Mitchell, Tucci, and Tronick have assembled a paradigm shifting volume that informs us about the unique vulnerabilities of children exposed to trauma and abuse. The book is organized around an evolving treatment model developed by staff, affiliates, and collaborators of the Australian Childhood Foundation (ACF). During the past decade, ACF implemented a bold and innovative strategy to inform clinicians, scientists, and educators about the breakthrough treatment for trauma and cutting-edge research that conceptualized the neural pathways through which traumatic events are transformed into debilitating mental and physical health. This strategy focused on engaging world renown innovators in the field of traumatology.
Initially, the ACF invited pioneering clinicians and scientists to inform their staff and to conduct workshops for clinicians and educators in Australia. This evolved into a biennial trauma summit in which world leading researchers, clinicians, and advocates in traumatology met in Melbourne and shared their knowledge and insights with more than 2,500 conference participants. As clinicians and educators were informed through these structured vehicles (i.e., workshops and summit), ACF incorporated this knowledge into a model of improved treatment for children with trauma histories, who were dependent on foster, relative, and adoptive care. This Handbook is a product of the synergistic collaborations between ACF and the clinicians and scientists who have been welcomed into the ACF community.
By targeting the volume to children, who following trauma and abuse, have been placed in foster, relative, and adoptive care, the four major points of the Handbook are unveiled. First, due to the greater physical and ‘neural’ vulnerability of the young child relative to a full-grown adult, trauma and abuse result in a trajectory with frequently poorer outcomes. Second, trauma experiences have the potential to retune the child’s nervous system from a normal state of welcoming and trust to a chronic state of defense devoid of the feelings of safety that the nervous system requires to thrive and develop. Third, treatment models for these vulnerable children need to reconceptualize the child’s chronic defensiveness as a neurobiologically-driven adaptive response that lowers thresholds to be aggressive and raises the threshold to detect and respond to cues of safety. Fourth, a unique model of care, therapeutic child care, is presented that attempts to facilitate the positive development of children with trauma histories, who have been removed from their biological families and placed in foster, relative, and adoptive care. These are the children who by being locked in a chronic state of defense are the least welcoming to well- intentioned approaches of support and the least receptive to cues of safety and trust.
As we study the impact of trauma and abuse, we learn through the absence of specific emotional reactions and social behaviors what it is to be a successful, adaptive, and social human. In the study of adult survivors, we see the loss of function in ‘real time.’ Almost immediately after the traumatic insult, we can see the massive impact of the trauma on the individual. We see trauma ‘retune’ a survivor from loving and trusting others into a withdrawn individual who distances from previous social relationships, finds it difficult to trust friends, and loses a sense of purpose and a desire to live. These changes occur rapidly as the body changes neural state in response to a violation of trust and an expectancy to be safe. This sequence provides a window to see the unfolding of phylogenetically newer neural circuits that evolved to enable connectedness and co- regulation with others. With this unfolding following trauma, reflecting a disinhibition of evolutionarily ancient defense mechanisms, we are informed that the critical and most devastating transformative biobehavioral feature is a loss of feeling safe and a capacity to connect and share moments of intimacy with others. This trajectory illustrating the loss of affiliative function and trust provides therapeutic clues of the importance of re-introducing cues of safety to down regulate states of defense and to provide opportunities to engage and co- regulate.
In the case of child survivors of trauma and abuse, the opportunity to feel safe is frequently limited or non-existent during early child development. These children are often abruptly removed from the care of their biological parents and assigned by government agencies into foster, relative, or adoptive care settings that, at least initially, do not provide a resource base of connectedness and co-regulation with family that would be consistent with biological (i.e., evolutionary) expectation. By being born into severely dysregulated families, these children never have had the opportunity to experience a prolong period of safety consistent with their bodily needs for health, growth and restoration. Without feeling safe, the child’s nervous system becomes highly reactive to violations of contingent reciprocity and incapable of the self- regulation necessary for spontaneous repairs.
