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 CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
CHIL
CHILDHOOD
Pediatric care is on the cusp of a transformation, from reactively identifying and treating the
consequences of childhood adversity to proactively building the skills needed for resilience, healing,
and thriving. Childhood Trauma and Resilience is a must for all pediatric professionals interested
in transforming their practice from “trauma-informed” to “resilience-centered” care.

TRAUMA &
—Andrew Garner, MD, PhD, FAAP, coauthor of Thinking Developmentally: Nurturing Wellness in Childhood to Promote Lifelong Health

CHILDHOOD TRAUMA
& RESILIENCE
A Practical Guide
RESILIENCE
Heather C. Forkey, MD, FAAP • Jessica L. Griffin, PsyD • Moira Szilagyi, MD, PhD, FAAP
A Practical Guide
With this practical guide, pediatricians and other child health professionals will learn to identify, evaluate, and treat
children and families affected by trauma and adversity when they present at the office. In addition to instruction for
hands-on acute care, the cohesive approach lays out a framework and concrete steps to focus proactively on resilience
and provide the best, most impactful care to all patients.
Childhood Trauma and Resilience includes mnemonics, charts, tables, reproducible handouts, and numerous case
studies to reinforce learning, as well as timely information on physician burnout and secondary traumatic stress.

About the Authors

Heather C. Forkey, MD, FAAP, is a professor of pediatrics and pediatric vice chair for wellness at the University of Massachusetts
Medical School (UMMS) and division director of the Child Protection Program and Foster Children Evaluation Service of the
UMass Memorial Children’s Medical Center. She also serves as medical director of Lifeline4Kids at the UMMS.
Jessica L. Griffin, PsyD, is a clinical psychologist, an associate professor of psychiatry and pediatrics at the UMMS, and executive
director of the UMMS Child Trauma Training Center. In 2020, she was awarded a multiyear, multimillion-dollar grant to develop
the national Resilience Through Relationships Center, housed at the UMMS, aimed at supporting parents, caregivers, and
children exposed to trauma. She also serves as executive director of Lifeline4Kids at the UMMS.
Moira Szilagyi, MD, PhD, FAAP, elected to serve as 2021 president-elect and 2022 president of the American Academy of
Pediatrics, is a primary care pediatrician, professor of pediatrics, and division chief of developmental-behavioral pediatrics
at UCLA, where she is also the Peter Shapiro Term Chair for Enhancing Children’s Developmental and Behavioral Health in

Forkey • Griffin • Szilagyi

Pediatrics. She is editor of Fostering Health and has worked for 30 years with children and teens in foster care.
Heather C. Forkey, MD, FAAP
Jessica L. Griffin, PsyD
For more pediatric resources, visit the
American Academy of Pediatrics at shop.aap.org.
Moira Szilagyi, MD, PhD, FAAP

AAP

CHILDHOOD TRAUMA - COVER SPREAD.indd All Pages 5/27/21 11:04 AM

 Available From the American Academy of Pediatrics
AAP Developmental and Behavioral Pediatrics
Addressing Mental Health Concerns in Pediatrics:
A Practical Resource Toolkit for Clinicians
Building Resilience in Children and Teens:
Giving Kids Roots and Wings
Child Abuse: Medical Diagnosis and Management
Managing Behavioral Issues in Child Care and Schools:
A Quick Reference Guide
Managing Mental Health Concerns in Pediatrics:
A Clinical Support Chart
Medical Evaluation of Child Sexual Abuse:
A Practical Guide
Mental Health Care of Children and Adolescents:
A Guide for Primary Care Clinicians
Pediatric Mental Health: A Compendium of AAP Clinical Practice
Guidelines and Policies
Pediatric Psychopharmacology for Primary Care
Promoting Mental Health in Children and Adolescents:
Primary Care Practice and Advocacy
Raising Kids to Thrive: Balancing Love With Expectations
and Protection With Trust
Reaching Teens: Strength-Based, Trauma-Sensitive,
Resilience-Building Communication Strategies Rooted
in Positive Youth Development
Thinking Developmentally: Nurturing Wellness in
Childhood to Promote Lifelong Health

For additional resources, visit https://shop.aap.org.

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CTAR BOOK.indb 2 5/16/21 2:54 PM
CTAR BOOK.indb 1 5/16/21 2:54 PM
 American Academy of Pediatrics Publishing Staff
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Published by the American Academy of Pediatrics

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The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists
dedicated to the health, safety, and well-being of all infants, children, adolescents, and young adults.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be appropriate.
Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the
American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.
The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any,
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This publication has been developed by the American Academy of Pediatrics. The contributors are expert authorities in the field of pediatrics.
No commercial involvement of any kind has been solicited or accepted in the development of the content of this publication.
Disclosures: Dr Griffin consults independently as a Trauma-Focused Cognitive Behavioral Therapy trainer. Dr Szilagyi disclosed a president-elect relationship
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 Authors
Heather C. Forkey, MD, FAAP
Professor of Pediatrics
Vice Chair for Wellness
Medical Director, Lifeline4Kids
University of Massachusetts Medical School
Chief, Child Protection Program and Foster Children Evaluation Service
UMass Memorial Children’s Medical Center
Worcester, MA

