattress. It is quite something to have the “tough” 10-year-­ old, feign disregard, and then completely relax and then claim as casually as they can, “You need to brush the other side again because ‘it’ needs it again!”

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The Technique I recommend the brushing is done only in prone position. This is a more “protected position” for a child. It is less open and vulnerable compared with lying on their back. If the child feels uncomfortable or is vigilant, however, they can sit and still be brushed. If the brushing is accepted, the child is asked to turn their face toward the therapist, orienting so there are no surprises or unknowns. This way the child can anticipate each contact. With each area brushed, or even each stroke, I narrate how many times and where I will be brushing. The brushing process is over clothing and depending on the child’s responses, is generally on their backs first. If this appears to be anxiety-evoking, I will instead brush their arms. Because it is more peripheral some children will tolerate this better for a first contact. I use a firm pressure but I always check in with the child on the amount of pressure they want. Light brushing can stimulate so a firmer pressure is preferable. I start with the child’s back, each arm, and then finish with each leg. If a child requests an area not be brushed, I respect their request. I tend, however, to start on their back because it is central and the core of their body and if this ends up being the only area they can tolerate being brushed, then it will likely have the greatest impact. I always balance the brushing. I brush one side first and then the other. I avoid leaving one side brushed and the other untouched. This can be associated with the felt sense of things feeling incomplete. I want to facilitate wholeness! I explain this purpose to the child if they are feeling restless and they rarely object. On these occasions, counting out loud helps increase their tolerance. They know how much longer it is likely to be before the brushing is finished. On the back, the brush is stroked from shoulder down back to the waist of their trousers and then circles through the air back to the starting position on the shoulders. Three strokes are completed. One off center, to the side of the backbone, another midway between spine and child’s side, and then one more toward their side. I do not stroke on their actual side because it is usually more sensitive and ticklish. Each stroke is alternated first on the left side and then on the right side to maintain balance and predictability. The brush action on the arms extends from shoulder to the end of fingertips. It is completed with an even, slow stroke and is then lifted to return to the shoulder. Emphasis is placed on the brush brushing off the fingertips smoothly as part of a cycle. This is consistently repeated and started again. Five brushes are given to add predictability. Each finger is brushed. I always tell the child when I am shifting and standing to reach the other side of their body. This reduces the chance I will trigger their vigilance. The stroking on the legs starts at the just below the head of their femur. I then move down the side of their leg to avoid the back of the knee and brush from their hip to the outer side of their foot. At the foot, I brush along the outer brush to the tip of the toe. Again this avoids sensitive areas. I do this five times to emphasize predictability and each toe has a turn being accounted for by a stroke.

And Don’t Forget Playfulness!

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Calmly transitioning from one movement to another is important and the speed needs to be sustained and very predictable. It is important to constantly monitor your own body tension. I take exaggerated deep exhales and the child often mirrors this back. Calmness can elicit calmness. Research on brushing rates, consistency of pressure, and the continuous stroking are in support with what I have found has intuitively worked (Aguirre et al., 2019; Weiss, 1979).

Warmth Sometimes a child can be so irritable or dissociated; touch is not something they can tolerate. When this is the case, I will offer another route. I ask if they are feeling warm enough. This has them momentarily pause and survey their body. I offer them a soft blanket or heat up a corn-filled animal to drape around their shoulders or to place in their lap. This simple provision of comfort can sometimes be just enough to demonstrate and reflect that you care and respect how they are feeling. If they feel “felt” and understood, they in turn can feel more secure. Again, these gestures replicate the attunement found in a healthy attachment relationship.

