Family Futures have developed a Multi-Treatment Approach to helping children with attachment difficulties and their parents.

UNLOCKING the PAST

OUR APPROACH

THE FAMILY FUTURES NEURO-SEQUENTIAL APPROACH
to working with adopted children experiencing

Developmental Trauma Disorder
Developing a neuro-sequential approach

Family Futures realise that we cannot just talk to children about their past, which is a frontal lobe activity; nor can we simply help children form more secure attachments without dealing in some way with the residue of trauma which had been somatically ingrained into the child’s system. One of the leading clinicians in this area famously described the problem as “the body keeps the score” (Van der Kolk 2007). Another pioneer in this field, Bruce Perry, defined the need for a neurosequential
approach to helping children (2007). For this reason, Family Futures believes that therapy should start with the primitive brain and its instinctual responses to stress, which are hard-wired into all mammalian brains. The model we have developed involves the following:

Learning to regulate the primitive brain response to stress
In terms of therapeutic intervention, we first focus on helping parents to help their children to feel safe, and to begin to learn how to regulate their feeling states. This requires parents to understand the physiology of stress, and how the brain and central nervous system respond to stress.

Stress responses are easily triggered in children with developmental trauma disorder; the release of cortisol produces the typical symptomology of hyper-arousal, hyper-vigilance, and fight, flight or freeze responses. Such hyper-reactivity could be seen as adaptive, and as a survival response in what might have been a threatening environment during infancy.

But what children with developmental trauma disorder have had little experience of is positive hormonal surges of oxytocin, serotonin and dopamine. The latter are stimulated by touch, attuned interaction with parent figures and positive reciprocal attachment relationships. Family Futures therapy therefore integrates the work of Peter Levine’s Somatic
Experience (1997 & 2006), Pat Ogden’s Sensorimotor Approach to Psychotherapy (2006), Sensory Integration (2005) and other forms of body based therapy and interventions from yoga to relaxation to help children and parents understand the stress responses and way to help the body calm and the heart rate stabilise.

So our neuro-sequential approach starts back to front, beginning with the primitive reptilian brain, allowing the child to experience, via the parent, what happy babies experience: periods of quiet alert. During such periods babies take in their environment and learn from their parents, wiring up their neurological systems in a developmentally adaptive way.

Because of the developmental insults the child has experienced, parents themselves have to go back developmentally, in order to then go forward. This requires the parent to parent the child as if they were much younger than their chronological age, even taking them as far back as the baby stages. This requires parents to massage and play games with their child, which involve touch and close eye-to-eye contact. It is not unusual for parents to play such games as peek-a-boo, counting fingers and toes; the sorts of interactions parents would normally have with an infant. Despite the chronological age of the child, developmentally traumatised children will often engage in these interactions with relish, as at some level, they themselves appear to be aware of what it was they missed out on when they were very young.
Bath times and bed times are very important, in establishing a predictable routine, which is nurturing and developmentally attuned. Meal times and food may have to follow a similar developmental catch-up, with the child going back to eating or being fed for a while to have that experience of being weaned from bottle, to mushy food, to solids.

Of course what parents discover very quickly is that their child does babyhood and infancy in a traumatised way. So yes, they are eager to regress and do regress, but remain hyper-aroused, hyper-vigilant, controlling or dissociative. By small steps and successive approximation (shaping), parents are supported in their attempts to try and ‘normalise’ an appropriate infant response. In the case of feeding, often children will have the tendency to want to control the feeding process, as a result of having been left to feed themselves with bottles or food. Parents need to help the child have a good baby experience, of being fed by the parent with good eye contact, with the parent controlling the feeding process.

In addition to regulating the child because of its early experience of trauma the child’s sensory motor development will also have been impacted by those experiences. At this stage we will carry out a sensory motor assessment in order to ascertain what sensory motor issues need to be addressed.

Our role as workers is to set the developmental context for parents and encourage and support them not to grow their children up, but to take them back, and to give them the babyhood and the infancy they never had but desperately needed.

