Trauma and Neurodevelopment
Brainstorm: Helping to heal childhood trauma
Traumatic events are those that “overwhelm the ordinary human adaptations to life and generally involve threats to life, bodily integrity, or a close personal encounter with violence and death” (Herman 1992, p.33). Numerous studies have shown that traumatic experiences during childhood “cause abnormal organisation and function of important neural systems in the brain, compromising the functional capacities mediated by these systems” (Perry 2006).
Because many of the children you work with have experienced trauma it is important to understand the connection between trauma and neurodevelopment and how the brain can help individuals heal, recover and restore their functioning. Being aware of some of the key principles of neurodevelopment will help you understand and address the full range of problems and interventions related to child abuse and neglect.
PRINCIPLES OF NEURODEVELOPMENT
Principle 1: Brain organisation and sensory input
The brain is organised in a hierarchical and bottom up fashion from the Brainstem to the Diencephalon, through to the Limbic and finally the Neocortex (see figure 1). The Brainstem and the Diencephalon mediate the more simple regulatory functions such as respiration, heart rate, blood pressure, sleep, appetite and body temperature. The Limbic and Neocortex control more complex functions such as language and abstract or concrete thought. The brain grows in a sequential fashion starting at the lowest more regulatory regions of the brain and continuing through to the upper parts of the brain.
The human brain is continually sensing, receiving, processing, storing and reacting to information from internal and external environments. Chains of inter-connected neurons known as neural pathways communicate and interact up and across the brain structures. As sensory input enters the brain, the lower parts of the brain, the Brainstem and the Diencephalon process it. Sensory input moves up and across the brain until it is interpreted and processed by the highest areas of the brain, the Limbic and Neocortex.
Stored memories and associations
The brain has a remarkable capacity to make associations between present neural activity and stored memories. As waves of neural activity move up the brain to the higher more complex areas they are matched against previously stored memories. If a pattern is associated with a previous threat (i.e. a sudden loud noise) neural activity occurs in the lower parts of the brain and flows up through the midbrain stems which initiates a set of responses that allow an individual to react in a reflexive manner. This alarm activation can take place before it reaches the highest cortical areas of the brain where the internal state of anxiety can be processed and interpreted. These immediate response or “neural cues” are important for a rapid response to threats - for example, withdrawing a hand away from a fire. For these “uninterpreted” responses to occur there must be memories of previous patterns of sensory inputs that were connected with threatening or traumatic experiences.
The stress response system
The brain processes new or unfamiliar information as potentially threatening and activates a stress-response. The purpose of the stress response system is to sense distress and address this challenge to promote survival. An individual’s response to stress varies and is influenced by many factors including pre-existing stress memories and responses, the presence of buffers and the nature of the stressor (Perry 2008).
There are two major interactive and adaptive response patterns to significant threat: the arousal response and dissociation. The arousal response activates the individual and prepares them to fight or flight. A child in this sate will most likely display externalising symptoms such as aggression or impulsivity. Dissociation occurs when an individual perceives that fighting or fleeing is futile. Children who disassociate may have a number of somatic symptoms like diarrhea or abdominal pains. Arousal or dissociation responses may be activated during a traumatic experience. This is often true for children who have experienced complex trauma. Responses to stress can become “sensitised” meaning that future stressors or challenges will activate the most common stress responses an individual has used in the past.
Implications of brain growth and organisation
The brain’s ability to make associations between patterns of neural activity and stored associations or memories is the cause of many trauma related symptoms such as distress, fear or physiological reactions. For example, a young child sexually abused by their mother’s partner will create a set of associations between a host of neural cues and threats. For the rest of the child’s life these neural cues have the capacity to activate a fear response that alters emotions, behaviours and physiology. Thus a touch on the shoulder by a teacher may trigger fear or reaction from a child, which is beyond the child’s conscious awareness and understanding. Likewise, a child who was physically abused in a garage that smells of oil at the time, could associate the smell of oil in a non-threatening location with the abuse and become fearful or terrified. In order to break inaccurate associations a child needs to be exposed repeatedly to experiences that create new associations and break trauma related associations.
A key to understanding traumatised children is to remember that they will often be living or operating in a state of low-level fear. Their emotions, behaviour and cognitive function will reflect their stress response (arousal or disassociate). Because the stress-response system occurs in the lower parts of the brain, it is important to remember that if a child is very anxious or distressed their functioning will be “brainstem” driven. They may act in very primitive ways. They may also appear to react disproportionally or in non-expected ways to new challenges or events. For example, children sensitised to stress who have never been to the zoo may find a visit overwhelming and may react by becoming aggressive or withdrawn. Caregivers who think this is a fun activity may not understand this reaction. They may become frustrated, discipline the child and continue on with the visit. Similarly, meeting caseworkers for the first time may place children in a heightened state and they may react by becoming hostile, unapproachable or unwilling to talk with us or follow our instructions.