And Don’t Forget Playfulness! This activity incorporates almost every essential modulating element. Regulation is not only about calming. It is wonderful to see a child’s serious look melt away and for even a brief moment, to become playful (Fig. 10.3). This is so often a missing experience. Some children don’t know how to play and simply repeat what they have seen on videos or in their daily lives. They have difficulty with animating toys or imagining “the impossible.” Blake, an Australian psychoanalyst, has made a significant contribution to my awareness of play. He notes “when you find yourself yawning, or not paying attention to the child’s play, then it is lacking the ‘aliveness’ and the child is merely making the motions of play versus engaging in playfulness” (P. Blake, personal communication, March 2, 2021). I have been told emphatically by a 5-year-old that there is no such thing as dragons, fairies or magic, and a sheep cannot be colored orange. I know we have a lot of play to do! Play allows the child to “take on different roles,” to “be the part,” to feel what the other character feels, to problem solve, and to be wildly creative. Being truly creative, they get to know who they truly are! This playfulness and opportunity for play can and should be brought into your interactions. When a child and a caregiver are attuned, I believe this is one of the most amazing experiences that can be witnessed. The dance is alive, interactive, and totally joyful! What a superb goal to head toward in treatment.

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Fig. 10.3  Mother tossing her child in the air: Both the mother and the child are secure and trusting in their play together

Caregiver Education Understanding and working with the caregivers is essential. For the greatest opportunity for repetition of consistency and contact occurs within the child’s home. Education needs to be provided to help the caregiver translate the events of the treatment session and transfer them into their own homes. Guided by the neurodevelopmental and biochemical evidence, interventions need to be suggested that can provide the child with new experiences and ways to develop new neural pathways and responses. This is the ideal situation. In reality, however, the therapist needs to be aware of the high incidence of intergenerational trauma in the families of these children. It has not been uncommon in my practice, to have parents share their own trauma experiences with me. Sadly, it is also not uncommon for the more traditional parent education classes to have limited follow-through by these parents (Newman et al., 2011; Newman, 2017; Slade, et al., 2005; Wakelyn, 2019). Sometimes when a child starts to behave differently, this can unsettle the parent despite their wanting remediation for the child’s behaviors. The change creates novelty and unfamiliarity, something which is avoided with vigilance. Supporting the parent, understanding their unconscious or overt resistance to change, and addressing their level of tolerance to change, helping them problem-solve and to learn playfulness can be critical in the process of improving a child’s ability to regulate.

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This education can come in a variety of forms. Commonly, in our clinic, we share interventions and have the parent witness any successes their child has had during activities. We also discuss resilience and the way a child can use managing behaviors in an attempt to gain a sense of safety, even if not socially convenient. We model proactive tracking of antecedent events before the disruptive behaviors and then demonstrate our process of trying to identify the child’s possible concerns and needs. When the parents start to understand that the child is using their behaviors as a form of communication, they begin to recognize that their child needs support and co-regulation. I teach the modulating qualities and skills to the parents, covering the elements as I have done here in this chapter for you. The caregivers become less dependent on rewards and consequences and start to notice the precursors to the behaviors. This allows them more opportunities to amend their behaviors proactively. They feel less personally persecuted and more compassionate. This is reflected back to the child in their new ways of interacting and removes them from the vicious cycle of constantly punishing their child and monitoring which items have been taken away. Education of school and staff is equally important. Children spend large portions of their day in school. The staff have the potential to greatly impact the child’s regulation and social development by modeling and engaging in co-regulation. These children have frequently missed opportunities to use language as a way to express themselves and to select key points in a social conversation. Their communication experiences have often been more directive. Due to inconsistencies in their life, they struggle with time and cause and effect concepts and organizing things in a logical sequence. They often lack an understanding of empathy and taking someone else’s perspective because theirs has never been considered. And their vigilance or dissociative behaviors interfere directly with their academic learning because they may be feeling unsafe and all their energy is focused on their real or perceived “survival” (Massachusetts Advocates for Children, 2005). When the adults in the child’s life are punishing the child for behaviors, versus understanding their purpose and function, the environment which the child is already perceiving as risky becomes more so and the adults more untrustworthy. This cycle needs to be stopped. I believe that it is essential to identify the environments in which the child feels safe and the personnel in these environments are regulated and more attuned with the child. This will have a major impact on reducing challenges of disruptive behaviors at home and in the classroom. The child’s perceived sense of safety needs to be emphasized and accounted for. As long as the child feels under threat, no amount of reward or consequence will entice their frontal lobe and executive functions to engage. Academic learning will continue to be out of reach for the child, and the targeted goals will simply be unobtainable. Development can only proceed when there is sustained understanding and attuned safety.

