I work with many children who have been traumatized in extreme ways, and have Post-Traumatic Stress Disorder.  Before adoption, many children in my practice were raised in orphanages under sub-optimal conditions, or suffered physical abuse or neglect in a birth family torpedoed by violence, drugs or alcohol.   Adoptive parents hope these children will flourish with enough love in their new home.  But lurking beneath the surface, the prior trauma impacts the child’s present life, and the way his or her nervous system functions.

Trauma arises whenever a child’s security and safety is in danger.  

One child at age 4 suffered his birth mother falling into drug addiction, and severely neglecting him.  Birth mother would take off on drug runs every weekend, and the 4-year-old had to fend for himself, without any parental supervision.    There was no food in the house and this boy remembered having to climb up to the top cupboards to find uncooked macaroni he would eat to survive.  That is trauma.  Imagine his terror and fear of being on his own, and the fierce sensations of starvation he faced.   And he faced this alone, without anyone there to comfort him.   Worse still, the neglect was happening at the hands of someone who he had the right to count on.  Repeated traumas like this are the most damaging.  Repeated trauma re-wires the central nervous system, making a child hypervigilant and on guard for the next abandonment, the next time of abandonment and hunger which is sure to come. Unfortunately, when a child such as this is taken into protective services and becomes part of a healthy family, the re-wired nervous system and PTSD travels with the child.

The trauma-wired nervous system travels with the child to their new adopted home

So when adoptive parents take into their lives a child who was previously traumatized, they may be unprepared for situations in which the child shifts rapidly from the Calm State (Regulated, able to handle arising emotions) to Fear-Based Nervous System States (Dysregulated, tantruming, emotionally flooded).    There are three main nervous system / mental states a child can be in at any one time.  A child may move rapidly from a calm state to a more severe state, and then take a long time to recover back to the Calm State.  Here are the three basic states:
The Calm State
The Aroused State (the nervous system is activated and on alert due to a sense that danger may be near)
The Fear/Terror/ HyperArousal State (the nervous system is on red alert because extreme danger is perceived)

The Calm State, of course, is the most optimal.  In the Calm State a child has their Brain Function working optimally, can concentrate, pay attention, take in ideas and learn.  In the Calm State, the child’s nervous system is calm and regulated, and they can show good judgement and maintain control over impulses.

As the Chart below shows, if a child moves into the Aroused or Hyper-Aroused state, all these normal, optimal brain functions are severely compromised:

NERVOUS SYSTEM STATES & DYSREGULATION:

                                     CALM         AROUSAL      HYPER-AROUSAL
                                                                                       Fear / Terror

Brain             Optimal           Unable to        Shut Down
Function                Learning         Think              Disassociated

Concentration,    Good                Distracted &   Attention Narrows.
Attention,                                 Internally         Focus is only on
Ability to Learn                      Preoccupied   The Perceived Threat

Nervous System Calm &            Fight, Flight    Will do anything

Regulated        Freeze,               or say anything
Fidget                 to avoid the threat

Impulse Control Thoughts       Impulsive/    Immediately Reactive
& Judgement        Override       Compulsive     Impulses Take Over                                     Impulses                                 Fight / Flight / Freeze

A child who has been exposed to extreme early-life trauma will be triggered into emotional dysregulation by situations which a non-traumatized child could easily navigate. 

What might be a minor upset for the non-traumatized child, for example not getting a cookie when he wants one, can be lead to a major meltdown for a previously traumatized child.   This is especially true for the child who suffered neglect or food deprivation earlier in life in their birth family or orphanage.

Triggers can push a child from the Calm State into a Hyper-Aroused, fear-based state

One child I worked with years ago, had PTSD reactions which demonstrate how triggering works.  He had spent his first four years in a highly dysfunctional drug family, before being removed from the birth family and adopted.  He had witnessed birth dad regularly beat up birth mom during alcohol-induced fights.  He had witnessed the police come to the family home to break up the yelling and fighting more than 2 dozen times.  Eventually the child was taken from the home.  Because the police came so often, and eventually took him away, he associated the police with danger:  being removed from his birth family which is a scary thing for any child, even if home is highly violent.   Triggers arise years later and make the past trauma, present in the Now.  The child’s nervous system reacts automatically and involuntarily, expecting that the past trauma will occur again in the present.  If police show up, he could be taken from his adopted family too.  One day he was with his adoptive mom at a store at the check out line.  The clerk, noticing the long line, spoke into her shoulder microphone that she needed “backup.”  The child’s behavior changed for the worse instantly.  The boy became very agitated and dysregulated.   He began fidgeting, pulling on adopted mom, demanding “let’s go” and making things fall from the store racks.  Normally a child might get a scolding for acting out, but adopted mom recognized what was happening:  Her adopted son had been triggered into the Fear/Terror/Hyperaroused state.    Adpoted mother recognized that her son was “not just being difficult” but had been triggered into the Aroused State, and she understood that making the child feel SAFE immediately was the correct response.  Many less skilled parents would have given a lecture or consequences for bad behavior.

