Over the last ten years our interest and understanding of these issues has matured. In the last paragraph of “Tina’s World,” we note that an hour a week of therapy was unable to “undo that set of associations,” which were related to her history of being abused. It is more accurate now to re-phrase that comment; therapy does not undo associations. Instead, it creates new associations which, over time, can become the new “default” or “template” for guiding responses to future experiences.

In Tina’s case, if she had been given enough time and opportunity to interact with healthy and attuned men and boys who provided sufficient positive or neutral interactions for a long enough time and in a clear enough pattern, she could have created new default associations about men—and male attributes. The associations created by her early history of sexual abuse would remain, although hopefully over time they would be much less “activated” and their intensity would fade.

The major challenge here is that we know so little about how to dose and schedule therapeutic experiences in order to create this therapeutic change. But study of the brain and how it changes may provide us some clues. These days, the buzzword in neuroscience is “neuroplasticity,” which refers to the capacity of neurons and their networks to be altered by experience.

This has important implications for the dosing of therapy: it suggests that even really short experiences can have a big impact. Indeed, long-term and enduring changes in neural networks can be created by an intense period of stimulation that lasts less than a minute. Synaptic splitting, which is one way these connections can change, can occur in mere seconds of intense stimulation—and if the intense experience is repeated four times within an hour, the change will be maintained long term.

Just as a traumatic experience can alter a life in an instant, so too can a therapeutic encounter. Unfortunately, in order for positive “doses” of interaction to lead to long-term change, much more repetition is needed. Consequently, the pattern and spacing required to ensure long-term maintenance of any therapeutic change is going to require a density of therapeutic interactions that our current mental health model of fifty minutes once a week cannot provide. For children like Tina to truly benefit from therapy, it needs to be embedded in a context of safe and positive interactions.

Chapter Two: For Your Own Good

Today, no one would argue that a three-year-old who witnessed the death of her mother, was slashed and left for dead, then placed in foster care is not at risk for suffering lasting psychological damage. While, thankfully, most children have the capacity to recover, the data suggesting that severe early life stress can have a lifelong impact has only continued to accumulate since this book was first published.

So too has our understanding of the role of sensitization and tolerance in trauma and healing. These are two key processes that alter critical stress response networks in the brain. Sensitization amps up the baseline activity and reactivity of these systems, while tolerance dampens down stress response reactivity. (See Figure 6 at the end of this commentary.) Importantly, there are certain patterns of activation that lead to sensitization and can cause problems, while other patterns lead to tolerance and can build resilience.

Neuroscientists have been studying these phenomena for over 50 years. Their relevance to experiences like drug use, addiction, and pain management have long been obvious, but ten years ago, their importance in understanding the effects of childhood trauma was only beginning to be recognized.

This same sensitization—often described as “walking on eggshells”—can happen with foster or adoptive parents when the behaviors of the child are, to the carers, completely unpredictable. Obviously, a child’s tantrum is not considered a “traumatic” event on the scale of witnessing a shooting, yet over time the physiological and psychological effects of many small, uncontrollable stresses can be very similar to those we associate with more extreme experiences.

The pattern and context of stress system activation—i.e., whether it is controllable or not, whether it occurs predictably or not—is as important as the intensity of the activation, and can sometimes be more so. In the real world, this means that a child of color living in poverty with no exposure to abuse, domestic violence, or other overt “trauma” can develop “trauma-related” problems that look just like those seen in a child who witnessed a shooting or lived through a natural disaster. And, if children like this also have exposure to overt major trauma such as community violence, their problems will be compounded.

The first and primary principle of neuroplasticity is that in order to intentionally modify—in any way—a specific neural network, we must first “activate” (or, in some cases “deactivate”) that specific neural network. This of course seems obvious; in order to learn how to play the piano, one must sit at the piano and play. Reading a book or watching a YouTube video about playing piano won’t change the specific neural networks responsible for piano playing. Your time at the piano may benefit from what you can learn in a book or video, but you will not create or modify the widely-distributed neural network that allows “piano playing” unless you activate it fully by actually tickling the ivories.

The same is true for traumatic memory and the sensitized stress response networks that are yoked to the complex, widely-distributed trauma reaction that follows the traumatic event. For Sandy, her set of trauma memories were reinforced and strengthened each time an evocative cue activated this chain: for example, when she did something as simple as drink milk. The vast majority of these activations for the first years following her mother’s murder were unpredictable to her because she didn’t know when to expect them. As a result, her stress response systems became more and more sensitized, and she often experienced an extreme and prolonged response. And as a result of that, she got worse.