Secure attachment formation and affect enrichment in the mid brain
Secure attachment behaviour and affect enrichment is only possible when a child is not living in a state of constant traumatisation all the time. Somebody once said, a traumatised child has two feet in the past, and their head looking backwards. A securely attached child has one foot in the present and one foot in the past, but they are looking through
the present to the future. We support parent and child to engage in attachment forming therapies. A good example is Theraplay (2009), developed in the 1960’s in America, a form of focussed play therapy designed to enhance attachments between parents and children. This is a model of therapy the team at Family Futures are also trained in. Theraplay is a dyadic form of therapy that involves the child and parent in a structured therapy. Theraplay theorists have identified four essential elements for secure attachment:
1. An appropriate level of structure
2. Nurture
3. Engagement
4. Developmental challenge

Appropriate levels of developmental challenge
In Theraplay, the first step is an assessment of these four elements in the child-parent relationship. The outcome of this assessment will determine the sort of activities that the therapist will support the parent and child to engage in. Each activity will target one of the four elements, working to redress any imbalance or deficit. These activities can be part of a therapy session but also can be practised by parents at home or by classroom assistants in the classroom. Theraplay has a universal application for all children since attachments are key to all children’s mental health. These interactions are playful, fun, and developmentally enhancing and help the child’s mid-brain development. They are
affect-enriching in that they expand the repertoire of accessible feelings, together with the child’s ability to name a wider range of feeling. This mid-brain-focussed therapy is developmentally a stage on from the hard-wired survival responses of the primitive brain, which require regulation and management: this work represents a move towards the development of experience-dependent neurological and synaptic connections. It is a positive experience of infancy free from the fear of trauma.

Processing and reflecting on the trauma - a higher brain cortical activity
When parents and children are able to achieve moments of calm and reflection, it is possible to help the child to begin to make sense of their early experience and the effect it has had on their feeling states, behaviours and relationships.

We believe that Daniel Hughes model of Dyadic Developmental Psychotherapy (2006 & 2007) which involves parents and children working together in therapy is the best approach to helping children begin not only make sense of their traumatic experiences but begin to develop a more secure attachment to their parents. As Dr Hughes says on his website, “Dyadic Developmental Psychotherapy because it is based on the premise that the development of children and youth is
dependent upon and highly influenced by the nature of the parent-child relationship. Such a relationship, especially with regard to the child's attachment security and emotional development, requires ongoing, dyadic (reciprocal) experiences between parent and child. The parent is attuned to the child's subjective experience, makes sense of those experiences, and communicates them back to the child. This is done with playfulness, acceptance, curiosity, and empathy. These interactions are contingent, i.e., when the parent initiates an interaction, the child's response determines the parent's subsequent action based on the feedback of the child's subjective experience of the first action. In that way, the parent constantly fine-tunes his/her interactions to best fit the needs of the child. The primary context in which such dyadic interchanges occur is one of real and felt safety. Without such actual and perceived safety, the child's neurological, emotional, cognitive and behavioral functioning is compromised.” The therapists at Family Futures are also all trained in Dyadic Developmental Psychotherapy, which underpins the essence of the Family Futures treatment approach.

At Family Futures, we enable the child to begin to address the trauma through a form of life story work. This approach is embarked upon in small manageable steps when the child is able to bear to begin to think about their early experiences and when such work does not retraumatise them. This life story work is integrated into reflective Dyadic Developmental Psychotherapy sessions, which involve parent and child.

As a precursor, one of the team will have done an exhaustive and forensic search of the adoptive child’s file when they were living in their birth family and in foster care. The aim of this exercise is not just to get a ‘coherent narrative’ of the child’s life with dates, times, people and places, but also to create as vivid a picture of the child’s lifestyle and day-to-day experience at each developmental stage. The actual story work is usually done using a large sheet of paper, e.g. lining paper, paints, crayons, and other creative media, to depict, using the metaphor of a road or a river, the child’s life course. The child is helped to understand their history by the therapist and parent painting, drawing and sticking pictures of significant events and relationships onto their time-line. This will be annotated by the child with their expression of feelings that they had then or that they have now, which they can represent using paint, pastels, colours and words. Other creative
arts therapy interventions are also used such as sand tray work, story telling, psychodrama and puppetry.

Through this process the child’s feelings and experiences are acknowledged, validated and empathised with. The child is also encouraged and empowered to express their feelings and to retrieve often unpleasant memories in the safe and accepting environment created by the parents and therapists working together. As and when the child inevitably becomes resistant, dissociative or dysregulated, the role of the therapist is to set a pace that the child can cope with, and model for the parents how best to help their child process their pain.