Knowing which of the three states a child is in makes a world of difference in terms of effectively parenting them in the moment.    For example, words and lectures that require executive function / brain power, won’t work with a child in the Aroused State – their brain is hijacked by fear at that moment.   The first order of business is to calm the child, make them feel safe.  Later when the child returns to the Calm, Regulated State talking and educating are possible.  But no learning can occur when the child is activated and Aroused in fear.

A child in the Hyper-Aroused Fear State

For a child in the hyperaroused fear/terror state, attention narrows and focus is only on disarming the perceived danger or threat.  The child’s nervous system becomes overwrought with fear and the child will do or say anything (including habitual lying) to avoid the threat.  Impulse Control is lost, and the child can become immediately reactive and impulses take over.  Adoptive parents need a different set of skills and tools to help a child in this state.   As adoptive parents,  we may not always know what triggers our child,  but with sensitivity and awareness, we can learn what plunges our kids into The Fear/Terror/HyperArousal State.  And we can be prepared with the key tools to help them return to the Calm State.  (These tools will be the subject of our next blog post.)

Shame is the feeling that there is something defective or deeply wrong with one’s self.  Children with attachment issues or early life trauma are especially vulnerable to feeling deeply ashamed of themselves.  Sometimes they have the mistaken notion that it was their behavior that led to relinquishment.  For example, one child believed she had hit her birth mom and that was the reason for relinquishment.  In reality, her birth mom’s unsuccessful struggles with methamphetamine dependence were the real cause.

Additionally, kids with early attachment and trauma have increased difficulty with emotional regulation.  Often times small triggers lead to tantrums they can’t stop themselves.  This inability at self-control is a major cause of toxic shame, or feeling bad about one’s self.

A healthy sense of shame — the knowledge that I did something I should not have — can lead a child to try harder to avoid misbehaving.  Toxic shame, however, results if a child comes to believe he or she is defective or bad to one’s core.  Toxic Shame is deeply painful and destructive.  Rather than feel toxic shame, a child will act out in extreme ways.

Here are key therapeutic parenting recommendations for parents to protect children from toxic shame and to help kids repair a healthy sense of self if they are at risk of toxic shame:

1) Use “Pizzaz” frequently.  Pizzaz is any compliment that highlights the successes or positive qualities of the child: ‘I really liked the effort you showed when you shared your new toy car with your brother.”  “That is not easy to do!”  “Way to go!”  Catch a child being “good,” effortful or positive and give them Pizzaz!

2) Avoid following discipline with rejection or withdrawal of love.   Let the consequence be the punishment.  Once it is served, let the child back into your good graces and positive feelings, quickly.  Don’t keep making them pay.

3) Avoid delivering consequences with long lectures or an angry tone. Sometimes parents use a condemning tone to reinforce that the child has been bad and help them “get the message.”   This increases shame.  Rather, let the consequences deliver the message, and keep the tone neutral and calm.

4)  We as parents need to work on our own emotional reactivity and avoid making devaluing comments.

5)  Normalize the child’s feelings and urges in the moment.   It is natural for a child to be upset if they do not get their way.  Rather then tell a child they are bad, let them know that it is hard dealing with such feelings.  Actively empathize with the child by telling them — “it is hard not getting what you want.”  “I am sorry it is so hard for you.”  This shows empathy and that the child’s feelings are normal.  “Of course you don’t feel like doing your homework.  I felt that way too.”

6) When dysregulation of the child occurs, usually there is a deeper experience of loss that triggered the emotional outburst.  Be sure to address and deal with the loss experience that is driving the behavior.  This can be a good reason to seek professional help.

7) Reinforce the child’s ability to do hard things, with effort and practice.  Reframe the child’s “I can’t” statements with different languaging such as:  “You just have not done it yet…” or “You won’t.”  For example, the child says “I can’t get control of my temper.”  Emphasize that they can work at and learn how by staying “It is hard to control temper, and you haven’t done it yet, but you can.”

8)  When a child has acted out use the phrase “At Least……” to give partial credit for something they did right.  The child learns they are not “all bad.”  For example, if the child has tantrumed for a half hour due to not getting something they wanted, tell them “You did have a tantrum, but At Least it was for a half hour and not a full hour like last week.”  In other words, find things that are small improvements and highlight them.  “You said a mean word to your brother, but At Least you stopped yourself from hitting him.”