Jessica L. Griffin, PsyD

Associate Professor of Psychiatry and Pediatrics
Executive Director, Child Trauma Training Center
Executive Director, The Resilience Through Relationships Center
Executive Director, Lifeline4Kids
University of Massachusetts Medical School
Worcester, MA

Moira Szilagyi, MD, PhD, FAAP

Professor
David Geffen School of Medicine
Mattel Children’s Hospital
Division Chief, Developmental-Behavioral Pediatrics
Peter Shapiro Term Chair for Enhancing Children’s Developmental and Behavioral Health in Pediatrics
University of California, Los Angeles
Los Angeles, CA

American Academy of Pediatrics Reviewers

Council on Child Abuse and Neglect
Council on Community Pediatrics
Council on Foster Care, Adoption, and Kinship Care

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CTAR BOOK.indb 4 5/16/21 2:54 PM
 ß
To all our patients and their families
for making us better at what we do
and to our families,
our safe harbors in life
ß

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 Equity, Diversity, and Inclusion Statement
The American Academy of Pediatrics is committed to principles of equity, diversity, and inclusion in its
publishing program. Editorial boards, author selections, and author transitions (publication succession plans)
are designed to include diverse voices that reflect society as a whole. Editor and author teams are encouraged to
actively seek out diverse authors and reviewers at all stages of the editorial process. Publishing staff are
committed to promoting equity, diversity, and inclusion in all aspects of
publication writing, review, and production.

CTAR BOOK.indb 6 5/16/21 2:54 PM

 Contents

ix Acknowledgments
xi Introduction

1 Part 1. Building the Resilient Child

3 Chapter 1. Brain Development: Early Childhood Through Adolescence
11 Chapter 2. Promoting Resilience
19 Chapter 3. Attachment
33 Chapter 4. Parenting
51 Chapter 5. Cultural Connections (Andrea Ocampo Rosales, MA)

57 Part 2. Effects of Adversity and Trauma

61 Chapter 6. Pathophysiology of Trauma
73 Chapter 7. How Trauma Can Manifest in Children and Teens

89 Part 3. Promoting Recovery From Trauma

91 Chapter 8. Engagement
97 Chapter 9. Patient Evaluation and Differential Diagnosis
107 Chapter 10. Surveillance and Screening
123 Chapter 11. Pediatric Management
141 Chapter 12. The Intersection of Trauma and Culture (Andrea Ocampo Rosales, MA)
153 Chapter 13. Supporting the Caregiver
159 Chapter 14. Integrated Care
169 Chapter 15. The Role of Medication

177 Part 4. Supporting the Clinician and Pediatric Settings

179 Chapter 16. Burnout and Secondary Traumatic Stress
187 Chapter 17. Trauma-Informed Systems of Care

199 Conclusion

201 Appendixes. Selected Handouts by Topic

203 Appendix A. Promoting Resilience Handouts
204 Appendix B. Attachment Handouts
206 Appendix C. Parenting Handouts
207 Appendix D. Cultural Connections Handouts
208 Appendix E. Signs and Symptoms of Trauma Handouts
209 Appendix F. Engagement Handouts
210 Appendix G. Pediatric Management Handouts

217 Index

vii

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CTAR BOOK.indb 8 5/16/21 2:54 PM
 Acknowledgments
Special thanks must go to our colleagues on the PATTeR and R.J. Gillespie, MD, MHPE, whose feedback during
team at the American Academy of Pediatrics (AAP), UMass, the book’s development helped make the final product
and UCLA, who have been thoughtful and wise consultants the very best it could be. Thanks also to the reviewers from
to the process and content; to Andrea Ocampo, MA, who the AAP Council on Child Abuse and Neglect, Council
contributed 2 crucial chapters on the role of culture in on Community Pediatrics, and Council on Foster Care,
trauma and resilience; and to Andrew Garner, MD, PhD, Adoption, and Kinship Care for many valuable insights.

