IN THE TEN YEARS SINCE THE original publication of this book, we’ve been delighted to learn that it has become part of the curriculum in a wide range of classes—including those covering psychology, psychiatry, social work, neuroscience and training for attorneys, other court officials, and educators. This study guide is intended to aid those who wish to use the book in a systematic way to improve their understanding of development, attachment, the brain and the effects of adversity, such as trauma and neglect, on children. This understanding can help us interact with all children in a way that is both neurodevelopmentally informed and sensitive to the possibility of trauma exposure.
To that end, we’ve included some questions and answers related to the key themes of each chapter. The answers here aren’t the only “correct” responses—we include them only to help instructors and readers understand the main points and how they relate to helping trauma-exposed children. The questions appear first, and the main points to explore when answering them are at end of this guide.
1. A critical part of working with traumatized children is recognizing that, in order to produce long-term changes in the brain and behavior, patterned, repetitive experience is required. What kinds of experiences would be healing or “therapeutic” with Tina—and did the clinical work with Dr. Perry provide those? What role did the “dosing” of therapeutic interactions play in Tina’s therapy?
2. Brain development occurs in a specific sequence: some regions mature earlier than others, and the successful maturation of later regions relies on sufficient development in areas that mature earlier. What does this suggest about why early trauma will have a different impact compared to later trauma?
3. What brain regions develop first, and how does this matter in terms of what kinds of problems will be associated with trauma that occurs at particular times?
4. What happens to the brain when a child like Tina experiences an aberrant early pattern, in her case, ongoing sexual abuse?
5. How does the stress of poverty affect brain development?
6. Here, Dr. Perry interacts with two of his mentors, Dr. Stine and Dr. Dyrud. Contrast the two men’s styles and conclusions about Tina and the behavior of her mother. Then contrast two schools of thought that may exist among people working with traumatized kids: one that uses the Neurosequential Model and one that is more traditional.
7. Why is the patterning of experience so important and how can you help create more predictability for the children you work with?
8. Why does frequent repetition matter, and how do you find a balance between repeating something enough for learning to occur but not too much as to become boring?
9. What was Dr. Perry’s therapeutic approach in his work with Tina, and what techniques seemed to be most important in helping her make initial progress? How can you use these ideas in your own work with children?
10. Here, Dr. Perry discusses how brains can have either a negative or positive response to novelty. What are some ways that traumatized children might respond to novelty that might lead adults to misinterpret their behavior?
11. How does their style of response to novelty affect children who have experienced trauma at home when they enter a new setting like a preschool, kindergarten, court, or therapist’s office?
12. Tina’s sexualized reactions to men and boys was often seen as evidence that she was a “bad” girl who was “acting out”—and responses to these behaviors by schools and other organizations tend to be punitive. What are some better ways of helping young children like Tina who replay sexual trauma? How can your organization be sensitive to the possibility that early sexual trauma is involved in children’s behavior?
13. As Tina’s impulse control improved, she learned to be ashamed about and hide her sexual acts rather than discontinue them. How can we help victims avoid this path?
14. After careful reading of the last paragraph of the chapter, describe how schools or other institutions which have regular, frequent contact with children could be game changers in their lives.
1. “Resilient children are made, not born,” (p. 38). How does the “right” amount and pattern of stress help children develop resilience?
2. How is building resilience similar to building muscle? How can facing appropriate amounts of stress aid learning and the development of self control?
3. What are the “arousal continuum” and the “dissociative continuum,” and why is understanding where a child is on these spectrums at any given time important in being able to communicate effectively with him or her?
4. What is tolerance, and how does providing slowly-increasing and predictable “doses” of stress build it?
5. What is sensitization and how does unpredictable, erratic, and sometimes large “doses” of stressful experience create it?
6. What is hyperarousal, and how might a child who is experiencing it behave? How can you avoid behavior and academic problems with children prone to hyperarousal?
7. What is dissociation, and what does this look like in children? How can you avoid behavior and academic problems in children who are prone to dissociation?
8. Why might a traumatized child who is experiencing hyperarousal and/or dissociation be mistaken for a child with ADHD? How can we ensure that these symptoms of trauma are not inappropriately understood and medicated?
9. Why do some traumatized children seem to deliberately antagonize new caregivers and create chaos, and what is the best way to deal with this?
10. Children like Sandy often reenact their traumatic experiences in play. How did Dr. Perry help her when she reenacted witnessing her mother’s killing? How important is it to let the child have control over these reenactment experiences?
11. What is “learned helplessness,” and how important is a sense of control to people who have to cope with large amounts of unpredictable stress?