A child’s exposure to extreme, prolonged or unpredictable stress reactions may influence their ability to learn. Introduction to life challenges such as transitions to new schools, academic concepts or unpredictable social situations can be overwhelming and induce fear, thus inhibiting opportunities for normal social, emotional and cognitive development.
Principle 2: Neural systems are designed to change in a “use dependent” fashion.
In response to challenges or threats, a child’s mental state moves along a continuum from calm to arousal then to alarm, fear and terror. As this takes place, parts of the brain shut down while others are turned on. Thus the brain changes in a use dependent way and systems that get constantly activated develop and functionally improve. Parts of the brain that do not get activated do not develop.
The symptoms and physical signs a child displays following trauma reflect the history of neural activation or inactivation. When a child is abused and their stress response is activated in a prolonged fashion, their neural networks undergo a “use-dependent” alteration whereby the brain will act as if the child is under persistent threat. They may become hyper vigilant, impulsive, anxious, or have problems regulating their emotions. Likewise, neglect can alter the stress response system and the networks in the brain that organise language, social interactions and attachments may not be activated and develop.
It is possible to change brain systems. However it will not be meaningful unless the actual neural network that moderated the system is stimulated. This concept is known as “specificity”. For example, if the brain is altered due to trauma, you must activate the trauma related networks.
Implications of the use dependent principle
The most important implication from the use dependent principle is that neural systems can change with repetition. Patterned, repetitive activities shape the brain. This repetition must be in the parts of the brain that moderate or are primarily responsible for the symptom.
Because the fear response system and trauma symptoms originate in the lower parts of the brain, any efforts to influence trauma related symptoms must therefore influence the brainstem. Efforts to influence higher parts of the brain (thought, affiliation, attachment, emotional regulation) without first modifying the simple regulatory functions facilitated by the brainstem (sleep, blood pressure, temperature) will be ineffective or insufficient. For example, if a child has developed trauma and has difficulty reading, targeting the cortex or upper part of the brain that regulates language and thought, will likely be ineffective.
Neglected or abused children can change yet the process can be long. It requires patience and an understanding of “use dependent” functioning. A child who did not experience a secure early attachment in the first three years of their life needs many positive nurturing interactions with trustworthy adults or peers. Similarly, children who were abused and who are impulsive, hyper-vigilant or anxious require repetitive brainstem activities to begin to regulate these brainstem systems. Effective interventions would include those that build new patterns in the brainstem such as dance, music, massage or other repetitive sensory activities.
Principle 3: The brain develops most rapidly early in life
The majority of the brain’s sequential and use-dependent development takes place in early childhood. By the age of four, a child’s brain is 90 percent of its size. The organising experiences of early childhood have the most powerful and enduring effects on the brain and functioning. Abuse or neglect in early childhood and related trauma alterations in the brain cause significant and disproportionate dysfunction compared with similar abuse or trauma experienced later in life. Although it is possible for the brain to change, it is easier to organise the brain in healthy ways than to fix or reorganise a poorly organised system.
Implications of the rapid development of the brain in early life
The most important aspect of this principle is the importance of the timing of developmental experiences. Similar trauma experienced at different times during a child’s life will affect the brain in different ways. Severe neglect or abuse in early childhood can have a devastating effect on a child and the longer a child is left in that environment, the more vulnerable he or she becomes. Even if the child is removed from the neglectful or abusive environment they may continue to be affected. This principle suggests that early interventions with a young child and their family are likely to be more effective than waiting until the child’s brain is organised in a way that causes dysfunction.
Principle 4: Some brain systems are easier to change
The brain is most malleable while it is developing and being organised. Change becomes more difficult as a child grows and the brain becomes more organised. In addition to the stage of development, the capacity of the brain to change (often known as neuroplasticity) is also related to the area or system of the brain. Not all parts of the brain are as plastic as others; the cortex of the brain is the most plastic. Cortex related functions such as beliefs can be modified throughout life with minimal effort. In contrast, the lower parts of the brain that mediate regulatory functions are the hardest to change.