What we’ve learned about these factors since we first wrote this book relates back to the concept of “dosing.” What is a moderate dose of revisiting a trauma and reactivating a chain of traumatic memory? Who determines what is moderate? Should it be the clinician who asks the child to recount the traumatic event—or the child?

When we ask a child to come to our office once a week for a 50-minute dose of revisiting, doesn’t that, in itself, take control away from him or her? Can we create safe and regulated settings for children to control the dose, space, and pattern of their healing journeys? In Sandy’s case, during our therapy, she could go back to these dark times, spend some moments living with the pain of the reactivated trauma memory—but she also could control her own disengagement, so she could regulate herself before revisiting the experience.

She controlled what parts of that experience she would reactivate and reenact—this provided controllability. She also decided for herself how long she would stay there—this controlled the dosage. She determined how much time would pass before she would revisit those experiences, which controlled the spacing of the experience. In our sessions, she allowed herself to activate some component of her pervasive trauma memory, and then created controllable, predictable, and moderate activation of her sensitized stress response systems. Over time, this led to a less reactive system, a shift in symptoms, and some degree of healing.

(The chart below illustrates the key principles here).

Chapter Three: Stairway to Heaven

Almost twenty-five years have passed since the disastrous raid on David Koresh’s Ranch Apocalypse in Waco, Texas, and in that time, our understanding of how threat and fear affect both groups and individuals has evolved.

Specifically, we have learned much more about the importance of relationships within a group to create opportunities for development and healing—or to do the opposite. Increasingly, we’re realizing that the health of the group can have a large effect on the health of an individual.

In the US, the responsibility for funding and carrying out child welfare services such as investigation, removing children from homes deemed unsafe, placing children in foster homes, shelters, kinship homes, and funding some level of evaluation and needed medical and mental health services falls to the state. Each individual state will choose how to do this: some states delegate the majority of these responsibilities to counties and provide some organizational oversight and funding, while other states have a system that is unified at the state level.

In all cases, the federal government provides some funding for these agencies. Title IV-E is a federal program that will reimburse states for some of the cost of providing foster care, adoption assistance, and kinship guardianship assistance on behalf of each child who meets federal eligibility criteria. Not all children who require care from Child Protective Services do meet these criteria, so generally speaking IV-E-funded cases are an underestimate of the actual numbers of children served by the states. Nonetheless, the shifts in Title IV-E-funded cases from 1984 through to 2013 indicate the dramatic change in the focus of child welfare resources.

So why does this shift in IV-E-funded cases matter? This entire book is about the impact that developmental trauma, neglect, attachment disruptions, and related childhood adversity can have on the child. And we know that the rates of significant emotional, behavioral, social, and cognitive problems in children removed from their homes can reach up to 70%, if not more, over time. The number of children in need grows; the problems related to their developmental trauma don’t disappear when they enter a “forever home.”

Over time, the burden of dealing with these children’s complex problems has shifted to the families providing elements of permanence for these children: kin and adoptive carers. But the child welfare system has not caught up enough (remember the “innovation gap”) to develop high quality “developmentally-informed” and “trauma-sensitive” resources for these families or for the foster families that care for hundreds of thousands of these children each year. We are simply shifting the problems from one system to another.

On top of that, schools are even less capable of being supportive of the foster family’s efforts, often ignoring good input from the foster or adoptive parent and implementing practices such as suspension, expulsion, seclusion, and restraint. All of these measures simply make things worse for the child and the family.

Then, there is the medical community—who should know more about all of these issues—who are viewed as the experts by schools, families, and, all too often, themselves. The medical community—including psychiatry—can be as trauma-and-development-ignorant as any other. Over the last ten years, this has not changed much, unfortunately.

And one area where this ignorance is especially tragic is in the inappropriate and harmful use of medications. If anything, this has become worse over the last ten years. Irrational psychopharmacology—where doctors prescribe medications for which there is no evidence of effectiveness or actual evidence that the medication does not work—has exploded. So has the use of multiple medications, or poly-pharmacy, even though there is rarely any evidence related to whether or not it helps.

