Emotional Regulation in Traumatized
and Severely Neglected Children
(Originally published October 2011)
Traumatized and severely neglected children commonly have great difficulty calming down and avoiding emotional melt downs in response to reminders of trauma or perceived threats. Children who have been repeatedly abused or neglected may be unable to prevent anxiety from developing into panic or anger into rage, and engage in extreme behavioral strategies to protect themselves or avoid events that might lead to out of control emotional reactions. Extreme reactions to seemingly minor stresses or frustration are common when children believe that adults are more likely to hurt than help them and when children do not trust caregivers to help them calm down. Young children are unlikely to learn ways to self soothe and calm down unless they can first turn to caregivers for emotional support and protection and are able to model caregivers’ responses to stress or threats.
These children’s extreme behaviors often frighten and alienate caregivers and professionals even when children are young and increasingly so as children age and begin to be physically threatening. In The Boy Who Was Raised As A Dog, Bruce Perry and Maia Szalavitz tell the story of a 6-year-old boy, Justin, brought to a hospital pediatric unit by a 60-year-old unrelated dog breeder who had been the child’s main caregiver for several years. This child had been placed in a dog cage next to dogs in cages for several years following his grandmother’s death. Medical experts had diagnosed the child as suffering from untreatable brain damage from the age of 2.
After the child was hospitalized, nursing staff put him in a locked cage because of his behaviors which included throwing food and feces at nurses and doctors. Perry and Szalavitz describe Justin as follows: “The little boy rocked back and forth, whimpering a primitive self soothing lullaby. He was filthy with his own feces, there was food all over his face and his diaper was heavy, soaked with urine… he resisted all (medical) procedures … he tore out his IVs, he yelled and screamed at staff and he threw his food.” The child also “began to throw feces and anything else he could get his hands on.” Periodically, the child uttered loud angry sounding shrieks. The nursing staff did not like the child and pretty much ignored him, neglectful care much like he had received at home.
Bruce Perry, a child psychiatrist with a background in trauma, was called in to consult, perhaps with the hope that he would confirm the prevailing medical view of untreatable brain damage. Instead, Perry attempted to imagine the world from the child’s perspective. “He looked terrified and confused; he had no understanding of this new, chaotic realm … At least his home in the dog kennel had been familiar,” Perry and Szalavitz state. Perry also understood that Justin was hungry since he had been throwing most of his food at passers – by. Perry approached the child slowly without quick movements or eye contact, speaking in a low, melodic, rhythmic tone, “almost like a lullaby.” “I approached him as one would a terrified baby or a frightened animal,” Perry comments.
Perry then offered the child a piece of muffin after modeling how to put the muffin in the mouth and chew it. “And then, suddenly, he grabbed at the muffin and pulled it into the crib,” Perry and Szalavitz state. Perry had Justin moved to a room with reduced stimulation; he reduced the number of staff caring for the child. He caused speech therapy, physical therapy and occupational therapy to begin immediately. Perry and one of his staff began to spend time every day with Justin. Perry and Szalavitz comment: “Every day he appeared to feel safer. He stopped throwing food and smearing feces. He started to smile. He showed clear signs of recognition and comprehension of verbal demands. He began to express affection and show signs of a sense of humor. Within a week, he could sit in a chair and stand with assistance; by 3 weeks, he took his first steps. He learned how to use a spoon and a toothbrush and to dress himself. He stopped sniffing like a dog. Perry and Szalavitz comment that “His brain seemed to be like a sponge, thirsty for the experiences it required, and eagerly soaking them up.” Justin was placed in a foster home a few weeks later and, according to these authors, continued to make rapid and remarkable progress.
This story has several important lessons:
(1) what Perry did that other medical experts failed to do was take a careful history of early caregiving arrangements; when Perry found that Justin had experienced severe lack of nurturance and care for several years, he had good reason to be skeptical of the child’s diagnosis.
(2) Perry attempted to imagine the world from the child’s perspective, and recognized that Justin was terrified and doing what he could to protect himself.
(3) Justin, like many traumatized and severely neglected children, was physiologically dysregulated as well as emotionally dysregulated. Regulation of bodily processes and emotions grows out of emotionally responsive caregiving which Justin had lacked for several years.
(4) Justin had to feel safe before he could benefit from common therapies available in the hospital setting.
(5) Reducing stimulation in the child’s environment and establishing a predictable routine helped Justin to develop a sense of safety.
(6) Nursing staff feared, despised and avoided the child and were not immediately happy that he could be helped.
(7) Justin was able to recover from severe neglect and trauma so quickly possibly because he had received positive nurturance for a year when he was an infant. By age 8, Justin could write a note in crayon to the psychiatrist who rescued him: “thank you, Dr. Perry.” Perry comments “I cried.”