Implications of the neuroplasticity principle
Because trauma related symptoms are related to dysfunction in the lower, less plastic parts of the brain, more repetitive work is needed to create change. Put simply, it is easier to change beliefs than feelings. To date, no medications exist to create the specific neural activation that is needed to organise and reorganise dysfunctional neural networks. However, medications can be used to contain brainstem dysregulation enough to allow positive repetitive experiences to occur through other therapeutic activities such as cognitive behaviour therapy.
Principle 5: Relationships are important to mediating major development experiences
No response to stress and trauma is the same. A child’s abilities to cope with stress, trauma and distress are influenced by genetic factors, healthy relationships and social connectedness (Ludy-Dobson & Perry 2010, Perry 2006). How relationships influence reactions to stress and trauma is mediated by two systems within the brain: the stress response system and the neural networks that are involved in bonding, attachment and social connections. At birth, the stress-response system is developing rapidly. Primary caregivers are the main source of patterned sensory input to an infant’s stress-response system. Their regular, predictable and responsive caregiving provides the patterned neural stimulation for the infant’s brain to develop an adaptive and flexible stress-response system and healthy attachment capacities. A caregiver who is absent, depressed, stressed, unresponsive or inconsistent causes the stress-response and relational neural networks to develop abnormally. This makes the child vulnerable to future stressors. These early development experiences create a set of associations or templates about humans.
As a child develops and interacts with others positively, their brain is creating a catalogue of safe and familiar attributes (i.e. their family, their home or their language) that, in future interactions, will tell their stress-response system to be calm. Thus the social environment has a powerful influence on a child’s neuro-biological functioning. Healthy permanent interactions with safe and familiar individuals can help buffer and heal trauma related problems. Research supports this principle showing that social connectedness is a protective factor against many forms of child abuse and neglect (Ludy-Dobson & Perry 2010, Travis & Combs-Orme 2007, Belsky, Jaffee, Sligo, Woodward & Silva 2005)
Implications about relationships and developmental experiences
The number, quality and stability of relationships matter to a child. Removing children from their family may also mean removing them from the networks they have developed at school, at sports clubs, at church or other places in the community. It is important to talk to children and find out who is important in their lives. Wherever possible create opportunities and connections between the children and sources of support. In addition to having a permanent place to live, it is also important for a child’s neurodevelopment and wellbeing to have relational permanency which means having lifelong support from a nurturing, safe, secure and predictable person.
THE NEUROSEQUENTIAL MODEL OF THERAPEUTICS (NMT)
Neurodevelopment principles demonstrate how a child’s exposure to trauma, neglect or abuse can impair early attachments and negatively alter the key systems and areas of the brain. The Neruosequential Model of Therapeutics (NMT) was developed to help practitioners understand that children who experience chaos, neglect or abuse have a different development trajectory than children in a more stable environment (Perry 2009). Children may be chronologically one age but have the capability of a younger age. NMT helps us to understand a child’s development history, how their brain is organised and how we can determine the strengths and vulnerabilities of the child in order to create and provide appropriate interventions. NMT is not a specific intervention or technique but rather an approach to clinical work informed by neuro-science (Perry 2006). It has three central elements namely: NMT developmental history, Brain Mapping and NMT interventions.
The NMT Developmental History
To understand an individual it is important to know their history. The NMT Development History is a core assessment that reviews the timing, nature and severity of development challenges that are scored and result in a “development load”. It allows an estimate of which neural networks and functions would most likely be impacted by trauma, abuse and neglect. The second element of the development history is a review of the relational history of the child. This involves understanding a child’s attachments and relationships that can buffer or exacerbate the impact of trauma and evaluates whether a child has enough people in their life to support them in the healing process.
The second element of the NMT approach is a review of current functioning that allows for an estimation of the neural systems and brain areas that are causing problems. It gives a quick impression of a child’s development status in different areas of functioning and assigns or “maps” current functions to the different brain regions. The map is generated by a multidisciplinary team and requires a senior clinician to lead the process. Each area of functioning is scored as either 1) fully functional, 2) partially organised/episodically functional 3) developing/precursors capacity emerging or poorly organised/ dysfunctional and 4) underdeveloped/not functioning. This mapping identifies the starting point and the activities most likely to meet the child’s developmental needs.
Many children have parents or caregivers who have experienced developmental traumas including neglect or abuse. Because NMT is concerned with the quantity and quality of supports available to a child, a mind map for the key members of a child’s network should be conducted to identify the strengths and vulnerabilities of the people involved in helping the child heal from trauma.