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References Abson, D. (2019, April 24). Therapeutic use of self. uk.linkedin.com/in/Deborah-­abson-­66aa13108 Aguirre, M., Couderc, A., Epinat-Duclos, J., & Mascaro, O. (2019). Infants discriminate the source of social touch at stroking speeds eliciting firing rates in CT-fibers. Developmental Cognitive Neuroscience, 36, 100639. Angelou, M. (2009). Letter to my daughter. Random House. Berthelot, N., Ensink, K., Bernazzani, O., Normandin, L., Luyten, P., & Fonagy, P. (2015). Intergenerational transmission of attachment in abused and neglected others: The role of trauma-specific reflective functioning. Infant Mental Health Journal, 36(2), 200–212. https:// doi.org/10.10002/imhj.21499 Bowlby, J. (1988). A secure base; Parent-child attachment and healthy human development. BasicBooks. Brackbill, Y. (1973). Continuous stimulation reduces arousal level: Stability of effects over time. Child Development, 44, 43–46. Buirski, P., Haglund, P., & Markley, E. (2020). Making sense together: The intersubjective approach to psychotherapy. Rowman & Littlefield Publishers. Byrne, J. M., & Horowitz, F. D. (1981). Rocking as a soothing intervention: The influence of direction and type of movement. Infant Behavior and Development, 4, 207–218. Dewane, C.  J. (2007). Use of self: A primer revisited. Clinical Social Work Journal, 34(4), 543–558. https://doi.org/10.1007/s10615-­005-­0021-­5 Dozio, E., Feldman, M., Bizouerne, C., Drain, E., Laroche Joubert, M., Mansouri, M., Moro, M. R., & Ouss, L. (2020). The transgenerational transmission of trauma: The effects of maternal PTSD in mother-infant interactions. Frontiers in Psychiatry, 11. https://doi.org/10.3389/ fpsyt.2020.480690 Evans, R. (1971). Richard Evans’ quote book. Publishers Press. Fancourt, D., & Perkins, R. (2018). The effects of mother-infant singing on emotional closeness, affect, anxiety, and stress hormones. Music & Science. https://doi.org/10.1177/2059204317745746 Haugvik, M., & Mossige, S. (2017). Intersubjectively oriented, time-limited psychotherapy with children: How does the therapist evaluate the therapeutic process and what are the therapist’s tasks? Journal of Child Psychotherapy, 43(3), 353–368. Health and Care Professions Council. (2013). hcpc-­uk.org/standards-­of-­proficiency/ occupational-­therapists/ Kestenberg, J.  S. (1967). The role of movement patterns in development 1. Dance Notation Bureau Press. Kestenberg, J. S. (1985). The flow of empathy and trust between mother and child. In E. J. Anthony & G. H. Pollock (Eds.), Parental influences in health and disease. Little, Brown and Company. Kestenberg Amighi, J., Loman, S., Lewis, P., & Sossin, K.  M. (1999). The meaning of movement: Developmental and clinical perspectives of the Kestenberg Movement Profile. Gordon and Breach Publishers. Kestenberg, J., & Sossin, M. (1979). The role of movement patterns in development 2. Dance Notation Bureau Press. Kestenberg, J.  S., & Weinstein, J. (1978). Transitional objects and body image formation. In S.  A. Gronick, L.  Barkin, & W.  Muensterberger (Eds.), Between reality and fantasy: Transitional objects and phenomena. Aronson. Knight, C. (2012). Therapeutic use of self: Theoretical and evidence-based considerations for clinical practice and supervision. The Clinical Supervisor, 31, 1–24. Kykyri, V., Tourunen, A., Wahlstrm, J., & Kaartinen, J. (2016). Soft prosody and embodied attunement in therapeutic interaction: A multimethod case study of a moment of change. Journal of Constructivist Psychology, 30(3). https://doi.org/10.1080/10720537.2016.1183538 Liljenfors, R., & Lundh, L.-G. (2015). Mentalization and intersubjectivity towards a theoretical integration. Psychoanalytic Psychology, 32(1), 36–60. https://doi.org/10.1037/a0037129