In short, small changes can go a long way to protect our kids from toxic shame.

When we truly understand what is going on inside a child with Attachment Trauma, we can make skillful, useful responses geared toward healing, rather than getting lost in anger and frustration.

Trauma falls into two categories:  Single Episode and Complex Trauma.

Single Episode Trauma:
A child getting lost at a grocery store is an example of single episode trauma.  In this instance the child becomes anxious, fearful and alarmed.  The parent’s sudden absence stimulates adrenalin and the child is gripped with fear for survival.   When the child finds its parent, the impact of the trauma may show itself as increased insecurity.  A return trip to the grocery story may “trigger” a recurrence of fear and anxiety.

Complex Trauma:
When a child experiences traumatic episodes that are repetitive, occur over a long time, involve violence or neglect by caregivers, and occur without warning or predictability,  the impact is intense and enduring.  This type of trauma causes long-lasting symptoms, alterations in personality structures, and serious neurophysiologic changes.   Real-life examples of complex trauma include:
· A 4 year-old girl who was left at home unattended repeatedly in days-long drug-seeking binges of her birth mom.  The child scoured the house for food and could only find uncooked pasta in the cupboards.   She endured intense hunger, was terrfied to be left alone, feared she would starve.  When her mother did return she feared the next episode.
· A two-year old born in Eastern Europe who initially was raised by his birth parents for a year in squalid conditions.  Malnourished due to poverty, the child was removed by authorities due to squalid conditions, parental neglect, and malnourishment.  The child spent months in an Eastern European hospital with multiple caregivers and in physical pain without adequate comforting.  After hospital discharge, the child spent two susbsequent years in an orphanage.  Adoptive parents visit the orphanage to pick up their adopted child at age 4 and witness verbal abuse of orphanage staff toward the children.

Complex Trauma conditions the child to be always on guard for the next abandonment or trauma.

Brain Development
During a traumatic episode the nervous system goes into high alert and produces adrenalin, the neurochemical which helps us respond with “fight or flight.”
When complex trauma occurs early in life, a child suffers a developmental double whammy.
First, the developing brain is bathed in chronic adrenaline, altering its formation, and reinforcing neurological pathways of insecurity, lack of safety, self-protection and defensive reactivity.

Second, when a child in a caring, functioning family has a single episode of trauma, the parents are there to comfort and sooth the child, developing neural responses that reinforce adaptive coping. The child in the dysfunctional, abusive situation has no outer support to reinforce adaptive coping.

The child is highly reinforced into fight or flight, adrenaline-based responses in the Reptilian Brain or Brain Stem.  At the same, due to lack of nurturing caregiving and the co-regulation of affect,  the child suffers from inadequate development of the Cerebral Cortex, the part of the brain that accesses reason, logic and creative solutions to problems.

The Attachment Cycle and Navigating the First Developmental State of Trust vs. Mistrust:

Attachment is the child’s internal sense that its caregivers are responsive to its needs and that the world is safe.  Consider this moment in the healthy development of a child:  The child feels an uncomfortable sensation in its stomach, its hunger causes it to cry out (dysregulation), attentive parents feed it, and the uncomfortable sensation goes away.   The child feels content, safe, secure and is “regulated.”  The child then starts feeling uncomfortable sensations because it has a wet diaper and cries out.  This is “dysregulation.” The crying or tantruming is a way of getting help.  Attentive parents change the diaper, the uncomfortable sensations go away and the child now feels regulated again.  Similarly, when the child feels alone or unsafe, it cries out and gains holding from attentive parents and the “dysregulation” is successfully resolved.

This Attachment Cycle of dysregulation, met by parental response, leading to regulation is played out dozens of times each day.   The parent-child dyad is building a sense of security for the child, and neurologically the child is laying down the pathways of attachment and connection: When I have a need, it is met, I am soothed and the world is a safe place.  Neurologically this becomes encoded in the child’s neurological structure, and when there is a dysregulation, the child begins to anticipate that its needs will be successfully met.

When a child’s parents, through neglect, abuse, or abandoning behaviors, fail to provide the regulating soothing or action, the opposite process is reinforced neurologically – the child learns that no one is coming, the world is unsafe, people I should be able to count on I cannot.