ix

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CTAR BOOK.indb 10 5/16/21 2:54 PM
 Introduction
She stopped me on my way out. I was leaving the presen-
tation room at a pediatric conference, having just partici-
pated in a session on the physiology of trauma and toxic
stress. Her eyes were intense, and her manner was rushed,
but the tone of her voice was what arrested my efforts to
leave. “Just before you go…what you said, it makes so
much sense. I get it. It’s so important, what you talked
about…you described my patients,” and more softly she
said, “and you described me.” She caught my eye again
and queried, “I want to do this work, intervene for my
patients…but how?”
The cognitive “aha” that this practitioner had when the
science of trauma and toxic stress was explained to her
was, for her, as it was for us when we first learned about it,
intellectually satisfying and profoundly motivating. It can
help explain patients, symptoms, and family systems that
seemed previously to have a common but invisible thread.
For us, it helped make sense of what we had seen clinically
for years. But, as this practitioner immediately recognized,
knowing what is happening physiologically but not having
the practical skills and tools to prevent, recognize, and
respond to trauma in the clinical setting can be painfully
frustrating. In some circumstances, this combination of
improved understanding of the science and helplessness
to influence it likely contributes to our own burnout and
secondary traumatic stress.
Pediatric medical care professionals are likely to be the
first, and sometimes only, professionals with the opportu-
nity to assess the myriad symptoms demonstrated by chil-
dren experiencing trauma. For many children, the issues
bringing them to pediatric attention are trauma related.
For instance, 68% of children cared for in a pediatric
health care setting have experienced exposure to trau-
matic events, and as many as 90% of children in urban
pediatric clinics have had a trauma exposure.1 We know
that these events if unaddressed alter the neuroendocrine
and immune systems of our patients in ways that can
have lasting consequences.
What’s more, the pediatrician is ideally situated for trauma
prevention. Like vaccines, resilience skills and attachment
are what keep children from experiencing long-term conse-
quences from trauma even when there are exposures, and
attachment and resilience building are what pediatrics is all
about. We use a prevention and developmental framework
xi
CTAR BOOK.indb 11
and our relationships with children and families to pro-
mote wellness. Resilience skills develop with attachment—
the support of a predictable, compassionate, and available
caregiver. With the support of those attachments, children
develop regulation skills, executive function, and efficacy
(the sense of being able to influence one’s environment).
By harnessing our relationships with children and their
caregivers, we have the opportunity to provide guidance
and practical skills to promote resilience—if only we
knew how.
This relationship can have impacts in both directions.
Studies catalog the myriad possible sources of medical
professional burnout. Alarming statistics on depression
and suicide in the health professions suggest not just that
the work stress is frustration with the electronic medical
record but that sharing the traumas of others can have
a profound impact on the professional. Understanding
the science of the stress response can guide the medical
professional as well, but the science needs to be applied
to provide practical methods to reduce the effects on our
neuroendocrine system. We must take care of ourselves
if we are to be at all effective with our patients. Again—
if only we knew how.
How do we teach families to help their children weave
together the threads of resilience? How do we empower
parents and caregivers to provide a strong seam to hold
those threads in place in the context or fabric of a family’s
cultural supports and social risks? How do we recognize
the effects of trauma that cause a child or family to become
frayed? How do we apply these principles to ourselves and
our colleagues so we don’t become frayed as well? How
do we weave this together in the medical setting, juggling
the time and economic constraints of pediatric practice?
That is what this book is about. As the physician I met at
the conference recognized, what providers need are the
practical tools, guidance, and pathways for us to respond
to patients and caregivers and help them and ourselves.
So, now, years after the physician I met at that conference
asked me the question, we now have an answer. This is
how to start.
Reference
1. Burke NJ, Hellman JL, Scott BG, Weems CF, Carrion VG. The impact
of adverse childhood experiences on an urban pediatric population.
Child Abuse Negl. 2011;35(6):408–413 PMID: 21652073
https://doi.org/10.1016/j.chiabu.2011.02.006
5/16/21 2:54 PM
CTAR BOOK.indb 12 5/16/21 2:54 PM
 PART

1
Building the Resilient Child
Introduction

Trauma-Informed Care: It’s All About Relationships

While this textbook touts its focus on trauma-informed The focus of trauma-informed care is on treating the care-
giving relationship—that between children and caregivers—
care, it is our hope that you will come to view it as a book
as our patient. But, in doing so, we have to recognize and
about resilience-informed care. It focuses on the centrality
focus on our relationship with the parent and the patient. It
of relationships in promoting resilience and healthy devel-
is how we undertake this care. And we must realize that the
opment to prevent and ameliorate the impact of trauma
relationships within the pediatric setting among colleagues
throughout childhood and adolescence. Trauma- and
create the milieu in which care occurs: we care for families
resilience-informed care requires a change in thinking
but we also care for each other. The thread weaving through
from the problem-focused model of traditional health care
trauma-informed care is that the key to resilience, trauma,
that focuses on “What is wrong with you?” (so I can fi x
and healing is relationships—and the most significant
you) to the life-course model that asks instead “What has
therapeutic tool we have is in tending relationships. This
happened to you?” and “What is strong with you?” (so I can
concept is so fundamental to pediatric care that it can be
help and understand you).1 The life-course approach recog-
overlooked as being easy or obvious, yet it is neither, and
nizes that what has happened to a child and/or family can
the skills to do this work need to be taught, practiced,
have profound and potentially lifelong impacts on physical
refined, and reinforced.
and mental health and social functioning for better or
worse.2,3 The sciences of neurohormonal stress response In this text, we cover the concepts of resilience, trauma,
systems, neuroscience, epigenetics, and immunology attachment, regulation, development, and self-efficacy, all of
have helped us understand and explain, at least in part, the which have, at their foundation, the safety and security of
impact of cumulative adversities on brain development and relationships. This text focuses on developing the skills and
how they can become in essence biologically embedded.4–6 tools that we need as pediatricians to leverage relationships
to support, promote, and develop those of our patients,
As pediatricians, we are in a unique position to prevent and/
families, and colleagues. We have not created this concept;
or ameliorate the impact of trauma, to intervene to manage
it is rather the fundamental feature of all forms of therapy
symptoms, and, thus, to promote resilience, that capacity to
and human development. We have drawn from an exten-
withstand or adapt positively to adversity. We meet parents
sive literature in several other fields (eg, mental health,
early in the formation of their families and, in many cases,
trauma, neuroscience, resilience, parenting, early brain
continue to care for them at specific and predictable inter-
development, epigenetics) to translate these concepts into
vals over time, especially in pediatric primary care. Families
pediatric care.
trust us for advice and guidance about child health, devel-
opment, and behavior. And we are, in addition to being Beginning with the publication of the Adverse Childhood
experts in child health, experts in prevention, child develop- Experiences study in 1998,8 science has taught us that child-
ment, family functioning, and parenting—and in resilience hood experiences of all types, as filtered through our care-
promotion. We promote resilience every day in every en- givers, become biologically embedded over time. We even
counter in which we offer empathy to the child or adult have a “top 10 list” (the Adverse Childhood Experiences
affected by trauma, focus on child and family strengths, survey) of childhood adversities predicting, in a dose-
encourage positive childhood experiences, and offer hope dependent manner, an array of poor adult physical and
of recovery. It is woven into the Bright Futures approach mental health outcomes.9–11 Researchers have added some
to engage families and provide anticipatory guidance. 7 items, such as bullying and experiencing discrimination,
1

