What Does Trauma-Responsive Work Actually Look like?
Over the last couple of weeks we’ve talked about the logistics of what trauma informed care is. Those foundations are so important so if you want a refresher, check out the previous posts on trauma informed care in OT and strategies for making your practice trauma informed. Now that we’ve covered the basics, it’s time to get more into the nitty gritty of what it actually looks like in practice. Keep reading for more about how this work actually looks in practice.
Trauma-responsive care is a way of being with children and families that resonates with me because it allows me to form deeper relationships with the children I work with. There are the concrete elements such as doing our own learning, sharing information with clients and families, doing screening and having ongoing supervision and reflective opportunities for ourselves. But just as importantly, if not more so, is the less tangible stuff- having a sense of what it will feel like to be in the room with a child or family member who has lots of trauma symptoms, staying present in the difficult moments, and doing your best work as often as possible.
Understand Your Client’s Life Experience First
Early childhood trauma has the potential to disrupt every developing system in a child’s nervous system and body (Hambrick, E., Brawner, T. W., Perry, B., 2019)). The Neurosequential Model™ is tremendously helpful in understanding exactly which systems are impacted. As Dr. Perry and others have shown us, the systems that are developing at the time of the trauma, are likely to be impacted or derailed by the child’s experience. That means, if a child experiences more negatives than positives while their sensory integration or relational systems are developing, they are likely to have some sensory and relationship challenges.
When I’m working with a child, my primary goal is to build a strong, sturdy relationship with them. Our difficult work of skill building will rest on top of that relationship. The relationship is a precursor to any developmental change that I hope to see. To that end, I want to have the best sense I can of what to expect, developmentally from them. Of course, a great deal of this information will come as I get to know them through time and assessment. But I can usually get a “good enough” guess about what I might see by hearing about the child’s history.
“The difficult work of skill building will rest on top of the therapeutic relationship with the child”
When I know what kinds of life experiences a child has had at what times of life, I’m better able to understand the symptoms and behaviors the child has. To put it (overly) simply, the questions I hope to get answered are:
At what points in the child’s life were there more negative/scary experiences than healthy/relational experiences?
How long did those periods last?
What was the intensity of the experiences?
Who were the safe, regulated adults who cared for the child throughout their lives and each of these hard times?
For many “typically developing” (I’m working on more up-to date language on this) children, positive/relational experiences far outweigh the negative or frightening ones. This allows their brains and bodies to develop in a predictable way that supports movement, communication & participation in childhood activities. But, we are often working with children who’s lives, from a very early age, are marked by more frightening or harmful experiences than healthy regulated experiences. Therefore, I expect to see symptoms and behaviors that match that profile.
Here’s a simple chart that shows a timeline of when some of the major developmental processes are developing and what symptoms we might see in practice when there is trauma during those periods.
My wonderful colleague Marti Smith has a beautiful discussion and more robust chart about these “critical windows of development” in her book The Connected Therapist: Relating Through The Senses (linked below).
Case Discussion
This information helps me know what to anticipate when I do a case consultation such as one I did for school team several years ago. During the consultation, I asked what seemed like hundreds of questions about the child’s early experiences-
who their caregivers were
how much support they had in caring for their child
what kinds of family routines there were, which relationships ended and how sudden did they end
and the list goes on.
Through the long process I learned that this 4 year old had been moved into foster care when they were an infant due to maltreatment by their family of origin. They then had several placements throughout their young life and developed big behaviors that were a challenge for resource parents to navigate. In response, some of the resource families had been abusive themselves in an effort to manage the challenging behaviors. Overall, this child had not had a consistent caregiver since infancy and had had to navigate many very scary moments on their own, even as a toddler and preschooler.
This history helps me anticipate, even before seeing the child that they likely have challenges that stem from sensory, regulatory, relational & attachment, communication, sensorimotor and executive functioning challenges. These are all of the big areas of development for young children!
In getting to know the child, I saw a child who on the surface appeared “normal” but had a very low frustration tolerance- any hint of challenge would result in protests that spanned from a simple “no” to running out of the classroom or aggressing at other children. He was extremely sensitive to loud noises, people moving around in his line of sight, often startling to noises like the toilet flushing in the classroom’s bathroom. Although he was very interested in playing with others, his bids for connection often looked a lot like aggression (knocking over a peer’s block tower) or confusion (standing frozen at the edge of a game without saying anything to the children playing). Here’s a look at what we saw, mapped with the developmental areas we looked at earlier.
In all of his challenging behaviors, we see evidence of developmental delays, likely a result from the extraordinary amount of trauma he had endured. In his big reactions to noises and distractibility we dig down to see sensory modulation challenges. In his low frustration tolerance, we recognize a sensitized stress response (a concept of Dr. Perry’s) which tells his brain at any sign of difficulty that there is potential danger and to fight, freeze or in his case, flee. In his challenges initiating play with friends in the classroom, we see a disorganized relational system that doesn’t accurately perceive social cues and his communication challenges preventing him from choosing language like “can I play” when he needs it.
It’s no wonder that one hour per week of psychotherapy was only making a small difference, the child needed profound support in all domains of development because their little brain was too focused on surviving when it was meant to be growing and learning.
The Neurosequential Model™ and occupational therapy research can guide our thinking in cases like this. The most useful strategy I have is to begin with regulation. A hallmark of this type of trauma is that it has resulted in this child being chronically over-aroused. His nervous system isn’t able to reach a calm state on it’s own. If and when it does, it’s easily triggered back into fight/flight/freeze mode by even small stressors. Without a regulated nervous system, connection with others and learning will be quite compromised.
So…what can we do?
First, we can return to the knowledge that children’s brains can change- it takes time, thoughtful effort, and a strong relationship. No matter how difficult our sessions are, how many toys are broken, holding onto this truth can keep us going!
Start with regulation
What are the times, people, toys or materials, and tools that help a child reach a baseline arousal state? For this child, he enjoyed movement and had 2 particularly favorite staff members he could spend time with. He developed a liking for a certain book in the classroom and enjoyed bringing it with him when he moved around. He also was most regulated during the mid morning, after the transition into the day but before the other big transitions.
The plan we developed for him was focused on regulation and we learned from him what to focus on:
Teaching took place mid morning, with staff joining him in his activities to provide him extra encouragement, explanations of things he was interested in and guidance to play with friends when he was naturally at his best
The classroom changed their rules to allow him to bring his beloved book (security item) with him, even though books were not typically allowed outdoors or outside of the library area
Teachers and staff worked movement into almost all of the activities for the classroom so he had a way to move and participate in the classroom plan
His teachers and staff had training on the impact of trauma and the sometimes slow pace of progress. With training and supervision/support, they were supported through their work with him over the course of the year.
Thanks for reading! Next week we’ll dive deeper into strategies like these! Let us know, how do you think about the challenging behaviors you see in your classrooms and clinics?
Resources & References
Hambrick EP, Brawner TW and Perry BD (2019) Timing of Early-Life Stress and the Development of Brain-Related Capacities. Frontiers in Behavioral Neuroscience. 13(183). doi: 10.3389/fnbeh.2019.00183
Smith, M. (2021) The Connected Therapist: Relating Through the Senses. Marti Smith Seminars, Inc. ISBN: 978-1-7372052-0-3
Disclaimer
The information provided on this blog is for informational purposes only. It is not intended to assess, diagnose, treat, or prevent any medical or mental health conditions. The content shared on this site should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician, mental health professional, or other qualified healthcare provider with any questions you may have regarding a medical or psychological condition. Never disregard professional advice or delay seeking it because of something you have read on this blog.