The third element of the NMT approach is the process of providing recommendations for interventions that are based on neuroscience and follow the brain’s normal sequential process of development. In brief, this involves starting with the set of deficits associated with the lowest areas of the brain (Brainstem) and then moving sequentially up the brain as improvements are seen. For example, this may mean starting with self-regulation issues such as inattention, arousal, impulsivity, associated with a poorly organised Brainstem or Diencephalon by using a variety of patterned repetitive sensory activities (e.g. music, yoga, drumming). Once improvements are noticed, work moves to relational-related issues associated with the limbic area of the brain and finally to memory, thought, perception or language type problems associated with the cortex that benefit from more verbal or insightful approaches.
Implications for child protection and out of home care practice
Understanding how the brain is impacted by abuse and neglect helps identify a child’s underlying vulnerabilities. This helps ensure support is tailored to a child’s developmental stage and their capacities so that it will have the greatest potential to help each child.
We need to know and treat the cause not the symptom. If we can use strategies which regulate the stress response systems, interventions and activities aimed at those systems will help create improvements in many areas of functioning. We need to be both respectful of biology and of development experiences.
Neuroscience adds depth to the current practice thinking about trauma informed care. Some of the most important things to remember are:
- History matters. The more we know about a child and parents’ history of abuse and neglect, the more likely we are to understand their current capacity and limitations.
- Think about where a child’s behaviour originates from and which areas of the brain would be regulating or controlling the behaviour you see. It is not our role to fix the behaviour, it is our role to help parents and carers understand the root cause of a child’s behaviour and how adverse experiences may have altered brain development and functioning. In short, you are building empathy in yourself and others to better support and understand a child.
- Think about a child’s developmental capacity not just their chronological age. What are they physically, emotionally mentally or spiritually capable of? Consult psychologists or other professionals who may help you understand or assess current functioning.
- The influence of abuse and neglect on brain development is greatest in early child-hood (0-4 years). Think about the different impacts trauma has on children of different ages and how you tailor activities and interactions to their capacities.
- Be respectful and aware of how important relationships are for a child’s social, physical and mental development and functioning. Talk to children about the important people in their lives. Wherever possible use creative techniques, (drawings, photography, diaries, and social media) to help identify people who will be available and capable of supporting children during the healing process. While our interaction may be brief, the important thing to remember is relational permanency; who will be there in the long term for this child?
- Children’s parents may have experienced traumatic experiences during their childhood and be dysregulated themselves. They may be operating at a very basic level and be anxious about FACS interventions. They may not be able to process the information you give them or adhere to some tasks required of them. Some tips to help include:
- make use of motivational interviewing to encourage the family to provide detailed information about their pasts.
- on your first visit do not overload parents with too much information, help plan and prepare them for work with FACS. Check their understanding of what you have said. Do not have long high level conversations. Try and break your conversations into a series of small specific topics and questions
- seek help to assess parents’ capacities and current functioning, and how this impacts on parenting and capacity to change.
- tailor case planning to their capacities. Work with other service providers to help parents receive the most appropriate and targeted support so they are able to help regulate, relate and reason with their children.
- It is important that people who will be an enduring part of the child’s life understands the child including they way their brain is organised. This includes carers. When working with carers help them understand that a child’s behaviour may be because of the way trauma has altered their brain development and subsequent functioning.
- One of the greatest qualities of the human brain is the ability to create and store memories. You are the memory you will become. When you first visit a child you will be unfamiliar. Think about having shorter more frequent and regular visits. Be attuned, responsive and attentive. Care for them and make them feel special. This will help ensure you will not be perceived as a threat and help them create a positive memory of you.
- Also think about the sequence of your engagement. Regulate, relate and then reason. A child needs to be regulated before you can relate to them and before you can reason with them. You also need to be regulated in order to project the verbal and non-verbal interactions that will help a child or young person feel regulated. If you are calm they are more likely to feel calm.
- Think about ways to help children feel regulated by bringing sensory activities into your engagement with children. Create opportunities for rhythmic dance or music, singing, poetry, meditation, or exercise. This helps create an environment that provides the template to organise the internal disorganisation many children experience. Respect their biology, ask them about their preferred way to play or express themselves and incorporate this in your interactions with a child. For example, if they like bouncing a ball or throwing it back and forth incorporate these activities as they can provide the rhythm and comfort needed to facilitate a more open discussion.
- Having the same or regular caseworker will be important to a traumatised child. They may be overwhelmed by a new caseworker or a change in caseworker. So if you need to reallocate, consider how to transfer the relationship so a child will still have a degree of consistency and predictability in their engagement with FACS.
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Travis, W. J., & Combs-Orme, T. (2007). Resilient parenting: Overcoming poor parental bonding. Social Work Research, 31(3), 135–149.