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 2
CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
to this brief survey,12–14 but it has withstood scrutiny despite
a number of shortcomings. Science has filled in some of
the blanks about how adversities in childhood can affect
physical health, behavior, development, and emotional
health decades later.15 We now understand that while our
DNA code is an unchanging blueprint, our interaction
with our environment determines which genes are ex-
pressed or not.6,16 Adaptation begins prenatally and con-
tinues throughout life but is most pronounced when our
brains are in rapid phases of growth and development, as in
our earliest years.17 We adapt to our environments because
of this amazing capacity to respond. Our caregivers, espe-
cially in our earliest years, create and mediate that envi-
ronment for us; it is in these earliest of relationships that
we learn about the world and relationships and that our
genetic potential begins to be realized or diminished.
In health care, the interest in childhood trauma and its
impact has led to a focus on screening for adverse child-
hood experiences (ACEs)18 and the social determinants of
health19 in an effort to understand the physical and mental
health and development of the patient. And while screening
has helped providers identify needs, such as food or hous-
ing insecurity, that need referral, many pediatricians have
been reluctant to screen for ACEs because they do not have
access to resources or know what they can do about them
in their offices. However, this anxiety may also reflect con-
cerns that screening in isolation, without establishing a safe
relationship with families first and having a clear plan for
follow-up, may have negative consequences.
A trauma-informed approach focuses not on the tasks, not
on the checklists to complete, but on the people and rela-
tionships involved (people who are, interestingly, human
beings, not human doings). The value of screening or any
other activity in pediatrics is that we have the longitudinal
experience with families, the scientific background, the
developmental grounding, and the trust of families in these
relationships. We in fact have a unique role to play. Now,
we just need the words and skills pulled from evidence-
based or evidence-informed practice in pediatrics, mental
health, parenting, and resilience to translate what we
know into practical support…that’s the core of this book:
supporting trauma-informed, resilience-promoting care.
References
1. Garner AS, Forkey H, Szilagyi M. Translating developmental science
to address childhood adversity. Acad Pediatr. 2015;15(5):493–502
PMID: 26183002
https://doi.org/10.1016/j.acap.2015.05.010
2. Szilagyi M, Halfon N. Pediatric adverse childhood experiences:
implications for life course health trajectories. Acad Pediatr.
2015;15(5):467–468 PMID: 26344714
https://doi.org/10.1016/j.acap.2015.07.004
3. Felitti VJ. Adverse childhood experiences and adult health.
Acad Pediatr. 2009;9(3):131–132 PMID: 19450768
https://doi.org/10.1016/j.acap.2009.03.001
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4. McEwen BS. Protective and damaging effects of stress mediators.
N Engl J Med. 1998;338(3):171–179 PMID: 9428819
https://doi.org/10.1056/NEJM199801153380307
5. van der Kolk BA. Developmental trauma disorder: toward a
rational diagnosis for children with complex trauma histories.
Psychiatr Ann. 2005;35(5):401–408
https://doi.org/10.3928/00485713-20050501-06
6. Shonkoff JP, Garner AS, Siegel BS, et al; American Academy of
Pediatrics Committee on Psychosocial Aspects of Child and Family
Health; Committee on Early Childhood, Adoption, and Dependent
Care; and Section on Developmental and Behavioral Pediatrics.
The lifelong effects of early childhood adversity and toxic stress.
Pediatrics. 2012;129(1):e232–e246 PMID: 22201156
https://doi.org/10.1542/peds.2011-2663
7. Hagan JF Jr, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for
Health Supervision of Infants, Children, and Adolescents. 4th ed.
American Academy of Pediatrics; 2017
8. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood
abuse and household dysfunction to many of the leading causes
of death in adults. The Adverse Childhood Experiences (ACE) study.
Am J Prev Med. 1998;14(4):245–258 PMID: 9635069
https://doi.org/10.1016/S0749-3797(98)00017-8
9. Anda RF, Dong M, Brown DW, et al. The relationship of adverse
childhood experiences to a history of premature death of family
members. BMC Public Health. 2009;9(1):106 PMID: 19371414
https://doi.org/10.1186/1471-2458-9-106
10. Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood
experiences and the risk of premature mortality. Am J Prev Med.
2009;37(5):389–396 PMID: 19840693
https://doi.org/10.1016/j.amepre.2009.06.021
11. Danese A, Pariante CM, Caspi A, Taylor A, Poulton R. Childhood
maltreatment predicts adult inflammation in a life-course study.
Proc Natl Acad Sci USA. 2007;104(4):1319–1324 PMID: 17229839
https://doi.org/10.1073/pnas.0610362104
12. Finkelhor D, Ormrod R, Turner H, Hamby SL. The victimization
of children and youth: a comprehensive, national survey.
Child Maltreat. 2005;10(1):5–25 PMID: 15611323
https://doi.org/10.1177/1077559504271287
13. Lupien SJ, King S, Meaney MJ, McEwen BS. Can poverty get
under your skin? basal cortisol levels and cognitive function in
children from low and high socioeconomic status. Dev Psychopathol.
2001;13(3):653–676 PMID: 11523853
https://doi.org/10.1017/S0954579401003133
14. Williams DR, Mohammed SA. Discrimination and racial
disparities in health: evidence and needed research. J Behav Med.
2009;32(1):20–47 PMID: 19030981
https://doi.org/10.1007/s10865-008-9185-0
15. Division of Violence Prevention, National Center for Injury Prevention