This process of mapping the child’s life story often starts in the here-and-now, acknowledging the safe, nurturing environment in which they now find themselves and working backwards chronologically into less safe and more scary times. This process can take months and often needs to be revisited at different times throughout childhood as the child’s ability to make sense and process their past develops. This life story works encapsulates the key principles of working with traumatised children, which are:
* Remaining in a safe and sensory supportive environment
* To have their feelings acknowledged (“You had those feelings”), and validated (“What was happening to you was horrible; it’s not surprising you had those feelings”), in an empathic way (“It was wrong what happened to you: I wish I’d been there to protect you and hold you”).
Helping the child to have mastery over their feeling states and their body, so that they don’t dysregulate

Positive identity formation
For children who experienced early trauma, which left them with negative self-attribution, shame and fear, a secure attachment forms a basis for the development of a positive sense of self and optimism about other people’s intentions and the future. At this stage in the therapeutic process, the child is free of pathological fear and has internalised the secure attachment with the parent figure as a positive sense of self and self-worth. From this position, with the parent and therapist, the child can begin to develop their cortical capacity for reflective, integrative, left-brain right-brain thinking, to think about themselves, their current relationships and their past, without the distorting lens of trauma.

Regrettably, this is often where therapy with adopted children starts, with Life Story Books, chronologies and contacts that have been viewed traditionally as providing continuity with the past. For the contemporary adopted child, for whom chaos, neglect and abuse were their first experiences of life, it is arguable that such continuity can be seen more as contamination and re-traumatisation if the steps, outlined above, have not been worked through. Conversely, the good news is that however bad or traumatising a child’s early experience and history might have been, if they have processed these feelings and experiences and have been helped to form secure attachments, then they can reflect upon their past and their present, and think about their future, with a greater sense of hope and optimism than would previously have been possible.

It is important to remember that the ultimate aim of therapeutic work with adopted children who have experienced early trauma is not knowledge but understanding and forgiveness: not forgiveness in a religious sense, but as the ultimate act of resolution. Such resolution is something that develops from within to its own, natural timetable, and cannot be imposed from the outside in a formulaic way, or through guilt. Just as the child has been helped to understand themselves in the context of their history, they need to be helped to understand their birth parents’ and their birth family’s behaviour in the context of their history.

Following the neuro-sequential approach, of enabling the child to move from primitive brain feeling states to mid-brain inter-personal affective relationships to cortical self-reflection, the aim of any therapeutic intervention should be to move children from fear to feelings and to forgiveness. Of course it is important to stress that such neuro-sequential therapy is not always linear and whilst the basic principle is to work from the primitive brain to the mid brain to higher brain reflective
thinking, sometimes the work weaves between these different levels of the brain at different stages of development, different times in the therapy and in response to different life events.

A multi-disciplinary approach
Consistent high levels of stress and repeated trauma in infancy have been identified as causing a syndrome called developmental trauma. Every aspect of a child’s development will in some way be impacted and potentially impaired by poor parenting, repeated separations and abuse. Because of this it is essential that every child has access to a multi-disciplinary team in order for a comprehensive assessment and treatment plan to be put in place.
For this reason at Family Futures, we employ the services of;
* Social workers
* Child and Adult Therapists
* Paediatric Occupational Therapists
* Clinical Psychologists
* Neuro-developmental Psychologists
* Teacher
* Paediatrician
* Child and Adolescent Psychiatrists

A systemic approach
Though the core of our work is focused on a neuro-sequential approach to trauma and attachment, at Family Futures we also work systemically, and integrate school, local networks of support for families and parent
mentoring and support as part of our wrap-around service.

The AIM of the PROGRAMME

• To address directly and change the child's attachment patterns
• To incorporate a holistic approach which integrates all treatment approaches: psychological, psychiatric, neurobiological, educational, dietary and paediatric
• To increase parents' and carers confidence and parenting skills
• To incorporate the extended family and professional support in maintaining positive changes
• To provide ongoing support to the family, as appropriate

ARTICLE
Working with the Elephant in the Room
By Alan Burnell & Jay Vaughan