1. Why was the original plan for placing the Branch Davidian children into separate foster care homes less than optimal?
2. Here, Dr. Perry advises the mental health agencies caring for the children to “create consistency, routine, and familiarity.” For the professionals, this meant “establishing order, setting up clear boundaries, and improving cross-organizational communication.”
Why are routine and predictability so important after a traumatic experience has completely disrupted the usual pattern of a child’s life? Why is it especially important that familiar and supportive people be involved, rather than a set of new professional helpers who may be better trained?
3. How can you ensure that during an emergency or disaster, the children you are working with have a stable, predictable, and relationally supportive environment?
4. Here, Dr. Perry discusses the creation of a “therapeutic web” among those who were working to treat the Branch Davidian children. How can your school or organization create such a web for the children you work with and work to maintain and improve it?
5. Dr. Perry identified a particular Texas Ranger who had been assigned to guard the children—one who was initially highly skeptical of his expertise—as a very positive influence because he was calm, supportive, and non-intrusive. What individual strengths do you see in people in your team that could be useful as part of a therapeutic web of support? In yourself?
6. Here, Dr. Perry says, “The research on the most effective treatments to help child trauma victims might be accurately summed up this way: what works best is anything that increases the quality and number of relationships in the child’s life.”
What is your staff doing now or what can you do in future to help build a variety of high-quality relationships in the lives of the children you work with? Record some practical steps to take that will make this possible.
7. Humans mirror each other’s moods and behavior and this can lead to “emotional contagion” of feelings like fear and anger. Moods tend to travel down the status hierarchy—so a parent’s bad mood is more likely to be echoed by a child and a boss’s fear is more likely to be picked up by her employees (p. 71). How can you use this principle to help calm children? When you are stressed out, what do you do in order to avoid spreading it to the children you work with?
8. The Branch Davidian children who had the best outcomes were not those who got the most therapy, were the least stressed, or were removed from relatives who continued to follow David Koresh’s religion. Instead, they were the ones who had the strongest, healthiest support systems, regardless of their religious beliefs. What does this suggest about how we should work with troubled children?
1. “When two patterns of neural activity occur simultaneously with sufficient repetitions, an association is made between the two patterns” (p. 91). How does this typically allow parents and children to interact positively? How can this principle be used in your work with children?
2. We often think of cuteness as silly and trivial—however, it plays an important evolutionary role. What is it and how can we use cuteness for self soothing?
3. What is “use-dependent” development, and how does this affect the way children’s brains respond to trauma?
4. What is a “sensitive period” in brain development, and how does life experience during these periods affect development?
5. Why might a child who has missed critical input during a sensitive period have behavioral and emotional needs that are similar to a much younger child, and how should this be handled?
6. How does nurturing touch and a pattern of mutual interaction between child and caregiver help the child learn to manage stress?
7. Why is being held and touched literally necessary in order for children to grow?
8. How does your own experience of being parented affect the way you parent? How can you use this insight to help children whose parents may have had their own experiences of trauma and neglect?
9. Some theories of mental illness and developmental disorders—infamously, with regard to autism, schizophrenia, and anorexia—have historically blamed parents and labeled the children’s behavior as “attention seeking,” “aberrant,” and “manipulative.” How can this perspective harm children and why is it better to try to first understand the child’s and parents’ histories and how they may shape the way they interact with the world?
10. Discuss and detail the therapeutic style of Mama P. Find at least five key ingredients of her intimate and effective work with Virginia and Laura. Then, draw as many parallels as possible with how your staff members could provide similar therapy for the troubled children with whom you work.
11. Why is it traumatic for babies and children to transition from one loving set of caregivers to another, and why is it harmful to children not to have one or two consistent, loving caregivers as they grow up? What can we do for children who have had many transitions between foster homes?
1. Compare and contrast the personalities and early experiences of Leon and his brother Frank. How did early experience affect each brother differently?
2. Discuss Leon’s aberrant sense of pleasure. Detail the wide-ranging effects this had on his behavior—from his reaction to discipline to his inability to feel compassion for others.
3. Is a child like Leon salvageable? What kind of interventions might have worked if caregivers had understood what had gone wrong in his early childhood?
4. What is “cognitive empathy” or “theory of mind,” and what is emotional empathy?
5. How do the different problems related to empathy seen in autism and sociopathy lead to very different types of behavior? How can we avoid stigmatizing autistic people as “lacking empathy?”
6. How can small, apparently-insignificant events combine over the course of development to produce large differences in outcome, and what does this mean for working with troubled children?
7. Whose fault was it that Leon turned out the way he did, and how much responsibility should be given to genes, parenting, the environment in which he grew up, and his own choices?