and Control. Violence prevention: adverse childhood experiences.
Centers for Disease Control and Prevention. Last reviewed April 3, 2020.
Accessed April 9, 2021.
https://www.cdc.gov/violenceprevention/aces/index.html
16. National Scientific Council on the Developing Child, Center on
the Developing Child at Harvard. Excessive stress disrupts the
architecture of the developing brain. Working paper 3. 2005
17. National Scientific Council on the Developing Child, Center
on the Developing Child at Harvard. The timing and quality
of early experiences combine to shape brain architecture.
Working paper 5. 2007
18. Harris NB, Marques SS, Oh D, Bucci M, Cloutier M. Prevent, screen,
heal: collective action to fight the toxic effects of early life adversity.
Acad Pediatr. 2017;17(7)(suppl):S14–S15 PMID: 28865647
https://doi.org/10.1016/j.acap.2016.11.015
19. Dubowitz H. The Safe Environment for Every Kid (SEEK) Model:
helping promote children’s health, development, and safety: SEEK
offers a practical model for enhancing pediatric primary care.
Child Abuse Negl. 2014;38(11):1725–1733 PMID: 25443526
https://doi.org/10.1016/j.chiabu.2014.07.011
5/16/21 2:54 PM
 CHAPTER
1
Brain Development:
Early Childhood Through Adolescence
Introduction
The human brain is a marvelous, complex, intricate struc-
ture that begins forming prenatally but continues to under-
go development at least into the mid-20s. An argument
waged for decades that was focused on whether brain devel-
opment resulted from nature (the genetic code) or nurture
(the environment); we now know that the answer is both
and of the interaction between the two. Brain develop-
ment results from a series of ongoing dynamic interactions
between our genetic blueprint, or DNA, and our environ-
ment, of which the safety, quality, stability, style, and tenor
of early caregiving are the most important components.1,2
However, the early environment also includes prenatal and
postnatal nutrition, toxins, and infectious agents; prenatal
maternal stress hormones; air and/or water pollution; family
style and structure; the larger social network; and exposure
to typical experiences, cultural norms, and negative
experiences such as violence and bullying.3
The early caregiving environments of infants and toddlers
are critically important because the neural structures laid
down in this period are the foundation on which all the
more complex structures are later built. Environment and
experiences influence which genes are expressed and which
are unexpressed when the early architecture of our brains,
which will determine our cognitive, interpersonal, commu-
nication, emotional, regulatory, and behavioral outcomes,
is being constructed. In fact, some of the most critical ele-
ments of brain structure develop in response to prenatal and
early childhood experiences, so that many foundational
structures are shaped well before a child begins school.4
In this chapter, we not only review the principles of typical
brain development in early childhood in particular but also
look at some aspects of brain development through child-
hood and adolescence. We also briefly address how emo-
tional development and executive function develop over
time. The word typical in this chapter is used to refer to
the experiences and environments expected to promote
optimal brain development. In Chapter 6, Pathophysiology
of Trauma, we consider how trauma hijacks and can even
derail typical brain development, especially when the child’s
3
CTAR BOOK.indb 3
caregivers do not provide safe, responsive, stable nurtur-
ance. In such situations, the child’s brain adapts to the
more dangerous environment in which they live.5–8
Fundamental Principles of
Early Brain Development
The brain is constructed over time in an ongoing process,
beginning before birth and continuing into adulthood. It is
built from the bottom up, from simpler lower-level brain
structures to more intricate and complex higher-level brain
structures. The ongoing interaction between the genetic
blueprint and the environment determines which genes are
expressed or not, and this, in turn, determines the evolving
architecture of the brain—which structures are built, what
neuronal connections are made, how and which circuits
are reinforced, and by how much.1,4,9
The largest environmental impacts occur in early
childhood when the basic brain architecture is being
rapidly built—when more than 1 million new neuronal
connections are being made every minute (Box 1-1).
Box 1-1. Basic Processes of Early Brain
Development
Neurogenesis
The brain initially makes far more neurons than it needs.
Dendrite arborization/branching
Neurons develop branches that increase the surface area for the
neurons to form synapses or connections with other neurons.
Synaptogenesis
Neurons form connections with each other via their branches or
dendrites, allowing them to communicate chemically and elec-
trically with each other and eventually form circuits, or pathways,
based on gene-environment interaction and amount of use.
Apoptosis/pruning
The infant and young child adapt to the world they are born into.
Some neural circuits will be reinforced through use, while others
will be pruned because of disuse.
Myelination
Begins earnestly in the second year after birth and dramatically
increases the speed of nerve transmission and communication.
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
As neurons proliferate, in a process termed neurogenesis,
they begin to form circuits, or pathways, that are reinforced
by use or diminished from nonuse. More complex circuits
are built on less complex circuits. Many brain circuits also
appear to have one or more specific sensitive periods, espe-
cially when circuits are rapidly maturing or reaching matu-
