28 Developmental Trauma

Val Forster

Introduction

The term developmental trauma was first used in 2005 by Dr Bessel van der Kolk, an American psychiatrist. He said that, not only do traumatised children develop a range of unhealthy cop- ing strategies that they believe will help them survive, they do not develop essential daily living skills.

KEY CONCEPTS

• Developmental trauma is the term used to describe the impact of early, repeated adverse childhood experiences (ACE) that happen within a childs important relationships.


• It is a means of capturing the complex psychological, biological and interpersonal sequelae of the experiences of neglect and abuse, such as physical, emotional or sexual abuse and any type of household dysfunction such as violence in the home, alcoholism, drug abuse and mental health issues.

• Any kind of trauma that repeatedly occurs during infancy and childhood impacts brain development. What happens in the first months of life, both prenatal and postnatal, has lifelong effects.

• Developmental trauma has remained a description of a cluster of symptoms and behaviours rather than a diagnosis.

Researchers continue to gather evidence to increase understanding, and clinicians strive to find better ways to help children and families whose lives are affected.

The Impact on Brain Development

The idea that trauma has an indelible impact on developing personality has a long history in psychology. Furthermore, the perpetrator of neglect or abuse is most often one of the primary caregivers. Such developmental trauma is relational, not a single event but cumulative, a charac- teristic feature of an impaired attachment relationship (Schore, 2015). The ongoing repetitive relational stressors embedded in a severely mis-attuned attachment relationship mean that the infant is experiencing not acute but chronic stress in the first two years of life. In this critical period, the human brain grows faster than at any other stage in the life cycle. This interval exactly overlaps the period of attachment so intensely studied by contemporary developmental psychol- ogy. A fundamental tenet of Bowlbys model is that, for better or worse, the infants capacity to cope with stress is correlated with certain maternal behaviours. Thus, the early social environ- ment, mediated by the primary caregiver, directly influences the final wiring of the circuits of the infant brain responsible for the future social and emotional capacities of the individual.

The ultimate product of this social-emotional development is a particular system in the pre- frontal area of the right brain that is capable of regulating emotions, including positive emotions such as joy and interest, as well as negative emotions such as fear and aggression. Experience not only affects the structure of the brain but the way the system of chemicals in the human body works. Chemicals, such as hormones (released from an endocrine gland into the bloodstream) and neurotransmitters (released by nerve terminals), send signals between neurons and other bodily systems. Some commonly known ones include serotonin, dopamine, adrenaline and oxy- tocin. High levels of stress in pregnancy lead to the production of the stress hormone cortisol, which crosses the placenta and can affect the developing foetus. Experiences of neglect or trauma, even when not consciously remembered, can affect both behaviours and hormonal systems.

The early years are vital. We are biologically predisposed to respond to potential danger by flight, flight or freeze, and quick surges of adrenalin and the release of cortisol are essential and lifesaving when a predator such as a man-eating tiger appears. Generally, after such shocks the body quickly goes back to normal, with blood pressure and heart rate reducing as we relax. The psychiatrist and neuroscientist Bruce Perry has described how traumatised children can barely relax, are constantly on the move and are in a desperately anxious and hyper-vigilant state. Such heightened physiological responses are a sign of a highly activated sympathetic nervous system. There is another response to the nervous system to stress and trauma, an activation of the parasympathetic nervous system. Here the body closes down, rather like a creature play- ing dead in front of a predator. Blood pressure and heart rate drop and parts of the brain that specialise in logical thought often shut down, while primitive survival mechanisms take over. This can give rise to the phenomenon of dissociation, in which an individual can seem to be cut off from their own experience. This may be part of the explanation why many children from highly stressful backgrounds often do not achieve well academically. They have learned to cope by being hyper-alert to danger, which impedes ordinary relaxed concentration, or they may go into a shut-down dissociative mode in which the thinking part of the brain shuts down.

Severe neglect has been shown to lead to atrophy in parts of the brain and to developmental delay, as well as to serious deficits in the ability to empathise, regulate emotion and manage intimacy and ordinary social interaction. Studies of severely neglected children adopted from Romanian orphanages have shown that areas of the brain primed for emotional understanding and expressiveness have shockingly little activity.

The Seven Pieces of the Developmental Trauma Puzzle

The seven areas of developmental trauma can be mapped onto the order in which the brain develops from the brainstem to the cortical brain.

Sensory Development

Infants and toddlers have not yet developed language to make sense of their experiences. All their memories are therefore sensory memories, and the baby operates mainly out of their brainstem, the bottom part of the brain responsible for basic functions such as heart rate, tem- perature and behaviours which aim to keep them alive. Memories before language are known as implicit, which means that, while the child cannot later recall and talk about them, their body has stored the memories in its sensory systems. Because traumatised children are stuck in fear mode as they grow up, their hyper-vigilance to signs of danger reduces their ability to filter out irrelevant sensory experiences, such as background sights, sounds and textures. This can mean that the childs sensory system becomes overloaded and they feel danger to be imminent, even when they are completely safe.

