People feel safe when they feel in control and the environment is predictable: this matters even for adults, but it is especially important for children and even more so for those who have experienced trauma or who have trouble self-regulating.

Sometimes people who work with children worry about being too repetitive. In an attempt to be innovative, they forget that balancing the novel and the predictable is the best way to teach. In Dr. Perry’s work with Tina, he used routine and warmth to make her feel safe, stuck to an established pattern in their interactions, and introduced novelty only when he could see she was ready for it. The trauma-sensitive rationale for this approach should be emphasized in discussing this chapter.

2–3) Discussion of this chapter should also focus on how the order in which brain regions develop determines which kinds of experiences can best reach a child. The lower brain regions that come on-line first—like the brainstem and diencephalon—are especially responsive to rhythm and routine. Children who have been neglected or otherwise traumatized very early in life when these regions most need calming touch and responsive care will often not be able to make progress until such needs are met. To build a foundation for higher cognitive skills, delays or disorganization in these areas must first be addressed.

5) Tina grew up in a poor neighborhood that is isolated from public transit, with high rates of violent crime and few support services for families. Discussion of how and why poverty increases the probability of “sensitizing” patterns of stress activation (for example: more unpredictability, chaotic living situations, food and housing insecurity) and makes recovery more difficult can help readers reflect on how to work with children from lower socioeconomic backgrounds and the extra challenges this can raise. Practical concerns, like childcare arrangements, costs (even ones that seem small to people with decent jobs), and transportation issues, need to be kept front and center when working with these children.

6) The differences between Dr. Stine and Dr. Dyrud (pp. 5–7) reflect two different ways of working with children. Dr. Stine’s was heavily reliant on medication, on brief weekly therapy, and on keeping therapy separate from the realities of day-to-day life. This distance is seen as important to the therapy, with failure blamed on the patient’s “resistance” or lack of resolve.

Dr. Dyrud’s approach was more personal and recognized how conditions like poverty can affect a child’s development. He sought to understand how aberrant behavior may reflect traumatic experience and attempts to cope with it and help patients change by learning better ways to self-regulate.

In discussing these differences, consider the nature of professional boundaries and how understanding children’s social and emotional environments can help the people in their lives make sense of their behavior and respond to it more productively.

Continual re-enforcement of the need for patience—and, particularly, the likelihood of setbacks and the fact that people do not change in a linear fashion—is critical. Also, it might be helpful to look at practices in your area that may inadvertently harm children because they do not change rapidly or all at once. For example, consider “level systems” in discipline that punish setbacks or any other kind of disciplinary practice that does not recognize the time and process of trial and error that it can take to learn different behavior.

10, 11) Novelty can be perceived either as exciting or threatening, and the way it is perceived will influence how children act. The conversation here can highlight how understanding different responses to novelty can help adults who work with traumatized children be more sensitive to their needs. Again, stress the importance of routine, repetition, and a sense of control and safety.

Chapter Two: Key Points

1, 2, 4, 5) Stress itself is neither positive nor negative: the context and the dose matter tremendously in whether stress will be a force for resilience or harm. Too much, and a child will be overwhelmed and unable to learn; too little, and she’ll be bored and tuned out. Children’s individual level of development and their own sensitivity to stress also matter.

This means that, when working with youth, it’s critical to have a sense of their particular comfort zones, just like a good trainer has a sense of the amount of weight each individual can lift safely at a specific point in a workout. The analogy to working out with weights is extremely useful here because the amount of weight a muscle can bear before training is many times smaller than it can lift after training—but lifting too much, too quickly, and too soon can cause serious injury. This can help ground the discussion in real world experience and help frame ways to individualize work with children.

Discussion here should explore key ideas, like tolerance (reacting less intensely as an experience becomes familiar) and sensitization (reacting more quickly and more strongly to situations associated with past negative experience), and how they affect the response to stress.

A child who tends towards hyperarousal will move under stress towards increasing vigilance, then to resistance, defiance, and sometimes aggression; a child who tends towards dissociation will move from avoidance, to compliance, to dissociative behaviors like sitting and rocking. (See chart on p. 296.)

