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121 MARCH 2009
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Bruce Perry

Each week I have the opportunity to learn from my colleagues and their clients in our web-based clinical teaching series. Participants will present a child they are working with and we will, together, examine the developmental history and current clinical issues of the child through the lens of neurodevelopment. This approach, the Neurosequential Model of Therapeutics or NMT, has been useful in our efforts to understand the origins of a child's strengths and vulnerabilities, and often this approach can lead to useful therapeutic insights and provide direction for clinical, educational and caregiving work moving forward. In future columns I will share more about this approach but I wanted to provide the context for many of my learning opportunities; they come not only from direct clinical work with children and caregivers but also from these consultations with colleagues.

This week I heard about a 14 year old boy, lets call him T, living with a wonderful foster family for many years. Yet he continues to struggle. There were many contributing factors, genetic, epigenetic, intrauterine exposure to alcohol, a disengaged neglecting mother, active substance abuse and severe domestic violence all of which led to his removal from his mother in the first years of life. After removal he was placed in a shelter with his half-brother for almost three years (yeah, seriously, a shelter “a short-term, transient, last ditch temporary placement). One day a staff member came to get his brother for something, took his hand, walked him out of the room and T never saw him again. No explanation to T; no preparation for T; no therapeutic follow up for T “or I suspect for his brother. The family of his half-brother’s father came to take his brother “but not T; T. was not related to them. This precipitous, catastrophic and confusing loss of the one stable relationship in the life of a four-year old boy was an example of how often our systems replicate and add to the traumatic, chaotic, neglectful experiences of these children.

This poorly handled transition reminded me of another in my earlier work. A boy in foster care had been struggling in his placement. The foster family told CPS (Child Protective Services) that they could no longer handle the child. The caseworker arranged for placement at a residential treatment center where I consulted. One day the caseworker came to the foster home, told the boy to collect his clothes and put them in a plastic garbage bag. “Why?” “We are going to go do laundry.” “Why should I put all my clothes in? Most of them are clean.” “My friend has a special washing machine.” They drove to the residential center; “Ok, go up and ring the bell. I’m going to go park the car.” A residential staff member, expecting this child, answered the door. The boy was standing alone at the door with all of his earthly possessions in a garbage bag. She let him in. “I’m here to do my laundry.” “What?” And the boy told the story his caseworker had told him. Again, no preparation, no opportunity to say goodbye to foster siblings or foster parents; we lie to these children all too often. When later confronted the caseworker claimed his insensitive and destructive behavior was to prevent the boy from melting down. Yet all he was doing was setting this boy up to be even more suspicious, guarded and even more likely to meltdown in the future. The caseworker’s avoidance of a little personal distress on his part led to much more distress for the child and for anyone working with him in the future.

Transitions permeate our lives. The capacity to successfully transition from one place to another, one activity to another, one internal state to another is fundamentally related to the capacity to self-regulate. And this, of course, is one of the main areas of difficulty with children and youth who have been exposed to developmental chaos, threat and trauma. And, as you might expect me to say, self-regulation is a brain-mediated function. Further, the reason maltreated children often struggle with this capacity is that the stress response systems in their brain are “sensitized.” This basically means that they are overly sensitive to any experiences or cues that in ANY way activate the stress response networks in the brain. So any function related to these stress-response networks will predictably be altered in traumatized children; attention, impulse control, sleep, fine motor control, regulation of lungs, heart, gut, skin, and a host of other functions.

Lets back up a little. The brain's stress response systems exist to keep us alive. These systems are continually getting input from the outside world (e.g., visual, auditory, tactile) through our senses and from the internal world (e.g., oxygen, glucose levels) from various sensory apparatus in the body. These incoming signals are matched against previously experienced and stored patterns of neural activity. The first and most categorical of “processing” steps takes place in the lowest areas of the brain (brainstem and diencephalon): is this information similar to patterns of safe and familiar or unsafe or unfamiliar? If safe and familiar, the stress response networks will stay at their current level of activity. If the cue is similar to previous threatening or traumatic experience, the brain will activate the stress response systems. And in most of us there is activation proportional to the level of novelty, challenge or threat. But not so with maltreated children; earlier in their lives they had to activate these systems in extreme ways and in chaotic patterns. The result is a poorly regulated and overly reactive stress network. Now when their brain receives input related to even minor challenges such as a test in school, a new child in the foster home or the need to stop playing at recess and go back to class, their stress response networks activate as if they are under threat! The extreme stress response in these children changes the way they think and perceive, the way they feel and the way they act. They will distort or miss verbal input, they will feel anxious and angry; they will be inattentive, impulsive and aggressive.

So. Back to transitions; each transition “in large or small ways “will change the pattern of neural activity coming into the brain. And in each of us this shift in incoming input makes our stress response systems “even if for a few seconds “turn on. Waking, dressing, travel to work, community meetings, public presentation, child's soccer game, home and sleep. Hundreds of little transitions, dozens of moderate transitions; all require our stress response to activate, proportionally-respond, re-set.

So now, think of the children and youth we serve. How challenging, how exhausting, how sad these children become as their brain works so hard to negotiate these hundreds of little transitions and dozens of moderate transitions in any day. And how much easier this would be for these children if we had, earlier in their lives, worked harder to help them negotiate their major transitions; to have more gradual and more predictable transitions with opportunities for regulating their dysregulated neural systems with healthy touch, positive relational engagement and honest, clear cognitive explanations.

There are ways to help these children begin to master transitions and build in healthy self-regulation capacity; but first we must regulate ourselves. How could the caseworker help that child with a healthy transition if he couldn’t regulate his own fear and distress about a potential “meltdown?” And how much of that caseworker’s self-regulation issues were because he was in a system where he was experiencing precipitous decisions, changes in job responsibility, punitive supervision and indifferent administration? Ah–so much to say, so little space.


Bruce D. Perry, M.D., Ph.D. is the Senior Fellow of The ChildTrauma Academy, a not-for-profit organization based in Houston that promotes innovations in service, research and education in child maltreatment and childhood trauma ( Dr. Perry is the author, with Maia Szalavitz, of The Boy Who Was Raised As A Dog: What Traumatized Children Can Teach Us About Loss, Love and Healing, a popular book based on his work with children, published by Basic Books. Over the last twenty years, Dr. Perry has been an active teacher, clinician and researcher in children's mental health and the neurosciences holding a variety of academic positions.

Bruce D. Perry, M.D., Ph.D.
Senior Fellow
The ChildTrauma Academy
800 Gessner, Suite 230
Houston, TX 77024

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