Foster children are much more likely than other children with similar problems to be prescribed multiple medications that will have no impact on their symptoms. These medications, particularly the so-called atypical antipsychotics (medications like Risperdal, Abilify, and Seroquel) can shorten life and have severe side effects, like weight gain great enough to increase risk for diabetes.

As a field, we have spent a lot of time and money getting, well, not too far, in understanding the complexities of brain development and its effect on behavior. With all of that said, we are still actually making progress.

As we slowly increase our understanding of development, the brain, and humankind, there will always be a gap between what we are learning and what we can actually apply. Right now, that chasm seems especially large—but it is often darkest just before dawn.

Sometimes, of course, we create practices, programs, and policy based on “what we know” only to learn later that this “understanding” was immature or even wrong. Psychiatry has far too many examples of this: the frontal lobotomy, ice-cold baths, and insulin-induced shock are only the low lights. The area of what is now known as “translational medicine” is intended to take what is being discovered in basic sciences and develop practical applications of those discoveries. The concept is good; the application part has been challenging, and this occurs at least in part both because of the “innovation gap” and the tendency of those who benefit from the existing approaches to push back when “translational” innovations emerge.

But for each principle, there are often important exceptions to the rule.

And simplification often includes hidden distortions that can lead to false conclusions when people try to generalize from it. An attempt to teach about the explosive rate of development in utero and in the first years of life, for example, can get turned into “Dr. Perry says it’s too late to change the brain after age three.”

Another example of this over the last ten years has been seen in the emerging “trauma-informed” world. The phrases “the amygdala hijacks the brain” and “an amygdala storm” have become common language amongst the “trauma-informed.” The attempt to teach a little about the neurobiology of threat interpretation and how fear alters the way we process and act on information gets turned into a distorting buzz phrase.

I don’t do very much forensic work, and when I do, I try to pick cases where I think I can learn something—and Leon’s case was, in fact, one of these. Over the last ten years, research has confirmed that people convicted of violent crimes, like Leon, have astoundingly high rates of early life attachment disruption and chronic developmental trauma, especially exposure to violence. These findings have lead to efforts to create a “trauma-aware” judiciary and “trauma-informed” juvenile justice and criminal justice programs—in prisons and probation. True rehabilitation will not be possible without awareness of the multiple complex effects of trauma, neglect, poverty, racism, and other developmental adversities. Addressing recidivism and successful re-entry to the community is impossible without a respectful, humane, and developmentally-informed, trauma-aware perspective.

“Translation” matters. It does help the people in these systems better understand these children, youth, and families, and this can truly help improve our systems. And, no matter how often our efforts at translation get twisted, we can’t give up. Connect, correct, clarify, and carry on.

Chapter Six: The Boy Who Was Raised as a Dog

Both Justin and Connor experienced severe early neglect, as well as other traumatic stressors that profoundly affected their development. For Justin, having been raised in a kennel with much canine, but little human contact, was obviously not a normal upbringing; Connor, who was simply left alone all day during the work week for his first 18 months by a negligent nanny also suffered enduring problems.

This chapter was written with that general frame of reference. Ten years on, however, I have become much more focused on the strength and resilience demonstrated by children like Connor and Justin in the face of such dramatic and devastating experiences. Most importantly, I want to know why they were able to make such rapid progress while other children with similar symptoms and seemingly similar abuse and neglect do not. The key word here turns out to be “seemingly.”

If the children in this book tell us anything, it is: “Listen closely and look carefully at my life story.” Unfortunately, in medicine, we are notoriously “bad listeners” and are often poor observers. It takes time to gather a complete and thorough developmental history—certainly much more time than a typical initial assessment visit to most clinics allows. Multiple sources of “patient history” are required to fill in the gaps. These include medical and educational records, conversations with parents, teachers, previous mental health providers, and more. All of these take time and money to gather. And even if you do all of this, if you don’t ask and don’t look for the presence of critical experiences that influence development, you won’t find them.

As we mention in this chapter, these two boys had two things in common: early neglect and a good response to developmentally-appropriate intervention. Closer examination of their histories gives us some clues to why they were so responsive to treatment. Despite his years of neglect, Justin did have positive relational connections in his first year of life, before his primary caregiver, his grandmother, died. Once he started living in the kennel, he also did have the warm physical contact and unconditional love that so many of us get from dogs, albeit in more typical situations.

In Connor’s case, he had normal and healthy loving parenting for the first eight weeks of his life—along with ongoing “booster” touch and connection in the evenings and weekends throughout the time he was neglected. Both of these boys had an abnormal but partial history of positive relational interactions in the first years of life. Even fragmented positive interactions were protective.