Consider here how stress can be modulated to avoid moving children into the more troubling parts of these continuums and, particularly, how Dr. Perry worked with Sandy by making himself appear small and safe, demanding nothing from her until she seemed ready to respond. Appearing big and scary would have pushed her towards hyperarousal, which was her way of coping with threatening experiences with men.

Whether you are a teacher, a social worker, a law enforcement officer, or a parent, you can use your understanding of these ideas in interactions with traumatized children. These children can move rapidly along these continuums if they frequently witness or engage in conflict with adults. Standing over them, raising your voice, and threatening them with dire consequences may be what they are familiar with from having lived with abuse, and they can go into survival mode quickly when faced with this template. Crouching down to their size, speaking softly but firmly, and making children aware that they are in a safe space can help keep children from becoming too aroused or dissociated to learn. Over time, they will be better able to deal with more intense experience.

6, 7) Understanding the differences between hyperarousal and dissociative responses is also important to working with these children. Here, discuss your own experiences of what these responses look like.

Both cases can be difficult to manage. Hyper-aroused kids can get our own adrenaline flowing—but we need to remain as calm as possible, keep our voices quiet, kneel down if needed, get close, and speak firmly. We must resist the temptation to make examples of these kids and embarrass them in front of their peers. That will only escalate the fear response. Still, you must also let them know that you have responsibility for setting the tone for everyone and you are not going to allow them to agitate or upset others. Be calm, present, fair—but not afraid.

Chapter Three: Key Points

1, 2, 3) As noted above, the Neurosequential approach emphasizes creating consistency, routine, and familiarity. Discussion here should center on how this can be engendered in the particular setting where you work with children and how keeping children in contact with familiar people and places is more important than many agencies tend to consider. Also, consider how to help re-establish routine when an unusual event has disrupted it.

4) A “therapeutic web” or healthy, supportive social network is critical to the recovery of traumatized children. Discuss here how to create this within your organization, and elicit comments about what kinds of issues may interfere with it and how to reduce them.

It’s also important for people who work with traumatized children to take care of themselves and one another. Helping each other with physical, emotional, and psychological health concerns makes for a staff that has energy and spirit. The more you can foster a “family” environment among your group, the better you will be at handling the most difficult cases.

Remember that it can be a pleasure both to help and be helped: don’t be an island of excellence, be a stream that flows freely to everyone who needs support. Celebrate the diversity of your staff, and make the variety of personalities a source of strength.

6, 7, 8) The number and quality of children’s relationships is a critical determinant of their ability to be resilient. However, working with troubled children can be difficult: many are cold, unfriendly, defiant, and seem hard to like. The mirroring qualities of our brains will automatically reflect this negativity and make us want to step away.

It’s our job, however, to give them a positive emotion to mirror and to be positive when they cannot be. They will often need many, many positive interactions before they can begin to reciprocate. If every staff member—from cleaner to CEO—makes it a point to greet at least one of the toughest kids every day, that child will ultimately have a hard time resisting feeling better. Numbers matter—and this discussion should stress this point.

Chapter Four: Key Points

1) Repeated, co-occurring or simultaneous patterns of neural activity create associations between these patterns. When these associations are pleasant, a virtuous cycle can begin in which, for example, learning becomes associated with success and people are seen as sources of support.

When learning is paired with a stable, predictable relationship, teachers—or anyone else who wants to help children change—can become a source of affirmation and joy. The brain makes an association between learning, connection, and pleasure.

It’s important to realize that, in many systems dealing with children—schools, juvenile justice, child welfare—an underlying assumption is that children learn best through punishment and failure, by picking themselves up by their bootstraps and learning to just “get it done.” But this is not how most kids are actually motivated: in fact, traumatized children are often triggered by failure itself, and this creates a stress response that can prevent them from learning from any “consequences.” This doesn’t mean that those who work with troubled children should have low standards or make everything easy—it’s just that we always need to keep in mind the particular child and what level of stress he or she can handle at that specific time.

Chapter Five: The Coldest Heart

1) The key points here are that Leon’s early life was marked by neglect and abandonment—while Frank had not only the support of both of his parents, but also their extended family during times when Maria became overwhelmed and wasn’t able to care for him. For Frank, human connection was consistent and available, which connected relationships with pleasure and relief; for Leon, his cries for help often went unanswered or were actually punished.