rity and beginning to function. The experiences occurring
during this time have an especially significant role in shap-
ing brain structure and capacity.1,4
Some examples of functional pathways with sensitive
periods include vision, hearing, language, and responses
to social cues.1,4,10–13 Sensitive periods occur at different ages
for different neural circuits.1 Different brain capacities are
built and come on line at fairly predictable ages and in a
predictable sequence as long as the environment is typical
and caregiving is responsive and nurturing.14,15 The sensory
pathways, such as hearing and vision, form early, followed
by language and more complex cognitive skills. Even so,
the multiple different circuits responsible for a given func-
tion, such as vision and the processing of visual images,
mature at different times.13,16,17 The simpler circuits for
vision that recognize color or shapes, for example, mature
before those engaged in more sophisticated and complex
visual processes, such as reading facial expressions.18
This layering or scaffolding from simple to complex and
integrated is true of all neural circuits studied to date.
The brain is a use-dependent organ. What is used is
strengthened and what is not used may be pruned away.
Once a neural circuit matures, it becomes less plastic, or
malleable, and therefore less able to adapt.1 In effect, the
brain’s capacity for change diminishes with age, although
it retains some capacity to adapt and change throughout
life, a concept referred to as “plasticity.”19 The brain is most
malleable in the first 3 to 5 years after birth, but there is
a second very active reorganizing period during puberty
and adolescence.9
Periods of rapid growth and reorganization are periods of
great opportunity to adjust a child’s trajectory in a more
positive direction through age-appropriate positive inter-
ventions and experiences. However, these are also periods
of great vulnerability, when adversities can derail develop-
ment.9,20 The fact that the brain is most plastic in the first
3 to 5 years after birth means that this is a crucial time to
provide age-appropriate experiences and interventions to
promote typical development.1,20 By adolescence, the basic
circuitry has already been laid down and a typically devel-
oping brain is better able to withstand and cope with nega-
tive experiences. However, because the adolescent brain
is undergoing rapid development, it is still vulnerable to
negative experiences. Also, while the brain remains
CTAR BOOK.indb 4
somewhat adaptive with increasing age, the intensity
of the efforts required to improve outcomes increases
with age.
The concept of developmental cascades is also important
to consider. In a typically developing child living in a sup-
portive or enriched environment, the pathways laid down
in early childhood provide a solid foundation for the more
complex circuits that follow, so that “competence begets
competence.”1,21 However, if children are exposed to a
variety of environmental risk factors, the developing
circuits accumulate changes that can damage the early
brain structures so that risk begets risk.
Brain structures and circuits also communicate and con-
nect in highly integrated and coordinated ways. They’re a
bit like a symphony orchestra, in which each instrument
has an important role to play but the music sounds correct
only if the musicians are skilled, the instruments are tuned,
and the composition and conductor are followed. While
the sound of the bassoon may be less obvious than that
of the violin or trumpet, its absence would profoundly
alter the listener’s experience. Just so, various neural
circuits must interact in precise and integrated ways
for the organism to undertake almost any action, from
learning language as a toddler to playing the bassoon
as an adult.
In Chapter 2, Promoting Resilience, we discuss how resil-
ience develops in the context of typical nurturance and
experiences. This implies that typical brain development
engenders the processes by which resilience becomes
biologically embedded over time in healthy, typically
developing children.
As we learn in later chapters, the lack of a safe, stable, nur-
turing caregiver in infancy and toddlerhood can derail the
construction of typical brain circuitry and connections.
Inadequate nutrition, infections, and prenatal, perinatal,
and neonatal factors are critical as well. In fact, mount-
ing data indicate that prenatal maternal stress can alter
the function of the newborn hypothalamic-pituitary-
adrenal (HPA) axis.22 After birth, maternal depression,
and the resultant impaired responsiveness to the infant,
also alters infant HPA axis function.23 Early childhood
traumatic experiences of neglect, abuse, and violence
exposure can profoundly impair neuron function, alter
neural circuitry, and change the connectivity and communi-
cation among neurons in ways adversely impacting the
development of cognitive, emotional, social, language,
and self-regulation skills.7,24
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Part 1—Chapter 1. Brain Development: Early Childhood Through Adolescence
Much of what we know about brain structure comes from
studies of deprivation on animals and humans. The most
profound example of the devastating impact of limited
attention and nurturance on all aspects of development
comes from studies of infants and toddlers who resided in
Romanian and other Eastern European orphanages.25,26 A
more precise example is the loss of vision that can occur
from an untreated “lazy eye” during infancy.27
Longitudinal Studies
Neuroscience is a rapidly changing field. In recent years,
some neuroscience researchers have been using longitudi-
nal neuroimaging to understand the course of typical brain