“Listening closely and looking carefully” means that we need to quantify children’s “relational health”—in other words, the nature, number, quality, and timing of their relational connections, what we might call their overall “social connectedness.” Social connectedness refers to the quality and number of connections an individual has with family, friends, and acquaintances: it is a key component of community and cultural cohesiveness. As we discuss in depth in our second book, Born for Love, this connectedness is a major factor in both individual and community health.

The “balance” between the scores on the adversity measure and the relational health measure gives us a more accurate estimate of true “developmental risk”—in other words, a child with a strong network of social connectedness is at far less risk from a potentially traumatic experience than a child without such support would be.

Over the last six years, The ChildTrauma Academy’s network of clinical partners has systematically evaluated over 30,000 children, youth, and adults using these adversity and relational health measures. We also looked at the current emotional, social, behavioral, and cognitive functioning of these 30,000 individuals.

What we learned included some significant surprises. The first and most important of these is that relational health measures are more predictive of outcomes than adverse developmental experiences are. In other words, having a strong social network with many, high quality relational interactions over time predicts good mental health and other positive outcomes better than traumatic experiences predict poor prospects. Relational connectedness buffers current distress and helps heal past trauma.

This observation has profound implications. For one, it’s consistent with data on population and community health, which shows that social support is critical for health and that communities lacking healthy social ties tend to be wracked by problems like diabetes, heart disease, obesity, and addictions. These findings are also in line with research on resilience, which again, links it to social ties and healthy support. Finally, it suggests important and practical intervention and prevention strategies, such as measures that aid school and community connection, programs to support and connect parents, and basically anything that helps people make friends and nurture families.

Our research also confirmed that the timing of developmental risk does make a significant difference in outcomes. In twelve-year-old children, for example, having been maltreated in the absence of social buffering during the first year of life—and then being in a much healthier and safer environment for the next eleven years—led to worse outcomes than the reverse; i.e., where the child was healthy and safe in the first year, but not for the next eleven! In this case, the first year of good experience helped “inoculate” against the eleven years of adversity—but unfortunately, a bad first year was really tough to overcome, even with eleven years of safe and positive experience.

Currently the public systems we have to identify and help the most isolated, marginalized, struggling young families—and their infants—are under-resourced and ill-equipped to meet the demands. As our society struggles with the myriad problems related to childhood trauma, developmental adversity, and relational poverty, it will be essential to infuse the problem-solving process with well-interpreted, quality data. If we don’t learn from these children and families—if we don’t systematically “listen closely and look carefully”—we will all lose out.

Chapter Seven: Satanic Panic

Starting with our work treating the children of the Branch Davidians in 1993, The ChildTrauma Academy has had a good relationship with the Texas agency that oversees Child Protective Services (CPS) in that state.

The leadership knew me, they had come to trust our work, and they frequently asked for input about ongoing program or practice issues. We, in turn, learned more about the challenges facing individual caseworkers and the CPS system as a whole. It was very tough work; individual workers and supervisors faced high workloads, emotionally wrenching situations, frequent high-conflict interactions with family members or attorneys, and, all too often, not a lot of support or clinical supervision.

Furthermore, the natural emotional contagion that occurs between humans makes proximity to continuous traumatic situations a perfect setup for “secondary” traumatic stress, with all of the anxiety, sleep problems, depression, irritability, and demoralization that can go with it. This combination leads to a depleted and burned out CPS workforce.

Unhealthy ways, of course, include disengaging or even dissociating and sleep walking through the work, or trying to self-regulate with food, cigarettes, alcohol, or other drugs. This continues to be one of the major challenges of most CPS systems; adequate training, ongoing support and quality clinical supervision are needed to help all staff manage this important but often distressing work.

In the case of Texas, CPS responded to these problems, in part, by issuing a grant for crisis intervention and debriefing to follow obviously severe incidents like what happened in Waco, in Gilmer as described in this chapter, and other cases of severe child injuries or deaths. Each year for over ten years, The ChildTrauma Academy was awarded this grant; our program proposal was always called “Crisis Intervention and Secondary Trauma Prevention.”