ATTACHMENT RESOURCES:

HELP ONE CHILD

Los Altos, CA

1-888-KID-HOPE

A non-profit support community for families who are fostering or have adopted children with attachment difficulties.

www.helponechild.org

ATTACh

The Leading Professional Association for Treatment & Training in the Attachment of Children.  Includes Parents and Professionals.

www.attach.org

Worthwhile Reading:

Parenting the Hurt Child,  Keck & Kupecky

Attachment-Focused Parenting,  Daniel Hughes

Building the Bonds of Attachment:  Awakening Love in Deeply Troubled Children,

Daniel Hughes

Parenting From the Inside Out,  Daniel Siegle

Healing Parents:  Helping Wounded Children Learn to Trust & Love,

Michael Orlans and Terry Levy

When Love is Not Enough:  A Guide to Parenting Children with Reactive Attachment Disorder,   Nancy Thomas

Real Parents, Real Children,  Holly vanGulden

Coming Home to Self,  Nancy Verrier

The Primal Wound,  Nancy Verrier

Beyond Consequences, Logic & Control,  Foster & Post

Parenting with Love & Logic,  Foster Cline

Relentless oppositional behavior exhausts and frustrates parents of children with attachment disorder.  To respond in a skillful way, first, we need to understand the subjective experience the child is having.
The Child’s Internal Experience:

Children with a history of trauma, abuse or neglect often live in a hypervigilant state.  Their prior life experiences have wired them to be “on guard” waiting for the next slight or injury.  These children experience a strong need to be in control of all situations to avoid being re-injured.

Often regular parental limit setting, such as denying a desired item, or a change in plans that rules out a hoped for event, can result in dysregulation and tantruming.   The child experiences the “no” as a deprivation which the child is emotionally or neurologically unable to cope with.  The child becomes “triggered,” or emotionally flooded, and the parasympathetic nervous system is overloaded.  The child has few skills to cope.  In the limbic system, the child is flooded with adrenaline stress hormones, and is caught in a “fight or flight or freeze” response.  The child is caught in the Reptilian brain and has difficulty accessing the logic centers in the prefrontal cortex to reason his way of the dilemma.

Three Strategies for Managing Oppositional & Defiant Behavior:

The Goal is to stay connected to the child during the period of dysregulation.  As a parent, you are successful if you can demonstrate to the child that the child’s tantruming process is “contained” by you.  This does not mean that you stop the tantrum.  It simply means that you demonstrate you can handle whatever the child throws at you without moving into a rejecting, shaming or an outwardly angry/rageful stance yourself.  The

Initial Goal is to attempt to anticipate and head off the tantrum before it starts.  The following techniques can be helpful in this.  Once a child’s tantrum has reached a certain point, however, there is no return, and the child is so dysregulated the tantrum must run its course.  It is as if a “storm front” needs to pass through.  Afterward, the child is often able regulate.  Always the goal is to soothe, co-regulate, and to set limits and gain cooperation without a power struggle

1)  Paradoxical Intervention:  With this tool, you give permission to the child in a calm, non-reactive tone of voice to do the unwelcome behavior while spelling out the ramifications or consequences they will face if they do the behavior.  Often children with attachment disorder have an instinctive need to make you feel the anger and upset they feel inside.  Their behavior is unconsciously geared to do so.  When you give them permission to do the negative action, and allow them the choice, many times they will pull back from the negative action.  For example:

• Parent to child:  “Time for dinner, please come to the table.”
• Child to parent:  “No, I’m gonna go next door to Tom’s”
• Parent to child:  “You could do that.  I know it would be fun to play.  Just be aware you would lose priviledges and could not go on the field trip.  But you could do it.”
• Then give space by walking away and letting the child decide.
• Avoid making the child feel like you are controlling him or telling him what to do.
• He is “hard wired” to show he is in charge and oppose you.  Therefore, leave him with the choice and follow through on the consequence if the choice is a poor one.
• If necessary, later enforce consequences when child is regulated

2)        Therapeutic Communication:
Languaging to help child regulate and digest his feelings:

Using Joining and Therapuetic Mirroring

The goal is to help the child feel understood, and to assist the child through the Co-regulation of affect.

1) Describe the problem from child’s eyes (Examples):

“You don’t want to quit having fun”

“You did not like it when John said a mean comment”

“You really want to use the computer right now and it is very frustrating you

2)  Describe / Mirror the feeling the child is experiencing:

“You are angry and frustrated.”

“You did not like what John said.  It felt like a put down”

“You don’t like the school policy of no computer use during this time.”

“When I tell you can’t do what you want it must seem really unfair and mean

and I bet it makes you feel like I don’t care about you.”

3) Normalize the feelings / Join / Take child’s side:

“I’d probably feel irritated at having to end something I was really enjoying too.”

“I’d probably feel hurt and irritated if someone said something I did not like too.”

“I’d be frustrated if I could not use the computer too.”