development as well as what happens to brain development
when a child is exposed to adversity at different develop-
mental ages, and how that, in turn, is linked to psychopa-
thology.9 A brief summary of studies to date documents
brain changes occurring from early childhood to early
adulthood in typically developing individuals.
1. There is a linear increase in white matter (consisting
mainly of nerve fibers or axons that transmit informa-
tion among neurons) from early childhood to adoles-
cence.28 Myelination, as seen in the amount of white
matter, progresses during childhood to adolescence
and is an important biological marker of maturity of
neural circuits. Myelination is associated with increas-
ing speed of nerve signal transmission but reduced
cellular plasticity.
2. Gray matter consists primarily of neuronal cell bodies;
it rapidly increases in volume until about age 10 years
and then decreases29,30 as many neural circuits begin to
mature and connections among them increase.
3. Myelination (and, thus, maturation) of the corpus
callosum proceeds in a rostral-caudal manner from
early childhood into adulthood,31 allowing for more
rapid communication between the 2 hemispheres
of the brain.
4. Brain maturation is linked to pubertal status, and
there is a burst of growth and reorganization during
this time.32 The transition from short-range to long-
range wiring in the brain through adolescence is
thought to represent optimization of neurocircuitry.33
5. Different areas of the brain, even ones adjacent to
each other, mature at different times and at
differential rates.34
6. Some connections among neural circuits and growth
trajectories of neural circuits are sex-hormone–
dependent and develop differently in girls and
boys in early adolescence.35
CTAR BOOK.indb 5
5
Longitudinal studies also show that psychologically trau-
matizing experiences in early childhood of maltreatment,
neglect, violence exposure, or chaotic caregiving alter
brain connectivity in areas of the brain serving cognitive
and affective processing and the emotional regulation
pathways.8 Maltreatment in childhood has been shown to
influence the volume of the amygdala and hippocampus
in adolescence. A longitudinal study of 117 adolescents by
Whittle and colleagues36 showed definitively for the first
time the longitudinal links among childhood maltreat-
ment, the development of psychopathology, and the rela-
tive sizes of the hippocampus and amygdala. A review by
Tottenham and colleagues suggests that early childhood
may be a time of increased susceptibility to adversity but
that the expression of the observed effects of stressors on
brain structures will vary with the age at assessment.2
Another area affected by trauma is the default mode net-
work (DMN), a group of interconnected brain structures
that are hypothesized to be part of a functional system
activated when one is awake but uninvolved in any specific
mental exercise. The DMN is believed to be the home of
introspective thought and self-reflection, which are most
active during periods such as daydreaming, recalling
memories, and envisioning the future and least active
during particular tasks such as paying attention. The
DMN has also been implicated in social cognition and is
the area that helps us to understand our relationships with
others.37 Some structures involved in the network include
the medial prefrontal cortex, posterior cingulate cortex,
and inferior parietal lobule.38,39
Puberty, a period of increased neuroplasticity, is now
regarded as a highly sensitive period of increased suscepti-
bility to the impact of trauma on the brain. Trauma during
early adolescence, especially during puberty, could have a
significant effect on neural circuitry by altering the more
typical integration patterns among brain pathways.9,17
However, this period of rapid growth also makes it
one in which positive experiences could improve the
developmental trajectory.
Thus, inputs in early childhood and again in adolescence
determine brain architecture and function, which in turn
significantly influence the individual’s future adult physical
and mental health, learning, and behaviors.
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
Emotional Development Is Built
Into Brain Architecture
We are all aware that certain cognitive skills, such as
language and communication, problem-solving, and orga-
nizational skills, are built into the brain and develop as a
child matures. The same is true for emotional development:
it is built into specific brain structures and matures over
time, simultaneously with the development of other, more
obvious skills, such as language and gross motor skills.40–42
In fact, the foundations of emotional well-being and social
competence are laid in the first several years in a child’s
primary attachment relationships and family but mature
throughout childhood and adolescence and even into
young adulthood.
Typical social-emotional development occurs in early
relationships and, like language and motor skills, begins
with acquiring simple skills on which more complex skills
are scaffolded over time.42,43 First, children must learn to
recognize and understand their feelings. Eventually, they
develop labels for them and learn to express and regulate
them. Marc Brackett condenses these skills into the acro-
nym RULER: Recognize your own feelings, and then
Understand, Label, Express, and Regulate them.44 One
other very important piece of emotional development is
not included in this acronym: the child also has to learn to
recognize and understand the emotional states of others.
Thus, as young children mature, their experiences, includ-
ing their emotional ones, become hardwired into their
brain structure.
Emotional expression, understanding, and regulation