In other words, we would have less need to have expensive after-the-fact interventions if we had more proactive program elements ahead of time. And yet, every year we had that grant, the Crisis Intervention component was funded and the preventative proactive component was defunded. Following event after event, we would give feedback about the practice, program, and policy actions that would prevent such events—such as the panic that occurred in Gilmer and the resulting custody cases and trauma—and every year our recommendations were disregarded and tucked away in someone’s file cabinet. It was frustrating.

The importance of self-care in effective child welfare work was just getting lip-service. Further, the crucial insight and support that frontline workers need to better understand these children—and themselves—was not being provided. Texas officials would listen to us when they were in the midst of a crisis—like in April 2008, when they asked us to lead the mental health and assessment process after the removal of 439 children from the Yearning for Zion (YFZ) Ranch run by the Fundamentalist Church of Jesus Christ of Latter-Day Saints (FLDS) in Central Texas. The FLDS is a polygamist sect led by “prophet” Warren Jeffs. Claims had been made that children being raised in the group were being sexually abused.

That was a pretty complex—and often surreal—situation, but that’s a whole other book. Seriously, it is. Maia wrote a book with one of the key witnesses in that situation, Brent Jeffs, who is the nephew of Warren and whose account of having been sexually abused in the church by his uncle set off the series of events that led to the raid. (It’s called Lost Boy.)

So how could we help change systems? All of these extreme and complex situations in the child welfare and mental health system where we were consulted were, to some degree, preventable. Think of each of the children described in this book and their life stories. Whether it is the parent, foster parent, therapist, case-worker, judge, FBI tactical team, pediatrician, teacher, or child psychiatrist, an awareness of the fundamentals of the brain, development, attachment, trauma, and neglect could have diverted or minimized the tragic trajectories of these children. Thus, the relentless focus of The ChildTrauma Academy has been on translation and dissemination of this content over the last thirty years.

We have much to be hopeful about in this area. We have been actively involved in the development and implementation of training and other “capacity building” projects that teach and implement the core concepts of our Neurosequential Model in multiple settings (clinical, school, juvenile justice) and for non-professional caregivers (parents, foster and adoptive parents). Over the last ten years we have developed curricula and related activities to teach these concepts to just about any profession you can think of—physicians and psychologists of all sub-specialties, social workers, nurses, occupational therapists, physical therapists, teachers, judges, parole officers, law enforcement, all the way up to the corporate and business community.

The most promising projects involve actually embedding these concepts into schools of social work, education, and medical school. When we engage professionals after they have been trained, we are asking them to shift or change their perspective: a big ask. However, when we teach the social work, education, or medical student these concepts up front, this becomes their primary frame of reference; it is much easier for them to immediately understand and implement developmentally-informed and trauma sensitive practices when they enter the field. As we’ve seen over and over, it’s better to start early whenever possible.

Chapter Eight: The Raven

The young woman stood patiently in the background as the group of people slowly dispersed. We had a brief moment of eye contact, both of us smiling. She looked familiar. But I meet so many people—and I’m terrible at remembering names, so I couldn’t place her.

I had just given a public lecture focused on the importance of relationships in shaping our physical and mental health. A small group of people approached me. This woman, however, stood apart, letting everyone else go first. Soon the auditorium was empty, aside from a few members of the organizing committee cleaning up—and an older woman in the very back of the auditorium with two young children.

She stepped forward, clearly anxious. “Do you remember me?”

“Funny. You always did joke around.” She rolled up her sleeve and I immediately recognized the raven tattoo.

“Amber. Oh wow. So great to see you.”

And it was. She looked different; older, no obvious piercings and her hair was light brown, almost blonde. She smiled as I asked her to catch me up on her life. We spent the next ten minutes talking and as we did, the older woman and the children walked from the back of the auditorium up to where we were sitting. I could soon see that the woman was Jill, Amber’s mom. When she approached, Jill smiled and we exchanged a few words about how they ended up in this city, which was far from Texas. Amber corralled her children, hugging one in each arm.

“I want you to meet my children,” she said, “This is Tori*. She is seven, and Thomas* is three.” She turned to speak to her children. “This is my friend Dr. Perry. We met a long time ago when I was just a little girl.”

Not so little, I thought. Interesting that she said that—maybe she felt smaller than she was at the time. The children had a moment of obligatory stillness, looked at me—probably trying to imagine “Mom” as a little girl—then wiggled out of Amber’s hug and continued exploring the auditorium under the watchful eyes of Grandma Jill.