Perry and Salavitz believe that traumatized children need large amounts of patterned repetitive learning activities to feel safe and a large degree of control (even at young ages) over their treatment processes, for example in play therapy. Perry echoes for children the theme that Judith Herman develops so eloquently for adults in Trauma and Recovery, i.e., that trauma victims cannot be coerced into doing the right things for themselves because lack of control is a defining characteristic of trauma. To coerce is likely to reenact traumatic experience.
Another outstanding book for foster parents, adoptive parents and child welfare practitioners caring for or working with traumatized and neglected children is Deborah Gray’s Nurturing Adoptions (2007). Gray’s perspective is that traumatized and severely neglected children learn emotional regulation through nurturing attachments to caregivers who have the commitment, emotional intelligence and skills to help children who initially lack trust in caregivers. Children with avoidant or disorganized attachment styles will not turn to caregivers consistently when they are tired, hurt, hungry or feeling lonely. Gray comments that “Children who experience a sense of safety with a parent learn to calm down with that person. They borrow from their caregiver’s coping abilities, and use that person as a base as they calm and feel safe.” Gray’s view is that foster parents and adoptive parents must be prepared to “teach their children soothing, calming and emotional regulation through their attachment relationship.” And Gray continues “Caseworkers will have the obligation to place children into homes that are prepared for and competent to help in these emotional processes.”
Gray provides practical developmentally appropriate advice for helping children of all ages. For example, for school aged neglected children, Gray summarizes the tasks of caregivers and therapists as follows:
To stretch children’s positive moods
To help children connect their thoughts to their feelings
To assist children in thinking about the feelings and thoughts of others at the same time that they think about their own feelings and points of view (difficult for children before age 6, but after 6 hopefully an emerging skill)
To teach children how to read the faces of others in real time and to relate to the feelings of others
To develop in children both optimism and a sense of mastery
To encourage in children an attitude of being in charge and responsible for having a satisfying life
School age children, Gray believes, need to practice reflecting and thinking about their lives. She suggests that parents write questions for children about their thoughts and feelings and allow children to respond in writing or by drawing pictures. She believes children should be encouraged to store positive memories and work at mastering impulses and developing social skills. Like Perry and Szalavitz, Gray emphasizes the importance of structure in daily routines and minimizing background noise. She cautions parents against using harsh tones or harsh language in managing child behavior. She comments that “A harsh approach may effectively convince children to behave and get back on track in the short term; over time, however, they will become more defensive and disorganized. They will feel as if they are back in a hostile setting and …will return to using their old defenses.” “Children do best, she comments, “when they feel safe and cherished.”
Gray views dissociation, i.e., freezing or detaching when frightened, as a ‘”developmental catastrophe” that keeps children from developing ways of coping and protecting themselves. Children and adults who habitually use dissociation as a response to stress begin to “uncouple the mind body connection.” “Dissociating children often seem lost in time,” she states. Children who habitually dissociate need help with emotional regulation before talking about abuse or neglect or other types of mistreatment, Gray believes. “These children will often flood with emotions during their first attempts at working on integration (of memories of trauma) with therapists or caseworkers,” she writes. In fact, Gray believes that even children who do not employ dissociation should not be pushed into trauma work until they have the ability to calm down.
The lack of emotional regulation will create serious obstacles to children’s ability to make and keep friends, cope with teachers demands in school settings, tolerate frustration when learning new skills, refrain from physical violence or deal with unexpected obstacles and stress in novel environments. For this reason, some traumatized children and adults value routine over novelty and accept strict limits on their ability to explore the world around them, encounter strangers or learn new things. They are at risk for ending up in restrictive settings in which force and coercion are used to control their behavior, or using drugs and alcohol to calm down and moderate painful emotions. They may also end up lonely and isolated because of fear of intimacy.
Gray comments that “Confidence in the ability to handle shifts in moods and reactions gives children an incredible ability to explore life and its challenges.” Children and youth who have learned to use nurturing adults and peers for support and strategies for calming down (for example, breathing slowly and deeply, asking for hugs, sharing feelings with friends and intimate partners, letting go of resentments or desire for revenge, meditation, attention without a goal) feel in control of themselves and able to cope with the world as it presents itself and as they intentionally build a life for themselves.
One implication of Nurturing Adoptions is that the quality of caregiving and children’s relationships with caregivers are the most important factors in helping children recover from trauma and neglect. Mental health therapists and programs can offer birth parents, foster parents and adoptive parents valuable advice and support, but the day in day out work of developmental repair for traumatized and neglected children must be done by parents, child care staff or residential care staff. Child welfare agencies need to recognize the critical importance of foster parents and adoptive parents in developmental repair, and provide the in- depth training on trauma and neglect and ongoing support (including expert consultation, respite care and emotional support for caregivers) to help children gain mastery over their emotions and their lives.
Gray, Deborah D., Nurturing Adoptions, Perspectives Press, Inc., 2007.
Herman, Judith, Trauma and Recovery, Basic Books, 1997.
Perry, Bruce D. and Szalavitz, Maia, The Boy Who Was Raised As A Dog, Basic Books, 2006.