What Is Developmental Trauma?
In the first years of life, infants and toddlers need safe, predictable, accessible, and loving caregivers. In this environment the brain is able to develop in a healthy, normal sequence of growth.
The brain develops from the bottom upward. Lower parts of the brain are responsible for functions dedicated to ensuring survival and responding to stress. Upper parts are responsible for executive functions, like making sense of what you are experiencing or exercising moral judgement.
Development of the upper parts depends upon prior development of lower parts. In other words, the brain is meant to develop like a ladder, from the bottom up. When stress responses (typically due to consistent neglect or abuse) are repeatedly activated over an extended period in an infant or toddler, sequential development of the brain is disturbed. The ladder develops, but foundational steps are missing and many things that follow are out of kilter.
Developmental trauma (DT) (or reactive attachment disorder) can manifest in a variety of ways — sensory processing disorder, ADHD, oppositional defiant disorder, bi-polar, personality disorders (especially borderline personality disorder), PTSD, cognitive impairment, speech delay, learning disabilities, and more.
Interventions for Developmental Trauma
Among the various approaches to developmental trauma, I find the work of van der Kolk and Perry particularly useful. Van der Kolk in his 2017 essay, identifies phases of intervention for developmental trauma. Similar to Hermann’s 1992 phasic framework, van der Kolk’s approach breaks down trauma integration into three phases, each with its own dynamics and requirements for treatment:
Establishing a sense of safety and competence. Engage with survivors in activities that do not trigger trauma responses and that give them a sense pleasure and mastery while facilitating self-regulation (van der Kolk, 2017).
Dealing with traumatic re-enactment. Survivors may replay their original trauma with other people. This can include perceiving people who try to help them, such as therapists, as perpetrators (van der Kolk, 2017).
Integration and mastery. Engaging survivors in “neutral, ‘fun’ tasks and physical games can provide them with knowledge of what it feels like to be relaxed and to feel a sense of physical mastery."
Perry’s Neurosequential Model of Therapeutics (NMT) provides a framework of brain development for work with developmental trauma. Using Perry’s framework, therapists can precisely target their work to whatever stage a child was in when trauma took place.
Traumatized children, Perry writes (2007), “need patterned repetitive experiences appropriate to their development needs, needs that reflect the age at which they missed important stimuli or had been traumatized, not their current chronological age.”
Following assessment, a therapist uses activities selected to address the area of the brain impacted by trauma. The goal is to bridge gaps in development that have been identified. For example, if assessment indicates gaps related to brainstem and midbrain functioning, therapeutic activities will include expressive arts, yoga, massage, etc. After these functions have improved, activities progress to facilitate further sequential development of the brain.
Attunement Is Key in Developmental Trauma Integration
Attunement is a process of giving complete, nonjudgemental, responsive attention to another person through eye contact, and other more or less nonverbal forms of attention and response. Though many parents do attunement so naturally they are not even conscious they are providing it for their children, frequent and extended experiences of attunement are among the most important requirements for children to develop sequentially.
In the first years of life, a child is fully dependent on caregivers to meet her needs. Experiencing frequent attunement is a basic need, essential to support healthy development in particular brain development. However, even in the best of circumstances, parents are not able to anticipate all of a child’s needs, so an infant inevitably gets upset from time to time. Schore and Shore (2008) call this “misattunement." Well-functioning parents respond appropriately to soothe the baby, which Schore calls “reattunement” (2008). Misattunement is unavoidable, and not damaging so long as it is followed by prompt reattunement. But ongoing stress (misattunement) without proper reattunement deeply disrupts an infant’s ability to experience being in the center – being attuned to. Infants, toddlers, and children who experience this disruption on an ongoing basis grow physically (although even physical growth can be stunted). But emotionally, the foundations for forming relationships, feeling safe and at rest in the world, and self-regulation are deeply damaged. These are the missing steps in development I referred to above. The ladder (brain) continues to develop, but without a foundation in attunement, and the sense of ongoing secure footing in the world it provides, the higher-order functions (logic, concentration, retention and ability to respond and not react) that follow develop above these missing steps. Children who do not frequently experience attunement are unable to form secure attachments (stable relationships). This applies not only to others but also to being able to be attuned to themselves, and to their own needs. Inability to attune to self and others is a precursor, of course, to a variety of destructive symptoms. Underlying many, if not all, of these is the perception of survivors that relationships are not predictable or safe or that life itself is not safe. Beneath the chaos and struggle that often seem to churn around these individuals is a determined effort to connect with others in the only way they know how — reactive engagement. Elements of an effective therapeutic framework for creating secure attunement include:
1. Experiential psychoeducation.
Educate the survivor and family members, in ways that fit their developmental capacity, about what happens when the child is triggered emotionally, afraid, and stressed. For adult clients, this includes understanding how developmental trauma affects them today. 2. Enhanced sense of safety.
I consider action in a safe space to be the preferred strategy for this, since in developmental trauma the damage took place at an age when imaginationand playfulness were supposed to be dominant and essential to facilitate brain development. The therapist uses activities that involve playfulness, imagination, and spontaneity appropriate to the child’s current age to trigger bottom-up brain development corresponding to the age when the developmental trauma took place. For adult clients, this also include activities that enhance playfulness and spontaneity. 3. Improved self-regulation.
Since our body detects stress (real or perceived), self-regulation relies on sensory integration. For this, we use sensory integration activities adapted to the age of the client when the trauma took place.
4. Safe regression.
The first three elements lay the groundwork for this phase. The activities in the therapy room foster creativity, playfulness and spontaneity while allowing for slowly introducing things that involve some risk and autonomy. It takes time. But not too much, and not too early: Repetition of these activities in many sessions builds a sense of safety, enabling the client to enter what I call safe regression. Developmental trauma requires a complex response.
It is not realistic to expect results with such an injury on all levels of well-being without addressing the many aspects of life impacted by it (emotional, cognitive, physical, spiritual and social). It is also unrealistic to expect that seeing a therapist once a week will be enough. After any injury, when we want to help someone heal we make sure they eat well, get enough rest, support their immune system and metabolism, improve their cognitive abilities, engage socially as much as they are able, and so forth.
Trauma therapy in general requires daily routines that facilitate long-term sustainability. Without these, we may see some progress, but it won’t be as long-lasting as when we address all of them at once. For developmental therapy this is even more true.
Living with developmental trauma is a lifelong journey. Survivors who are able to integrate their trauma can expect, like everyone else, to experience movement throughout their lifetime between a sense of attunement, misattunement, and reattunement. Without adequate neurodevelopmental intervention, they will spend more time in misattunement and find reattunement more difficult. With proper intervention and greater integration come less time in misattunement and greater fluidity in returning to attunement.
Courtesy of Dr. Odelya Kraybill, an integrative trauma therapist who teaches about sustainable trauma integration in the US and abroad.
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