This clinical “rupture” of the treatment process with Amber described in this chapter is characteristic of the discontinuity of most therapeutic work with maltreated or traumatized children. In most public mental health clinics, the average number of consecutive clinical visits before there is an unplanned break in treatment is about three. The family moves, or wears out, or the crisis that brought the child in passes. If the child is in foster care, he may end up going home, or to the hospital, or a residential setting, or another foster home. The fragmentation of therapeutic contact is complicated by the medical economic model, which tends to approve and pay for ten or maybe twenty visits.

Ten years of abuse, neglect, humiliation, marginalization—twenty placements—two grade-levels behind in school, speech and language problems, sensory integration issues, no friends, no family, no social skills, impulsive, inattentive, dysregulated, attachment problems, hundreds of evocative cues from years of maltreatment, now in a new foster home. We approve twenty sessions of Trauma Focused-Cognitive Behavioral Therapy for all of that.

The caseworker checks the “therapy” box and we all move on. Any wonder the long-term outcomes for children in the child welfare system—despite the millions of dollars and person-hours spent trying to help them—are so bad? Maybe part of us doesn’t want to see how things play out for our patients; maybe part of us wants to believe the magic of our twenty sessions: one hour a week actually built in a new “template” for relationships, re-organized the stress response networks in the brain, created a new set of “default” associations to bypass the evocative cues, taught the child social and cognitive strategies, built in new executive functioning capabilities in the cortex, and jumped the child two grade levels in school. (Oh, I forgot—that is not our job—that is for the schools to fix.)

Indeed, one of the most important and recurring findings regarding health—in all domains of life—is the powerful role of relational continuity, enduring connectedness with others. The key role for relationships in resilience and healing has been described for decades; yet we continue to develop educational and therapeutic models that pretend that people are interchangeable. Each year in elementary school we get a new teacher: the special bond that can form has a shelf-life, the academic year. Then, in middle and high school, each year, we have many more new teachers.

Certainly, these relationships are important, but what about the power of continuity? If a mentor starts with an at-risk child in middle school, has lunch with that child once a week for the school year, and mentors the same child all the way through high school, there are multiple benefits to the child—including a significantly higher rate of graduation. The duration of the mentoring relationship appears to be one of the major factors in effectiveness. Having a series of mentors over the same time period has fewer benefits, and for some children, these ruptured relationships make things worse. Healing relationships are not interchangeable: we recognize this with marriage and family, and we don’t expect people to simply substitute in a new spouse or new siblings when the school year changes. We recognize it with our own adult friendships, but we have a hard time appreciating the need for this kind of permanence in children’s lives.

And this is a good thing, because these children and youth need help. But it can be not so good when “the well runs dry.” Living with and caring for children affected by trauma and neglect can be very challenging, to put it mildly. It can often rapidly lead to exhausted, demoralized, disengaged, and burned-out caregivers. The very qualities that make a foster parent capable of connecting, empathizing, and nurturing can make her vulnerable to the emotional turmoil these children carry and can create. Secondary trauma can affect these families, just as it does caseworkers or clinicians working in the child welfare system. And of course, as noted earlier, the system is not great at providing support, training, or supervision for foster and adoptive families.

While it is getting better, the vast majority of situations leave these families with challenging children and minimal support. Add to this the tendency to overload the best foster families with too many challenging children at one time and you set up a perfect storm: a higher probability of child-on-child bullying and abuse, a higher probability of very symptomatic, dysregulated children, and a higher probability of disrupted placement. And that, of course, is simply another relational discontinuity, and this failure further reinforces the child’s distorted view of himself and the world. All of this contributes to poor outcomes for the children and youth. It is not unusual for us to work with a child who has had dozens of failed placements.

But they were working on reunification within a few months. Previously, the child’s mother had been in an abusive relationship and she’d been using multiple drugs. After her children were removed, though, she got out of that relationship, completed rehab, and was now back in school learning a trade. I envisioned a fragile young mother just getting her life together so I asked more.

It turns out that she had seven children in three different placements—and all of them were struggling and having difficulties in their placements and in school. The plan was to reunite them all in her custody. I could see clearly that this would fail. One single parent, with minimal extended family or community connection, was expected to care for seven extremely troubled and traumatized children, all while dealing with her own trauma issues and recovery from addiction.