4) Ask for positive behavior for the child to get what he wants:

“If you can be part of class right now and participate, you can play again at

recess.”

“If you can talk calmly now, we can talk to John about what upset you.”

“If you can leave the computer alone right now, I can help you use it during

the computer class “

3) Engage the Child with PACE

PACE is a powerful set of tools for joining and connecting to help prevent episodes of dysregulation, or to sooth a child through an episode in progress.   Engage the child with PACE when it appears she is heading toward dysregulation.  Always talk in a positive, non-angry tone.

Example:  Child is playing with spiderman and superhero figures and refuses to pick up his toys and come into the house when asked.
Playfulness  —

Play alongside the child for a moment or two.  Then have superman figure say to spiderman, “what do you say we fly home for dinner.  I’m kinda hungry!”  Spiderman Man I would love to be able to do the same thing – tell my boss I won’t teach today!  Hey you are good at telling me you won’t do things you don’t want to do!  Do you think you could use some of your magic and get me out of having to teach today?
Acceptance –

You are having a really hard time today (said with compassion)

“I am sorry it is so hard.”  “I wish I didn’t have to live by the rules sometimes too.”
Curiosity  — I wonder what is different today?  Yesterday you were willing to take out your book”
Empathy

“It can be hard having authority figures tell you what to do all day.  I get it!  Sometimes you just want to be your own boss!”

4)  Avoid anger, sarcasm, controlling him, power struggle or the child will escalate further.

Children with Attachment Difficulties do better when given a directive, if parent gives the direction and then walks away so child has time, space to comply

Avoid putting oxygen on the fire.

Respond vs. React

Self-Monitor to avoid coming across as negatively evaluating, judging or criticizing as this presentation will trigger the child.

ATTACHMENT DISORDER:  THE CHILD’s INTERNAL EXPERIENCE

Ongoing abuse, neglect, institutionalization, cause compound or complex trauma.  A cascade of internal experiences and symptoms results including:

· Mistrust of Parents and Authority, Resulting in Extreme Need to Control Situations and People.  The child has experienced that early caregivers were not reliable, and may have been actively hurtful.  The child’s survival instinct will not allow himself or herself to be in a position of risk again, and unconsciously resists any receptiveness to parenting.  The child feels a need to be in control.

· Hypervigilance – the child is “on guard” constantly monitoring the environment, waiting for signs and signals that the next episode of abuse or neglect is near.  Hypervigilance is a form of anxiety.  This hypervigilance can be so strong as to prevent learning,

· Dysregulation or tantruming is a sign in the child that it has encountered an emotional field that is overwhelming to it.  The emotions are too big to digest, and the child has melt down.

· Experiences any limit setting, consequences or parental disapproval not as teaching tools to improve behavior, but as deprivation.   This deep sense of  deprivation results in tantruming.  The child needs to control all situations to feel safe.  Typical parenting approaches like setting limits trigger the child into the experience that the adoptive parent is as depriving as the abusing, neglectful or abandoning early caregiver.

· Emotional Numbing & Emotional Cutoff – children of complex trauma become flooded by powerful emotions of fear, desperation, hopelessness and helplessness.  Facing these emotions repeatedly became intolerable so the child shut down to their emotional experience.  Feelings take shape in the body in the form of bodily sensations.  The child learns, as a coping mechanism, to shut off signals from the body.  Trauma has caused a defense mechanism of emotional numbing.  The child may be unable to report on feelings he or she is having, and may make up nonsensical answers to querries about internal feelings.

· Deep-Seated Shame and a conviction that “I am bad.”  From repeated experiences of abuse or neglect or parental absence, the child develops an unconscious belief system.  Common beliefs include that the child must be “bad, unworthy, and unlovable” and must have done something to deserve the abandonment.

· Oppositional defiant behavior, distancing behaviors, constant negotiation to get what is desired, regressed behavior, feigned lack of understanding, ignoring, avoidance, resisting physical contact, nuisance chatting, are all mechanisms of control employed by the child.  These should be understood as reactions out of fear and survival instinct, and an attempt to communicate the core feelings of anger experienced during trauma, rather than as a direct manipulation of the parent.

· Heightened Anxiety as a response to free time or an unstructured day.

· Reliance on primitive defense mechanisms including:
o        Splitting
o        Projective Identification
o        Dissociation / Disconnection
o        Projection of old mother onto new mother

· Can try to control adults by threatening tantrums to get what the child feels is essential supplies to avoid

· Can be superficially charming to non-caregivers.

· Highly sensitive to perceived loss of connection with parent, experience of lack of contact, experience of disapproval or parent’s actions perceived as deprivation.