When a traumatised child is feeling stressed, they may have sensory flashbacks which means that they re-experience the bodily feeling of immediate danger, with no way to make sense of it or to communicate verbally, since the memory has no language attached to it. Children will either over-respond or under-respond to incoming sensory information because their brain cannot find the middle ground of working out which information is necessary and which infor- mation means danger. They may struggle to know how much force to press on things, find it difficult to recognise the nature of textures (e.g. rough, smooth, heavy or light), and they may struggle to find good balance and co-ordination.

Dissociation

Dissociation is a survival mechanism and one that is often over-looked in traumatised children. When a child is subjected to physical abuse, in the moment of violence they cannot physically escape, but they can escape in their mind. All humans have a natural ability to leave the room when their trauma is utterly unbearable. Babies and toddlers dissociate when they are in dan- ger or when their experience is intolerable. It is vital for infants who are suffering frightening things. It enables them to keep going in the face of overwhelming fear. Dissociation is a sepa- ration or disconnection between thoughts, feelings and behaviours and a separation between the mind and the body. It is the minds way of putting unbearable experiences and memories into different compartments, e.g. a child may remember a traumatic event but have no feel- ings attached to the memory or may show challenging behaviour, but have no memory behind the behaviour. These different parts of the childs experience are connected, but they learn to survive by becoming unaware of the connection.

In developmental trauma, the child often continues to dissociate, even when they are no longer in danger. Their brain cannot turn it off. Because memories are fragmented into many little pieces by dissociation, children often have a flashback to a memory, a feeling, a behaviour or a physical pain, with no understanding of why or what triggered it. This can feel disorienting and confusing, as the child believes they are in immediate danger. The more frightening the childs traumas were, the more likely they are to dissociate and the more sophisticated the ways they develop to dissociate. Children are usually unaware that they dissociate or zone out and they cannot put into words what is happening. Dissociation leads to a range of behaviours that can often be understood by adults as challenging, naughty or lazy.

Attachment Development

Children who start life in a frightening or neglectful environment adapt to their environment. Children learn from as early as a few months old that certain behaviours keep danger at bay and other behaviours increase the chances of danger. They develop a range of attachment strategies. These are there both to prevent harm and to keep a parent/carer as close as pos- sible. Traumatised children tend to develop one main attachment style, which could be either insecure avoidant or insecure pre-occupied (anxious). These terms are a better way of under- standing what is happening than the more general disorganised style.

Avoidant children learn early on that showing their feelings and having needs bring danger and make their parent/carer withdraw. They learn to hide their feelings and act as if everything is fine. Inside they feel frightened, vulnerable, worthless and hopeless, but on the outside, they often seem bright and competent. These children are often not a concern for parents and teachers until later childhood, because they do not show behaviour problems until these are triggered by something stressful.

Pre-occupied children learn that showing feelings and extravagant behaviours is the only way to be noticed and keep parents/carers close by. They learn to exaggerate behaviour and emotions and to be angry and upset for long periods. Inside they feel petrified, anxious and unlovable. On the outside they appear angry, aggressive, disruptive and rude. To have an adult solve the crisis would be frightening, as it might mean the adult goes away. Some chil- dren swing between these strategies. It appears disorganised, but is in fact highly adaptive. It explains why school staff often see one part of the child and the parents/carers another.

Emotional Regulation

Emotional regulation is a skill that children learn in early childhood. It means that, by the time they are six or seven, they know how to notice that they are having an emotional reaction, know what the emotion is, express it in a healthy and clear way and finally manage the emo- tion well, so that they can become calm. Babies and toddlers cannot regulate their emotions. They rely on their parent to co-regulate. This means that the way the parent responds to the childs emotions regulates the emotions for them, which trains their brain how to respond to emotions in the future. Through this co-regulation babies learn that their feelings are accept- able and manageable and will not kill them or push others away. A baby or toddler whose crying is repeatedly met with being hit, ignored, mocked or by panic in the parent, learns that their feelings are dangerous, hurt others and hurt themselves. This becomes an internal working model.

In children who have moved frequently between carers or who have harmful parents, the part of the brain responsible for emotional regulation does not develop as it should. It becomes stuck in the toddler phase of emotional regulation where they cannot do it for themselves and need an adult to co-regulate for them. In children with developmental trauma, their brains ability to regulate their emotions is the same as a 3-year old, even though they might be 14. The child cries, shouts, sulks, stomps their feet, slams doors, bites, hits, runs away, explodes with no warning, over-reacts to small things and so on. This explains why these children are often described as naughty or attention-seeking. The toddler-like behaviour is seen but the emotional need is hidden. If adults can respond to the childs emotional age rather than their actual age, then the child can be helped by co-regulation and begin to learn that skill. Children who have poor emotional regulation often turn to unhealthy regulation coping strategies as they grow into adolescence, such as drug and alcohol abuse, self-harming and sexual encoun- ters. These strategies function to either enliven them from feeling dead inside or relax them from high levels of anxiety.