8. What are the legal and social implications of the complexity of the way sociopathy develops?
1. Why is it important to understand the sensory environment—and the sensory sensitivities of particular children—before trying to communicate with them? How might the environment where you work affect people with sensory differences—and what are some ways you might make it easier for them?
2. Why is it a bad idea to surprise or suddenly interact with traumatized and neglected children? How can you use awareness of this in order to improve the environment and approach you take to working with these kids?
3. Why is taking a good case history so important in working with children with behavior problems? How can you learn more about the children you work with in order to understand their behavior?
4. How can brain changes associated with neglect be misunderstood as pre-existing brain damage and what implications does this have for traumatized children?
5. Detail the steps Dr. Perry and other staff took as they began Justin’s therapy. How was each area of the brain given attention?
6. How might living with dogs actually have provided some of the social stimulation Justin needed as a young child? How can animals and interactions with animals be used to help similar children?
7. How did Dr. Perry use what he’d learned from Justin to help Connor, and what parts of the brain did he target in sequence?
8. How can nonverbal approaches like music and movement classes or massage reach parts of the brain that talk therapies cannot?
9. Why is it critical when working with traumatized children to let them control the pace and intensity of the therapy?
10. Why can helping children understand brain development help their recovery?
1. Researchers used to believe that memory was stable and that recall was like mentally looking at an old video or photograph. Now we know that every time a memory is recalled, it can be mentally “edited” and changed, like a file that’s open on a computer. What does this mean for how we should approach therapies based on childhood memories?
2. Child sexual abuse is real and not uncommon—but children are also suggestible if they are questioned repeatedly and believe that they have to give the answer that their interrogators (whether parents, teachers, therapists, or police) want to hear from them. How do you strike the best balance when dealing with potential cases of sexual abuse?
3. During the 1980s and 1990s, many Americans became convinced that there were networks of Satanic cults whose members sexually abused and ritually sacrificed children taken from nursery schools and daycare programs. Although dozens of people were convicted of perpetrating such abuse, no physical evidence (such as the bodies of children who were sacrificed) was ever found, and these convictions were eventually overturned.
4. What is “emotional contagion” and what does it tell us about why even modern societies can fall prey to such panics? How did Dr. Perry try to avoid getting wrapped up in the panic in Gilmer, Texas, and how can you protect yourself from being taken in when these sorts of fears are being spread?
5. Why are coercive methods like “holding therapy” dangerous to children, particularly those who have already been traumatized?
6. Therapists used to believe that everyone who had certain conditions like eating disorders or addictions had suffered childhood trauma but many couldn’t recall it—and consequently, attempting to find these hidden memories would solve their current problems. What’s wrong with this approach and why can attempting to find “repressed” memories actually sometimes do harm?
7. Should children who have been through a traumatic experience be pressed to discuss it if they don’t show symptoms? Why or why not?
1. What are traumatic memory “triggers,” and how do they affect survivors?
2. After examining Amber’s case, detail the signs of a dissociative threat response that you might be able to recognize in children you work with.
3. Why do trauma survivors sometimes turn to “cutting” or other forms of self-mutilation? What effects does this have on the brain?
4. Why did Dr. Perry tell Amber that she didn’t have to meet with him and she shouldn’t trust him until she knew him better?
5. Why did Amber try to get her abuser to drink alcohol and sometimes appear to “encourage” the abuse? What does this tell us about the importance of control to coping with trauma?
6. Should “triggers” always be avoided, or should survivors gradually learn to cope with them? Why?
7. What types of drugs produce experiences similar to dissociation? To hyperarousal? Why might these similarities put trauma survivors at increased risk for addiction?
8. What gender differences are there in the dissociative response, and how might these affect your efforts to calm students and help them be prepared to learn?
1. What is Reactive Attachment Disorder (RAD), and which children are at risk?
2. Why do children with RAD tend to act indiscriminately affectionate?
3. Why is it important not to “hear hoofbeats and think of zebras” as physicians say, when considering whether a child has a rare condition like RAD or a mother has a rare condition like Munchausen by proxy?
4. How does examining records and information from multiple sources in a child’s life help in figuring out complex cases like this?
1. What is “splintered development” and what makes it so frustrating for parents and teachers?
2. What is the best way to help a child who may act appropriately in some situations, but revert to the behaviors of a much younger child in other cases?
3. Why does stress in particular tend to push children to act in less mature ways?
4. Why was it so important to get peer support for Peter, and why was teaching the whole class—and not just Peter himself—a better approach?
1. Why are supportive relationships so critical to mental and physical health, and how does this reflect the way our stress systems are wired during childhood?
2. What can you do to increase the number and quality of the relationships that the children in your life have?
3. How can your community become more supportive of traumatized children? List concrete changes that can be made in order to support relational health.