The impact of disruptions of normal child-parent connectedness may be visualized through the Tronick still-face model ((Tronick et al., 1978). This brief laboratory manipulation requires the mother, after social engaging and interacting with the infant, to abruptly freeze her face in a blank expression for a couple of minutes. This disengagement serves as a violation in the expectancy for reciprocal interaction and co-regulation with the mother. Often this disruption results in the child crying or going into a tantrum. The disruption is short lived, when the mother is required to repair the disruption by re-engaging and calming the infant. As a model of transitory disruptions and repairs, the still face paradigm provides insight into the adaptive flexibility of the child’s nervous system. It is a model of the normal ruptures and rapid repairs that occur in healthy family units. However, in homes of abuse, repairs are infrequent and infant bouts of crying and tantrums often trigger physical and emotional abuse.
Using the still-face paradigm as a model of ‘normal’ ruptures and repairs, researchers have been able to track the potency of maternal cues (e.g., facial expressions, intonations of voice, and gestures) on the infant’s behavior and autonomic state. The still-face paradigm provides a model to observe the adaptive importance of the caregiver’s engagement in the regulation of the infant’s physiological state to optimize health, growth, and restoration. However, violations without repairs, which characterize the environments of the children removed from the care of their biological parents, functionally retune the child’s nervous system into a state of chronic defensiveness. This is in contrast to more optimal developmental environments, which reframe transitory disruptors into opportunities for repairs. A predictable cycle of disruption followed by repairs functions as a neural exercise increasing the effectiveness and efficiency of the repairs. This sequence improves the child’s resilience. These sequences enable self-regulation to emerge from predictable opportunities for co-regulation. As the social interaction between the caregiver and infant becomes a predictable mode for co-regulation, a trust emerges that enables transitory violations, which are followed by repairs, to become a neural platform for humor (e.g., peek-a- boo) and play.
In contrast to the normal sequence during which a parent actively co-regulates the infant and the infant trusts the intentions and consequences of the parent’s behavior, children from severely abusive homes start their vulnerable and dependent lives in volatile contexts dominated by cues of danger and threat. These cues are sufficient to chronically trigger the child’s neurophysiology into states of defense. Therapeutic child care is proposed to treat this vulnerable group. Critical to an understanding of this paradigm shift in treatment is an understanding that the chronic defensive states observed in children, who come from these backgrounds, reflect an adaptive ‘biological’ survival strategy that is relatively independent of intention and conscious awareness. Rather than expressing an intention to be aggressive, oppositional, and defensive, due their early abusive history, their nervous systems are tuned to be hypervigilant and hyper-defensive. Without being able to efficiently calm their physiological state and to downregulate their defenses, these children provide few opportunities to co-regulate with another that in turn could provide opportunities to establish trusting relationships with caregivers, therapists, educators, or peers.
Polyvagal Theory (e.g., Porges, 2011) forms a component of this new model by emphasizing the important role that physiological state plays in mediating the effectiveness of an intervention. Within a clinical treatment model, Polyvagal Theory emphasizes that physiological state functions as an intervening variable either opening or closing the portal for trust and co- regulation. Consistent with ACF’s goal, therapeutic child care incorporates a respect for the child’s physiological state and how that state changes thresholds that will either facilitate the child feeling safe and trusting others or become defensive and biasing the nervous system to detect risk (i.e., neuroception), even when there is no real risk in the environment.
At the core of the new model is a strategy to build relationships of safety with the child. Thus, although moving the child from abusive biological parents removes threat, it is not the equivalent of providing the child with the neurobiological state that promotes feelings of safety. The importance of safety and especially fostering feelings of safety become the theme of the new paradigm and is central to several of the Handbook’s chapters and was introduced by two of the co-editors in an earlier publication (see Tucci, Weller, & Mitchell, 2018).
As I read the ‘Handbook’ I was reminded that trauma and abuse need to be understood from a biological perspective and not solely from behavioral, sociological, and psychosocial perspectives. A biological perspective informs us that the survival repertoire of an abused child, being physically small and neurological immature, is limited to more primitive defense systems dependent on the fight and flight (i.e., mobilization) and dissociation/death feigning (i.e., immobilization) strategies. These strategies tend to be reactive and reflexive, rather than being voluntary and intentional. The defensive strategies functionally are dependent on physiological states that preclude moments of feeling safe and trust. The ‘retuned’ nervous system of the abused child makes it difficult to reverse the antisocial tendencies and to rehabilitate the child into a more typical social context of trust and co-regulation. Thus, as proposed in the Handbook, a new treatment model is needed that acknowledges the abused child’s need to ‘feel’ safe.
