Healing Childhood Trauma Through Dyadic Relationship-Based Interventions

The importance of early dyadic relationships to children’s development is well-documented in the literature, but what happens if an infant is exposed to multiple environmental risks, when early experiences are threatening, unpredictable, neglectful or abusive? This article aims to provide answers to this question and offer ways to mitigate the effects of trauma and adversity on the brains of our youngest children.

by Dr Salam Soliman

The Importance of Early Relationship

Humans require a lot of caregiving after birth. They are more immature than any similarly sized species and are dependent on a caregiver for much longer.¹ Caregivers are needed to provide basic scaffolding in early childhood, which means that parents have an important role to play in terms of support and also challenges to their children so they can successfully manoeuvre the developmental milestones.² Research has confirmed that a caregiver’s attunement and regulation have significant implications for the child’s development.³ Hence, there is a well-documented need to address maternal external supports to promote this important relationship. External supports may include ensuring families have sufficient food, diapers and access to quality childcare. A growing body of research also suggests the importance of attending to the caregiver’s internal supports to optimise this relationship. Internal supports include assisting the caregiver with reducing their level of stress and anxiety, having someone who cares for them, helping them make sense of times they feel triggered and overwhelmed, and finding ways to remain calm when faced with stressful situations.

During the child’s early years, there are sensitive periods during which the brain is highly malleable and sensitive to environmental input. During that time, a child’s brain experiences neural overproduction initially, with more dendritic connections produced than are needed. If the child is not provided with sufficient healthy experiences, the neurons are fewer and shorter. This is followed by a pruning or a selective elimination of these connections emanating from sensory experiences. Connections that are not used will be pruned (the term “use or lose it” is used to describe this process). This pruning process leads to increased efficiency and impacts sensory pathways and language and other more complex functions. Attachment theory suggests that the early relationship between the child and their parent is a powerful influence on the child’s development. Additionally, this relationship serves as a template for the child’s expectations of future relationships.^1,4 The Circle of Security programme offers a very accessible graphic to demonstrate this important dynamic (see Figure 1).

An abundance of research confirmed that a caregiver’s ability to imagine the child’s mind (often referred to as reflective functioning in the literature) is a formidable determinant of secure attachment and many other positive outcomes for the child. Parental reflective functioning refers to the ability to step back from one’s behaviour and think about its impact and meaning, as well as imagine what might be going on in the mind of the child and see it as distinct from one’s own. This capacity in the parent provides the child with a presentation of the contents of the parent’s mind that is both the same and different from the content of the child’s mind. For example, responding to a crying child with empathy suggests that the parent is able to imagine what is in the child’s mind while simultaneously implicitly acknowledging that it is not the same as what is on the parent’s mind.^5,6,7 Parental reflective functioning is considered important because it assists in making behaviour predictable, promotes and maintains attachment security, enhances communication, and encourages meaningful connections between the internal and external world.⁷

Impact of Trauma and Stress on the Developing Brain

Abuse, neglect, and substandard institutional care can have devasting outcomes for infants and children.^8,9 The Romanian orphanage system of the 1960s serves as an example. In 1966, during the Nicolae Ceausescu regime in Romania, all forms of contraception were banned. This led to many babies being abandoned and left in orphanages. Babies were left for 23 hours in their cribs, deprived of human interactions. Interestingly, the children’s basic physical needs, such as feeding and diapering, were attended to. Children made adaptations for survival, which resulted in severe stunted physical growth, impaired IQ, as well as emotional and behavioural impairments. These studies along with many others cemented the importance of the serve and return, which is the attuned nurturing interactions between a caregiver and a baby, for healthy physical, emotional, and psychological development.^10,11,12,13 See Figure 2 for a visual representation of the long-term impact of trauma on a child’s development.

The National Child Traumatic Stress Network offers the following definition of child traumatic stress: “Child Traumatic Stress refers to physical and emotional responses to events threatening ‘life or physical integrity’ of a child or of someone critically important (e.g., parent or sibling). The traumatic event overwhelms the child’s capacity to cope. This results in both trauma effects as well as disruption to normal development.” Additionally, trauma has a cumulative effect: the more traumatic the experiences, the stronger the correlation with psychiatric conditions, poverty, caregiver mental illness, single parenthood, and low maternal education. There is also a synergistic effect: certain risk factors are more impactful than others, and their combination produces unique outcomes.¹⁴

In sum, trauma damages the brain’s foundation and results in a smaller brain volume, a compromised immune and nervous system, and an imbalanced neuroendocrine system. Furthermore, sustained stress on those systems (allostatic load) results in damage to organ systems and tissues. The duration, types of stress, context, age, sex and genes, as well as the caregiver’s response to the child impacted by trauma all have a further impact on the body’s response.

In considering the caregiver’s response to the child’s trauma, it is important to note that there are three levels of stress commonly discussed in the literature: positive, tolerable and toxic. Positive stress is defined as brief increases in heart rate accompanied by mild elevations in stress hormones. This type of stress is positive in that it motivates us to complete tasks or get out of the way of an oncoming train for example. A tolerable level of stress is a serious, temporary stress response modulated by the presence of a carrying adult. Toxic stress is defined as severe prolonged stress without adequate adult support.¹⁵

Trauma-Informed Interventions

Taking a trauma-informed perspective to work means understanding that trauma now and in the past continues to impact us and the families we work with. This is true on personal, interpersonal, and systemic levels. For example, historical trauma carried by minority groups continues to impact them even when the cause of the trauma has been removed. Epigenetics is the study of how behaviours and the environment can cause changes that affect the way genes operate. While this process accounts for ways in which a caring and attuned environment can positively influence the expression of a genetic predisposition toward anxiety, depression, etc., it also offers an explanation for the way that trauma transcends generations and can be passed on without the child themselves experiencing the trauma. This is true, for example, for Holocaust survivors and descendants of slavery. It is said that “trauma, not transformed, is transferred.” However, unlike genetic changes, this process is reversible; with the right intervention, we can repair the damage.