2) The ability to take pleasure in human relationships is critical to healthy development because proper socialization relies on children finding connecting with others to be rewarding. The implications here are profound: in cases like Leon’s, where, instead, relationships are seen as unreliable or painful, a distorted view of humanity can develop. For one, if human connection itself isn’t pleasant, children won’t aim to please parents or teachers, which will make discipline and education difficult: if the child doesn’t care what adults think, he has little incentive to seek their praise or comply with their demands.

Secondly, such children will only value others as objects: possible sources of money, food, casual sex, or other pleasures that don’t rely on connection. This means that they will also view others as seeing the world in the same way: that, for example, love is just a word you say to get sex, and compassion is just a pretense people make in order to look good or a ruse used by the weak. Consider what the social world would look like if you had this perspective.

A neurosequential approach would have also recognized that he had missed out on the touch, talk, and interplay as an infant that are needed to develop healthy self-regulation and sensory regulation. This approach could have provided opportunities, like animal-assisted therapy and repetitive, simple, supportive interactions with adults, in order to make up for what was missed.

A responsive school would have allowed a child like him sensory breaks to move around and help regulate himself, and once he started to do well in any of these settings, he could have started to have more positive relationships with teachers and peers, which could begin to create a virtuous, positive cycle. Of course, the best remedy would have been having parents who did not neglect him in the first place—but children who have suffered similar neglect have been helped by these approaches and had much better outcomes.

4, 5) Cognitive empathy or “theory of mind” is understanding intellectually what it is like to take someone else’s perspective, while “emotional empathy” is understanding what it feels like emotionally from that point of view. The distinction is important because those who struggle with cognitive empathy—like some people with autism—can be caring and supportive once they realize what the other person is feeling, while those who lack emotional empathy—like sociopaths—are much harder to reach.

7, 8) These will tend to be a matter of spirited discussion: no right answers here!

1, 2) These questions deal with the importance of understanding a child’s sensory experiences and previous environment in order to help. Sensory differences can make new or overwhelming environments (noisy, bright, crowded, etc.) difficult for many children: discussion should focus on how to reduce surprise, minimize intensity, and allow for individual differences in sensory tolerance.

3) There can never be too much emphasis on the importance of understanding a child’s history from as many perspectives as possible, in our view.

4) While “neuroplasticity” has only recently become a buzzword, the reality is that every experience, memory, and sensation reflects a change in the brain. In Justin’s case, doctors overlooked the power of a deprived environment to change the developing brain. It’s important to realize that environment, emotional trauma, and stimulation (or lack of stimulation) can cause big changes to the brain, not just obvious forces like injury or birth defect.

5) Dr. Perry first began by trying to make Justin feel as safe and comfortable as possible. He did everything he could think of to reduce his fear and to try to feed him in a way that would create positive associations and pleasure. He didn’t attempt to question him, just spoke rhythmically and used calming body language. These efforts were intended to help Justin “regulate” first. The sequence of engagement should always be “regulate, relate, then reason.”

6) Dogs are highly social and tactile animals, and their warmth and contact probably helped Justin survive, providing at least some stimulation for his developing brain while he lived in the kennel. Interacting with animals can be very healing for traumatized children because it is often simpler and more predictable than dealing with people.

7, 8) Connor’s therapy followed a similar sequence to that of Justin. His early neglect had left him with touch defensiveness. So Dr. Perry started by using a slow, safe, systematic, and rhythmic massage therapy. Connor’s mom was present to soothe him and learn the technique herself. Connor’s heart rate was monitored to keep stress manageable.

Next, Connor started a music and movement class to improve his sense of rhythm. This targeted both the brainstem and the midbrain, but it also helped him with social skills. It improved his gait and reduced his need to rock and hum. Nonverbal therapies helped address problems with areas in the brain that are not reached by language.