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Loewy, J. (2015). NICU music therapy: Song of kin as critical lullaby in research and practice. Annals of the New York Academy of Sciences, 1337(1), 178–185. Massachusetts Advocates for Children. (2005). Helping Traumatized Children Learn: A report and policy agenda. Massachusetts Advocates for Children. Medical Dictionary. (2009). Farlex and Partners. http://medical-­dictionary.thefreedictionary.com/ therapeutic+use+of+self Newman, L. (2017). Parenting with feeling: Early intervention program for high risk parents and infants. https://www.mav.asn.au/__data/assets/pdf_file/0015/21741/MCH-­Conf-­Apr-­2017-­5.-­ Parenting-­with-­feeling-­Prof-­Louise-­Newman.pdf Newman, L. K., Harris, M., & Allen, J. (2011). Neurobiological basis of parenting disturbance. Australian and New Zealand Journal of Psychiatry, 45, 109–122. Slade, A., Sadler, L., Dios-Kenn, C.  D., Webb, D., Currier-Ezepchick, J., & Mayes, L. (2005). Minding the baby: A reflective parenting program. Psychoanalytic Study of the Child, 60, 74–100. Sleater, A. M., & Scheiner, J. (2019). Impact of the therapist’s “use of self”. The European Journal of Counselling Psychology, 8(1), 118–143. Solman, B., & Clouston, T. (2016). Occupational therapy and the therapeutic use of self. British Journal of Occupational Therapy, 79(8), 514–516. Stanton, S.  D. (2016). Intuition: A silver lining for clinicians with complex trauma. Published by ProQuest LLC .Copyright of the Dissertation is held by the Author. ProQuest Number: 10165534. Stevens, J., & Krenner, W. V. (1999). Training with the master. Lessons with Morihei Ueshida, Founder of Aikido. Shambhala. Taylor, R. R. (2008). The intentional relationship: Occupational therapy and use of self. F. A. Davis. Taylor, R. R., Lee, S. W., Kielhofner, G., & Ketkar, M. (2009). Therapeutic use of self: A nationwide survey of practitioners’ attitudes and experiences. American Journal of Occupational Therapy, 63(2), 198–207. https://doi.org/10.5014/ajot.63.2.198. PMID: 19432058. Wakelyn, J. (2019). Watch Me Play manual, parts 1 and 2. Version 1. www.tavistockandportman. nhs.uk/firststep Weiss, S. J. (1979). The language of touch. Nursing Research, 28(2), 76–80.

Conclusion

There are only two lasting bequests we can hope to give our children. One of these is roots, the other, wings. (Johann Wolfgang von Goethe)