Behavioural Regulation

Each individual has a window of tolerance, i.e. a state of physical and emotional arousal that is tolerable and bearable. In this state, a child can think, learn, love and relax. For trau- matised children, small everyday things, like a request to brush their teeth or a change of classroom, spirals them out of this calm relaxed state. They become hyper-aroused (overly aroused) or hypo-aroused (under-aroused). Traumatised children will be over- or under- aroused most of the time and, in either state, their behaviour is out of their hands. They cannot control it as they are in automatic survival mode and they cannot think, reason or rationalise when feeling under threat. Children who are overly aroused are in fight/flight. Their brain tells them they are in danger and their body responds. They can run, hit, scream, shout, squirm and disrupt. Under-aroused children shut down. They go numb, zone out and cannot connect or think. In both states the childs heart rate is very fast. They might sweat or shake and they are hyper-vigilant to every detail in their environment. It is worth remembering that, at the core of a trauma experience, there is a loss of control. Traumatised children become experts at regaining control, and these behaviours cause significant chal- lenges for adults.

Cognition

Developmentally traumatised children often struggle with under-developed cognitive skills, meaning their ability to do things like plan ahead, problem-solve, organise themselves and learn from mistakes. This is because they are often stuck in their limbic system and brainstem and are exhausting all their reserves trying to stay safe and to work out whether adults can be trusted or not. This leaves few resources for the higher brain skills which are needed for good cognitive functioning.

Self-Concept and Identity Development

Our self-concept starts forming from the very first messages we receive about ourselves from the adults in our lives. If children receive the message that they are not worth keeping safe, that they are disposable or that their crying pushes others away, their self-concept will reflect this. Those who have suffered early trauma often live with a very deep sense of being bad and unwanted. This becomes their template for how they see themselves and for how they think others see them. Accepting that they are lovable and worth keeping safe can take a very long time. Chronically traumatised children often feel confused and lost. They do not feel as though they belong with anyone or anywhere and are often in search of validation from others. This can make them very vulnerable to being exploited in relationships or present as flitting between friends and groups to try to fit in.

Mental Health Symptoms

Developmental trauma is an umbrella term for these seven areas of impact. In addition to these developmental difficulties, a child can experience discrete mental health difficulties, such as episodes of depression, anxiety and specific trauma symptoms. Often these symptoms are understood and treated in isolation. However, for chronically traumatised children, seeing mental health symptoms as part of the overall picture of developmental trauma is key. Dr Allan Schore, Dr Bruce Perry and Dr Bessel van de Kolk, and many other clinicians and researchers, are clear that developmental trauma can be repaired over a long enough period. Children are resilient and adaptable, and neuroscience is showing us all the time that the brain is flexible and open to being re-wired, if given the opportunity.

Case Study: Mary

Mary was seven when she was referred by her school who were having trouble managing her behaviour, as were her adoptive parents. Both Mary and her older full sister were taken into care following interventions begun prior to Marys birth. They lived in separate foster homes.

Her birth parents used drugs and alcohol and had a violent relationship. They were not able to recognise that this had a negative impact on the childrens development both in pregnancy and after and failed to alter their behaviour. Both parents had poor childhood experiences.

Mary moved to her adoptive home when she was three and a half. She had one foster family but also spent periods of time with her birth mother until she was one and a half while assess- ments were carried out. She has not seen her foster carers since. It was reported that Mary struggled with developing friendships. She needed 1:1 support in the classroom and was indis- criminate about hugging and kissing both staff and pupils. Her behaviour was at times described as sexualised. Her parents feel she functions much younger than her chronological age. She is disruptive and controlling and destructive with toys. She screams, tantrums and stamps her feet. She can be aggressive to other children and has been excluded from school for this.

The initial assessment was able to conclude that Marys early life fulfilled the description for developmental trauma. Marys parents were invited to attend a group for parents and carers that offered information and strategies about developmental trauma. They began to feel that they understood that Marys early experiences had affected her and became more creative in dealing with the difficult behaviour by bearing her attachment style in mind and by responding to her emotional age rather than her chronological one. Mary was offered an assessment and then weekly work in a creative therapy to carefully explore her thoughts and feelings in a way that was attachment focused with sensory elements. She began to explore themes of abandon- ment, belonging and control. The work continues.

Multiple-Choice Questions

See answers on page 669.

1. What is an ACE?
   
   
   
   1. Average childhood experience
   
   
   2. Acrimonious childhood experience
   
   
   3. Adverse childhood experience
   
   
   4. Anxious childhood experience
   
   
   
   


2. Explain why traumatised children continue to dissociate when they are no longer in
   
   
   
   1. They were never taught to dissociate by their
   
   
   2. Memories become
   
   
   3. Memories merge and become
   
   
   4. It is linked to their temperament and not any traumatic
   
   
   
   


3. What are the two types of attachment style most seen in traumatised children?
   
   
   
   1. Avoidant and pre-occupied (anxious)
   
   
   2. Avoidant and secure
   
   
   3. Avoidant and disorganised
   
   
   4. Disorganised and secure
   
   
   5. Pre-occupied (anxious) and disorganised