As these lower brain regions began to strengthen, Dr. Perry added parallel play therapy to improve the limbic system. He allowed Connor to dictate the terms of the interaction, reducing the power differential. He only used talk therapy if Connor initiated it and, otherwise, simply quietly shared space with him, building trust. Soon, Connor became more ready to move outside his comfort zone and learn to socialize.

9) Different brain regions respond to different types of stimulation, so reaching areas that are not involved in experiences that can be verbalized requires other approaches. Music and movement are especially helpful because they reach deep emotional parts of the brain, which may need healing before verbal therapy can even be effective.

10) It is always important in treating trauma to understand that, because traumatic experience is at its essence a feeling of powerlessness and helplessness, control over one’s current experience is crucial for recovery. Discussion should center here on how allowing children to set their own pace and responding sensitively to their reaction to intensity can make the difference between re-traumatizing someone and helping him or her to recover. Remember the importance of dosing and spacing. An acceptable “dose” for one person may be overwhelming for another.

11) Often times, understanding how things work can help people step out of their own experience and look at the situation more effectively and compassionately. Teaching kids about their brains is one way to do this. It allows them to become “co-therapists” and collaborate in the process of selecting and sequencing educational and regulatory activities that best fit their interests and needs.

Chapter Seven: Satanic Panic

2) The key point is that sexual abuse cases require exquisitely sensitive handling: avoid the extremes of seeing it everywhere and using interrogation techniques that can create false reports—but at the same time, don’t refuse to believe that it may have occurred. If there is any doubt, genuine expert advice should be sought.

3) “Emotional contagion” is the basis of empathy—it’s when you “catch feelings” from people around you, and it’s useful in connecting people to each other. However, it can also lead to political overreaction and bad policy. Recognizing the signs of moral panics—like believing incredible claims without sufficient evidence, being caught up in a group that refuses to question any of its beliefs when presented with legitimate conflicting evidence, and feeling pushed by fear to act without thinking—can help restore rationality.

4, 6) Coercive methods are dangerous because they repeat a key element of trauma—the person involved has no choice and no way out. This is also why children should never be forced to discuss traumatic experience: some people cope best by not verbalizing.

Chapter Eight: The Raven

2) Both Amber and Ted had dissociative responses to reminders of their trauma, and at their most extreme, these led to loss of consciousness. If you have experience with traumatized or at-risk children, discuss what dissociative responses—most of which are far less extreme—might look like. For example, some children simply appear to be “not present” and inattentive.

3) “Cutting” and other types of self-mutilation can be attractive to trauma survivors, especially those who have “sensitized” dissociative responses because they stimulate the release of the brain’s natural heroin-like chemicals, the endogenous opioids, which include endorphins. This can produce both a “high” and a dissociative state, which can allow relief from traumatic memories and experiences.

4, 5) Dr. Perry’s invitation to Amber to interact with him only at her discretion and to trust him if he seemed trustworthy is another example of how important it is for trauma survivors to have control over key elements of a therapeutic process if it is to be effective. Amber’s attempt to get her abuser to drink so that she could control the timing of the abuse was one of her ways of coping: it is important to understand that this did not mean she desired or consented to the abuse.

7) Stimulants, like cocaine and methamphetamine, produce experiences that are similar to hyper-vigilance, while depressants, like alcohol, opioids, and benzodiazepines, produce feelings that are more distancing, like dissociation. Because these drugs have these properties, this can be one way that trauma increases addiction risk.

8) In general, females have a higher risk for and are more prone to dissociative responses to threat, while males are more likely to have a hyper-vigilant response. The hyper-vigilant response can lead to aggression, which is also more common in males. Understanding these differences—and recognizing that people of both genders often have both types of responses—can help tailor our approach to these children.

It’s also important to note that, since dissociative responses are basically aimed at being invisible, traumatized girls are less likely to come to the attention of teachers or other authorities, while boys will be more likely to get in trouble through visible, aggressive reactions. We need to look out for both responses—and offer these children ways to work through them in order to ensure that all children who have been traumatized can maximize their potential.

Chapter Nine: “Mom Is Lying. Mom Is Hurting Me. Please Call the Police.”