This, and similar situations, prompted me to develop a new “metric”—in this case, a measure of the strengths of a particular caregiver and home, balanced against the challenges posed by the specific children in the home. Simply subtracting the challenge score from the strengths score gives us a “caregiving reserve” score. Anything below -200 is pretty challenging; the family described above scored -860 on this measure. We have added this “Caregiving Challenge Estimator” (CCE) to our online set of Clinical Practice Tools and it helps treatment teams and families see when they are either setting up a foster family to “burn out”—or creating a situation in which a biological family reunification will likely fail.

Would a metric like the CCE have helped anyone see Merle more clearly? Could it have helped child protective workers recognize that James was in a potentially dangerous situation? In this case, probably not. The metric would have shown that the caregiving challenge in Merle’s home was well beyond her capacity to provide—but she had what is thankfully a rare pathological need. When we try to understand the behaviors of someone like Merle, it always takes us back to their personal history. What happened to her during her own childhood, when she was growing up? We tend to parent the way we were parented. We speak the language spoken to us when we were young. We mirror the gestures and facial expressions of our parents, family, and culture. Humans pass both good and bad things down from generation to generation. How does that happen?

As you might expect, it’s complicated—but this is another area where we have learned a great deal more than we knew when we originally published this book. There are multiple mechanisms that shape us. The most obvious of these factors is genes, but there is a new wrinkle in our understanding of genetics that makes understanding the way genes work even more complex. It’s called “epigenetics” and the research here shows that the environment into which a child is born helps determine which genes become active and which remain silent. For example, in a calm, safe environment, certain genes will be highly active—but in a chaotic and unpredictable situation, different genes will dominate. This is part of how the environment in the womb and in children’s first few years of life affects development.

Transgenerational trauma—which is passed down from one generation to the next—is an important aspect of the emerging field of traumatology. There are several lenses that can be used to look at the transgenerational impact of trauma; one of the most important of these is socio-cultural. Over the years we have worked with multiple groups that have been affected by relatively recent histories of genocide, ethnic cleansing, or cultural genocide. These include First Nations communities in Canada, Aboriginal communities in Australia, multiple Native American tribes in the United States, and several tribal or ethnic groups in Africa and central Europe. The complex impact of their large-scale multidimensional traumatic experiences is rarely appreciated and has not yet been studied nearly enough.

I believe that systematic analysis and study of these experiences is extremely important: what we learn here will not only enable us to help trauma survivors overcome their symptoms, but will also move us towards a more just society, which doesn’t have to replicate oppression and pass its scars on to our children and our children’s children.

Chapter Ten: The Kindness of Children

Peter’s teacher—and his school—demonstrated remarkable flexibility and tolerance by allowing me to visit his class to discuss the brain and neglect. If I hadn’t had some stature in this area, I suspect the response might have been, “We have worked with children like this for years. We know what to do.”

Indeed, for the last thirty years, a major frustration for trauma-aware parents has been the experience of finally figuring out what works to help their child stay regulated and learn, and then trying unsuccessfully to share it with the school. For example, one mom might tell a teacher, “I know it seems silly but he likes to keep this small toy in his pocket,” or, “If you see him start to get really quiet and withdraw, you might want to let him just walk around a little,” or, “You have to give him a couple of warnings before you make a transition.” Sometimes a teacher or principal will listen, but often not. And, of course, if the fourth-grade teacher listens and makes accommodations, it is no guarantee that the fifth-grade teacher will do the same. Again, relational discontinuities disrupt progress for these children.

In 2010, Steve Graner—a lifelong friend of mine who happens to be an English teacher and coach—heard me speak at a daylong conference in our hometown, Bismarck, North Dakota. He and one of his teaching colleagues, Crystal Halseth, a science teacher, immediately saw the benefits of applying the concepts I was teaching about the brain, stress, and development to better reach children in their classrooms.

They talked with me and other colleagues at The ChildTrauma Academy, and we sent them the material we use for clinical training. We had always worked with schools to help them better understand children affected by trauma; we had hoped to develop a version of the Neurosequential Model for Education (NME). We were working to modify our training process and metrics so that they could be used in educational settings. But we were all so busy that the process of developing the model was slow. And so, we were happy to let Steve pick up the ball.

With their energy and time, we finally had a way to develop the beta-version of the NME. In 2012, Steve retired from teaching, and we convinced him to come out of retirement to lead the ongoing development and dissemination of this program. As we will explore a bit further in the last chapter of the book, the growth and effectiveness of the NME has been impressive.