The early works of Bowlby and Ainsworth brought the attachment theory into the limelight. Children were seen in a close relationship with their primary caregiver and not as separate entities. When the relationship provided a secure base, it helped to establish the foundation of safety, essential for the child to progress from a fully dependent state to independence. Schore and Schore (2007) continued this work and integrated the current biological and physiological research with the attachment theory. The mother–infant relationship provides the opportunities and experiences in which the child’s developing systems can mature. The consistency and availability of the caregiver and the close attunement between the two create a synchronized, dynamic right brain to right brain connection. Their communication is intricate, and non-verbal, and operates often below their level of consciousness. Schore and Schore propose the attachment theory be renamed the “regulation theory” because this attachment relationship is so closely entwined with the development of regulation. Since the “decade of the brain” and the extensive research that has occurred concerning the impact of complex trauma on the young child, interventions have shifted from a cognitive approach to one that is more body-centered. If a child is not able to regulate and flexibly adapt to their surroundings, they will be impacted physically, emotionally, and socially. Our first experience of regulation is in the intimate caregiver relationship. The qualities of this attuned relationship can be integrated, at a similar body level into our interventions. These modulating qualities have been proven over and over to be essential. If we shift the concept of safety from its cognitive status and move it into a child’s “felt’ sense, it can replicate the experiences that these children have missed. When a child can consolidate this sense of safety internally, they can then “carry” it with them and have the potential to relate and interact with others in a more positive and versatile manner. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0

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In my work with children who have experienced complex trauma, I continue, however, to be struck by their incredible resilience. Given their traumatic life experiences, often at the hands of those who should have been protecting them, they continue to demonstrate an amazing and extensive array of managing behaviors. They persevere in trying to manage their surroundings and to create their own sense of safety. “Life is not always a matter of holding good cards, but sometimes of playing a poor hand well” (Robert Louis Stevenson). We need to respect these behaviors and appreciate how and what purpose these behaviors are serving for the child. Until the child feels safe, they will hold onto their strategies, effective or not, to continue to be able to “survive” in their world. We need to provide them with the experiences of that safe and secure base. Then they can learn to fly!

Reference Schore, J. R., & Schore, A. N. (2007). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36(1), 9–20. https://doi. org/10.1007/s10615-­007-­0111-­7

Index

A Adolescent trauma interventions, 6, 11, 47, 84 Adverse Childhood Experiences (ACE) study, 7, 71–72 Ainsworth, 13–19 Allostatic load, 70–72 Animal responses to threat, 82 Attachment, 3, 6–8, 11–25, 29–32, 34, 37–43, 46, 50, 62–64, 68, 74, 81–83, 89–91, 94, 102, 108, 111, 112, 114, 115, 125–127, 136, 142, 143, 147–149, 152, 159, 163, 165, 166, 170, 177 Attachment and abuse, 17–18 Attachment development, 16, 29 Attachment security, 21, 91, 126, 127 Attachment theory, 7, 12, 14, 17, 34, 41 Autonomic nervous system, 42, 57, 61, 62, 64, 114 B Beebe movement observation, 109 Behavior management, 7, 40, 79–94 Behaviors in children with complex trauma, 6, 43, 129–137 Bion, 20–21, 46, 127 Body language, 41, 102, 116, 126, 135, 162, 163, 172 Bowlby, 12–14, 16, 18, 19, 94, 125–127, 162 Brain anatomy, 35

C Canalization theory, 82 Child and adolescent mental health assessments, 129 Child trauma, 90, 108 Child trauma interventions, 30, 108 Child trauma treatment, 90 Complex trauma, 3, 4, 6, 9, 11, 32, 40, 43, 48, 49, 68, 72, 129, 131, 148, 173 Complex trauma assessment, 3–9, 129–137 Complex trauma children, 9, 48, 125–127 Complex trauma children and adolescents, 6, 11 Complex trauma interventions, 40 Complex trauma neurology, 6 Complex trauma regulation, 125–127 Complex trauma treatment, 4, 9 Complex trauma treatment in children, 4 Containment and safety, 7 Coping strategies, 29, 74, 82, 159 Co-regulation, 12, 32, 33, 40, 46, 79, 109, 166, 179 Cortisol and trauma, 36, 58 D Development of attachment, 114 Developmental trauma in children, 46 Disruptive behaviors in children, 69, 87 Dissociation, 3, 63, 73, 84, 88, 89 Domestic violence and the child, 23, 48, 89 Dysregulation, 4–6, 13, 32, 34, 41–43, 68, 75, 80, 87, 127, 129, 130