1) The most important things to recognize about reactive attachment disorder is that it is rare; it is caused by extremely aberrant early environments, like orphanages or multiple early loss of parent figures; and it involves cold, antisocial, manipulative behavior, often alternating with apparently indiscriminate affectionate responses to strangers. Further, remember that you can’t get an accurate understanding of the relational or cognitive capacities of someone who is very dysregulated. Frequently, “attachment” and cognitive problems improve dramatically when the child’s stress response systems are calmed.

2) The seemingly affectionate behavior these children exhibit around strangers is less of a genuine emotional response and more a “submission” type reaction aimed at placating those who might, for all the child knows, be his or her next caregivers.

3) Rare conditions, like RAD and Munchausen’s-by-proxy, are easy to mistake for more common syndromes, and because misdiagnosis of these conditions can lead to severe consequences for families, it is absolutely critical to first rule out more likely potential explanations.

4) Once again, taking good histories / knowing as much as possible about a child’s life from multiple sources needs to be emphasized!

1) “Splintered development” refers to the idea that one area of functioning will develop normally while others may not. For example, a child may exhibit significant age-appropriate strengths in one domain—like large-motor functioning (sports)—and be four years behind in social skills and two years behind peers in academics. State-dependent functioning refers to the shift in functioning that occurs when we move from one brain state—like being calm—to another state, such as fear. We all experience these shifts; an example is the less mature and irritable way we are when we are tired, sleep-deprived, or sick. But, for traumatized children and those with developmental disorders, these shifts can be rapid and extreme: one minute, the child will be perfectly able to function in class, and the next he will be on the floor, screaming.

Understanding what triggers these shifts and being able to “meet the child where he’s at” can help—but learning how to manage this can be challenging and frustrating because the outbursts may appear random and can look like all progress has been lost. This is another reason to be sure that systems recognize that progress is not linear and change takes time. Remember—know the “stage” (i.e., where the child is developmentally in motor, social, emotional, and cognitive domains) and the “state” of arousal (i.e., calm, alert, alarm, fear, terror).

2, 3) The most important thing to understand about helping these children is that stress is the most likely trigger for regression. Since they are so reactive, small stressors can set them off; as they activate their stress response systems, they shut down key cortical networks. The more dysregulated they become, the less access they have to more mature networks in their brain; by the time they are in “panic” mode, their functioning is more similar to a frustrated toddler than a fifteen-year-old adolescent.

4) While we often think about children being naturally and carelessly cruel—and have historically seen bullying as inevitable—the reality is far more complex. The bullying of children who are seen as “different,” like Peter, occurs in context: some schools and societies look the other way, while others work actively on inclusion and tolerance.

Dr. Perry’s visit to Peter’s school helped his peers understand his strange behavior—and, by doing so, defused the fear and rejection that often occur when kids are faced with a child who seems extremely unlike them. Teaching the whole class about brain development helped make what was weird and frightening about Peter explicable—and this helped him get the social support he needed.

More generally, students who begin to understand the brain begin to recognize why differences among peers exist and why those differences do not have to be feared. They begin to recognize that different temperaments and personalities exist and that other people may experience the world in very different ways, some of which can lead to unusual behavior. They also start to understand their own fear responses and how they can use things like strong relationships, exercise, music, better sleep, and diet to cope.

Understanding our own brains also leads towards empathy, a greater understanding of others and how helping others can not only improve the world, but is also a source of pleasure and joy.

And, importantly, schools and communities that do not tolerate bullying and that model inclusion see reductions in not only childhood behavior problems, but also in teen drug use, crime, and adult mental health issues.

Chapter Eleven: Healing Communities

1) This is a good place to re-iterate how important relationships are to good health and to reducing the impact of overwhelming stress. Our brains are wired to rely on support from others for comfort and healing: the fact that social brain regions modulate stress systems is fundamental to understanding these connections. Babies are initially dependent on their parents to modulate stress: the development of the brain’s stress systems relies on nurturing, responsive parenting.

Further, uncontrollable stress affects the body via the brain: it will impact mental health through many of the brain’s circuits, and it can increase diabetes, heart disease, and other physical health problems directly via the autonomic nervous system, neuroendocrine, and neuroimmune systems as well as by increasing the probability of unhealthy high-risk behavior, like smoking and overeating.