This is where a partnership with parents becomes incredibly important. We will not be able to heal the child until their caregiver is healed and available to them. Often the way to start is by addressing the family’s immediate concrete needs and looking for programmes like the one I work with (Child First) or the ANCHOR program in Singapore to partner with towards intensive support for the family. Several active ingredients seem to be required to make this partnership work best: Reliability of the providers, immersion in family life and helping with life skills, intimacy with the family, providing an ethical holding environment that acknowledges power and inequity in the relationship, and assisting the parent in making meaning of their own behaviours and that of the child.

The goal of the Child First model is to both decrease the multiple environmental stressors through intensive care coordination and build a protective shield for the child through a psychotherapeutic intervention, establishing a nurturing, responsive parent-child relationship. To accomplish this, Child First uses a team approach with a licensed mental health clinician and a care coordinator.¹⁶ This approach addresses three problems in existing service strategies for families impacted by stress and trauma:

1. 1. It is very challenging for a single therapist working alone to have the time to provide treatment and also connect to the vital services that families need. Our coordinated, team approach ensures that services can be accessed.
   2. Parents and their children have experienced significant trauma but will not go to outside services. Child First’s home-based, two-generation approach enables parents and their children to begin the process of healing from their own trauma, eliminating barriers to treatment by offering home-based services which reduce stigma, eliminate transportation difficulties and childcare needs.
   3. Treatments that target the elimination of child behaviours and/or teach parenting skills alone do not address and heal the trauma. Furthermore, parents dysregulated by their own trauma responses have difficulty learning and integrating new skills. Child First helps to build nurturing, responsive parent-child relationships, which are not only fundamental to healing both child and parent but will continue to protect the child from the impact of future adversity.

References

1. Bowlby, J., 1969. Attachment and loss, Vol.1: Attachment, London: Hograth Press and the Institute of Psycho-Analysis.
2. Stern, D., 1987. The interpersonal world of the infant: A view From Psychoanalysis developmental psychology. International Journal of Early Childhood, 19(1), pp.73–74.
3. Snyder, R., Shapiro, S. & Treleaven, D., 2011. Attachment theory and mindfulness. Journal of Child and Family Studies, 21(5), pp.709–717.
4. Fonagy, P., Gergely, G. & Target, M., 2007. The parent-infant dyad and the construction of the subjective self. Journal of Child Psychology and Psychiatry, 48(3-4), pp.288–328.
5. Fonagy, P. et al., 1991. The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 12(3), pp.201–218.
6. Grienenberger, J. & Slade, A., 2002. Maternal reflective functioning, mother infant affective communication, and infant attachment: Implications for psychodynamic treatment with children and families. PsycEXTRA Dataset.
7. Slade, A., 2005. Parental reflective functioning: An introduction. Attachment & Human Development, 7(3), pp.269–281.
8. Bloom, S.L., 2019. Trauma theory. Humanising Mental Health Care in Australia, pp.3–30.
9. Steele, M., 2018. Trauma and attachment. Developmental Perspectives in Child Psychoanalysis and Psychotherapy, pp.51–72.
10. Guyon-Harris, K.L. et al., 2020. Early caregiving quality predicts consistency of competent functioning from middle childhood to adolescence following early psychosocial deprivation. Development and Psychopathology, 33(1), pp.18–28.
11. Guyon-Harris, K.L., Humphreys, K.L. & Zeanah, C.H., 2020. Adverse caregiving in early life: The trauma and deprivation distinction in young children. Infant Mental Health Journal, 42(1), pp.87–95.
12. Insel, T., 1997. A neurobiological basis of social attachment. American Journal of Psychiatry, 154(6), pp.726–735.
13. Macfie, J., Cicchetti, D. & Toth, S.L., 2001. The development of dissociation in maltreated preschool-aged children. Development and Psychopathology, 13(2), pp.233–254.
14. Peterson, Sarah. “About Child Trauma.” The National Child Traumatic Stress Network, 5 Nov. 2018, www.nctsn.org/what-is-child-trauma/about-child-trauma.
15. Harvard Center for the Developing Child (n.d.). Stress and Resilience: How toxic stress affects us and what we can do about it. https://developingchild.harvard.edu/resources/stress-and-resilience-how-toxic-stress-affects-us-and-what-we-can-do-about-it/
16. Lowell, D., Paulicin, B., Carter, A., Godoy, l. Briggs-Gowan, M. (2011). A Randomized Controlled Trial of Child FIRST: A Comprehensive Home-Based Intervention Translating Research Into Early Childhood Practice. Child Development, 82 (1), pp.193–208.

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About the Author

Dr. Salam Soliman is the Director for the Center for Prevention and Early Trauma Treatment (CPETT) for Child First, National Service Office for Nurse-Family Partnership and Child First. CPETT is a Substance Abuse and Mental Health Services Administration (SAMHSA)-funded National Child Traumatic Stress Network Category II Center in the United States. Dr. Soliman is a licensed clinical psychologist, a certified school psychologist, and an infant mental health mentor.