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Thomson-Link, Complex Trauma Regulation in Children, https://doi.org/10.1007/978-3-031-40320-0

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Index

E Early brain development, 30–31 Experience dependent brain development, 29, 41, 46, 81

O Occupational therapy trauma assessment, 129 Orbitofrontal lobe development in regulation, 38, 41

F Felt safety, 125 Fonagy, 21, 46

P Parent trauma education, 16, 130, 165, 178 Play and trauma, 57–75 Polyvagal ladder, 68 Polyvagal theory, 8, 61, 68, 109 Proximity control, 136 Psychoeducation for trauma, 16, 131 Psychosocial development, 47 PTSD, 3, 4, 45, 46, 73

G Grounding, 146 H Healthy attachment, 11, 25, 108, 163, 177 HPA axis, 45, 57–60, 62, 71–73 Hypervigilance, 4, 42, 43, 67, 73, 84, 141 I In-utero stress, 60 K Kaplan, B.J., 22, 150 Kestenberg, J.S., 8, 24, 25, 103, 104, 106, 127, 163, 164, 166, 173 M Managing stress, 70 Medical trauma, 4, 90 Mirror neurons, 8, 101, 102, 162 Modulation of behaviors, 91 Mother-child synchronicity, 23, 25, 110 Mother-infant attunement, 13, 18 Movement observation, 8, 109 N National child maltreatment statistics, 4 Neglect, 3, 4, 7, 17–18, 20, 23, 39, 41, 43, 49, 50, 64, 72, 74, 88, 90, 131, 153, 170 Neuroception, 64, 141, 162, 164 Neurological changes in trauma, 41–43 Neurology and attachment, 29, 31 Nonverbal body language, 162

R Regulation development, 31, 41, 42, 45, 60, 101, 125, 140 Regulation theory, 7, 34, 71 Research neurology trauma, 29–50 Resilience, 81, 94, 179 Right brain to right brain, 106, 108, 112 S Safety, 4–7, 9, 11, 12, 18, 19, 22, 23, 25, 31, 32, 40, 42, 43, 48–50, 64–66, 69, 74, 75, 82, 84, 87, 90–92, 94, 101, 103, 107, 110, 113, 117, 125–127, 131–135, 139–146, 149, 150, 158, 159, 161, 162, 165–166, 171–173, 179 Safety and attunement, 125 Schore, A.N., 4, 7, 13, 29–31, 34, 39–43, 46, 60, 71, 86, 106, 108, 111, 112, 115 Schore, J.R., 34, 41, 46 Secure base, 13, 14, 18, 19, 21, 25, 79, 81, 91, 101, 125–127, 134, 136, 140, 141, 143, 144, 146, 149, 151, 159, 162, 166, 173 Sensory integration, 148–150 Sensory processing, 4, 9, 30, 71, 148 Sensory vigilance, 84 Strange situation research, 14–15 Stress and trauma, 73 Stress priming, 60, 73 Stress responses, 87 Stress systems, 57–58

Index T Therapeutic use of self in treatment, 8, 127, 161, 162 Trauma and behaviors, 4, 5, 40, 60, 66, 73, 74, 80, 82, 91, 92, 130, 131, 139, 148 Trauma and brain development, 40 Trauma and NICU, 71, 90 Trauma caregiver education, 178 Trauma coping skills, 40 Trauma intake assessments, 137 Trauma interventions, 150

187 Trauma language changes, 86–87 Trauma physiology, 6, 8, 57–75 Trauma triggers, 44, 71, 80, 88, 111, 114, 131, 136, 137, 143, 151, 175 Trust interventions, 7, 11, 32, 43, 65, 94, 103, 143, 149 W Window of tolerance, 66, 67 Winnicott, D.W., 17–20, 22, 32, 107, 127