There is a contrast between the importance of how ‘feeling’ safe optimizes development and how good intentions of educators, family members, therapists, advocates, and government agencies may misinterpret the biological need for safety and infer that the removal of threat is the panacea. Institutionalization of removing threat as the sole priority has resulted in the displacement of children from families and familiar communities.
In Australia the Lost Generation reflects an intention by institutions that did not match the biological needs of the child born to indigenous peoples. In Australia we can see the impact of marginalization and disenfranchisement on mental and physical health and all aspects of child development. From a Western scientific perspective, we see the effects in ‘real time.’ Although similar strategies injured native cultures in both the United States and Canada, the initial legislation that promoted the separation of child from family and culture occurred several decades before the policy was implemented in Australia; the understanding gained from these traumatic separations did not lead to enduring lessons. We are now at a historical time when we need, as stated in the Handbook, cultural humility.
Decades of research have documented what ancient societies intuitively knew about fostering and optimizing development in children. These societies knew and respected the importance of delivering cues of safety through family and community. During the past 100 years, anthropologists have re-discovered the important role that family and community has in enabling a child to feel safe.
Within our contemporary society (and science), we tend to minimize feelings and focus on cognitions and language. Perhaps, as modern Indo-European languages evolved from oral communication to written transcriptions, the syntax was optimized to describe objects and observations. This enabled scientific discoveries to be shared and allowed structured prose and poetry to proliferate. As the syntax and grammar of these languages became formalized, the languages became poor vehicles for the expression and sharing of feelings. However, on the positive side, modern European written languages have an obvious benefit of sharing unambiguous descriptions of events and objects.
When it comes to expressing our feelings, we tend to use primitive vocalizations such screams and not words. When suffering pain physicians do not ask for words that convey qualitative or quantitative differences in the experiences. Instead, physicians ask the patient to rate the pain on a scale from 1 to 10. It comes as no surprise that feelings of safety have only recently been brought into discussions of mental health treatment. Common use of English does not provide a syntax that distinguishes between feeling an external object and feelings experienced inside one’s body.
The Handbook unambiguously emphasizes that the therapeutic child care of abused and traumatized children requires a new paradigm that emphasizes the role that ‘feeling’ safe has in treatment. We learn that cues of safety are distinct from the words used to communicate. Cues of safety are conveyed through neurobiological channels that do not require cognitive processing (e.g., neuroception). These cues are frequently conveyed by intonation of voice (not words), by spontaneous facial expressions, and welcoming hand gestures and body posture. In emphasizing this point, it encourages therapists to explore the cues of safety that have the capacity to open brief time windows during which the child’s physiological state becomes calm. It will be during these brief moments that the astute therapist can build sufficient trust to dampen feelings of defense. As these moments expand in duration the relationship starts to have the capacity to co- regulate, with the potential to repair disruptions.
The Handbook provides an important step in providing an integrated treatment model, therapeutic child care, that is consistent with the observations of therapists, the experiences of children, and the science that has evolved to explain the neural pathways through trauma disrupts function. It will be through treatment models, such as therapeutic child care, that children who have experience abuse and trauma early in life will have an opportunity to ‘feel safe’ and be enabled to spontaneously re-engage with the world of trust, co-regulation, and relationships.
Foreword to MITCHELL, J., TUCCI, J., & TRONICK, E. (2019). Therapeutic Care as it Evolves. The Handbook of Therapeutic Care for Children: Evidence-Informed Approaches to Working with Traumatized Children and Adolescents in Foster, Kinship and Adoptive Care. London UK Jessica Kingsley Publishers
References
Porges, S.W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, attachment, Communication, and Self-Regulation. New York: WW Norton.
Tronick, E., Als, H., Adamson, L., Wise, S., & Brazelton, T. B. (1978). The infant’s response to entrapment between contradictory messages in face-to-face interaction. Journal of American Academy of Psychology, 1, 508–516
Tucci, J., Weller, A., & Mitchell, J. (2018). Realizing “deep” safety for children who have experienced abuse: Application of Polyvagal Theory in therapeutic work with traumatized children and young people. In S.W. Porges SW & D. Dana (Eds.), Clinical Applications of the Polyvagal Theory: The Emergence of Polyvagal-Informed Therapies. (pp.89-105). New York: WW Norton.