develop over time in the caregiver-child relationship.
Newborns rely on caregivers to help soothe their distress,
and responsive caregivers do so by noticing newborn dis-
tress, responding calmly, gently holding and comforting
them, assessing the source of their distress, and resolving
it for them.42,43,45 As the infant matures into toddlerhood,
they require their caregiver to help them both manage
distress and recognize and interpret their feelings as they
begin to understand and label their own emotions. Thus,
caregivers help children recognize and name their emo-
tions, develop emotional self-regulation skills, and interpret
the emotions of others. By early childhood, children grow-
ing up in typical environments have a broad emotional
vocabulary and repertoire and insight into a wide array of
emotions in themselves and others. This process requires
the interrelated development and interconnection of mul-
tiple maturing neural circuits across the brain, including
the DMN. The areas of the brain involved in emotional
regulation also interact heavily with the areas involved in
executive function.40,46,47 Child emotional development is
CTAR BOOK.indb 6
important for the individual’s own future and for social
functioning across a variety of environments in which
they will live, play, and interact with others. Just as more
complex communication skills are scaffolded onto less
complex ones, more complex emotional skills depend
on the foundation of earlier, more basic skills.
Young children are capable of intense emotions across
the spectrum, from anger to elation and sadness to hap-
piness. Responsive caregiving helps a child recognize
and regulate these extreme emotions. For children living
with significant parental conflict, outright violence, or a
caregiver who is unattuned and unresponsive, emotional
development can be derailed because of the body’s stress
responses. The brain circuitry for emotional development
and regulation can be altered, sometimes to the point that
it becomes the tinder for current and future mental health
problems. Research now demonstrates that traumatic
experiences in childhood are strong predictors of later
psychiatric illness.9,36,48–50
Mental Health
The foundations of emotional and behavioral health are
built in childhood.40 Significant mental health problems
occur in young children, including anxiety, depression,
and attention-deficit/hyperactivity disorder.51 Some are
caused by the impact of trauma on the young brain, while
others may have a strong genetic component. A preexisting
genetic vulnerability to stress, moreover, can increase the
negative impact of childhood traumatic experiences on
long-term mental health outcomes.52–54
The quality of relationships in early childhood is impor-
tant for lifelong mental health because it is within these
relationships that the child’s sense of self and of self in rela-
tion to others develops (see Chapter 3, Attachment) and
the foundations of emotional and behavioral regulation
are established. The lack of at least one safe, nurturing
relationship that is stable over time in a child’s life is likely
to negatively affect multiple neural circuits involved in
cognition, language, social skills, and emotional and
behavioral regulation. As we discuss in later chapters,
young children have a very limited capacity to recover
from adversity in the absence of nurturing caregiving.
In young children, it can also be challenging to determine
whether a given behavioral or developmental concern
represents a transient difference in maturation that will
resolve or a more significant problem or a delay in develop-
ment. Young children process emotional experiences and
adverse events differently than older children, teens, and
adults, which adds to the complexity.40,45 In pediatrics, we
also depend on the caregivers of young children to report
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Part 1—Chapter 1. Brain Development: Early Childhood Through Adolescence
their concerns and provide an accurate history. Because
extreme stress or trauma is consistently associated with an
increased risk of developing psychiatric conditions, includ-
ing depression, anxiety, and posttraumatic stress disorder,49
it is important to respond when emotional and behavioral
development are off track and to consider all the potential
causes, from genetic to environmental, including adversity
and trauma.
Trauma in the earliest years, in the absence of protective
buffering, has the most profound impact on neurodevelop-
mental outcomes. It changes the lower-level neural circuits
in ways that can become permanent, essentially embed-
ding the traumatic experiences into brain architecture
and function. While the traumatized brain may retain
some plasticity, it does not process information in the
way it would have had there been exposure to a more
typical environment early in life.40
Although our understanding of the development of differ-
ent types of psychopathology is in its infancy, evidence
is mounting that different mental health diagnoses are
associated with specific brain circuits.55 The timing of
the stressors in child development may affect the type
of psychopathology that ensues and/or its severity.2,56 For
example, in one retrospective analysis of a large adolescent
database, Marshall reported that trauma during early
adolescence was likelier to be associated with an anxiety
disorder, while trauma during grade school was likelier
to be associated with depression.49 Sadly, risk factors
often come in clusters (eg, poverty, parental mental health
problems, exposure to violence, chaotic caregiving), so we
often have to intervene on multiple fronts simultaneously.
However, intervention is critical because of the brain’s
plasticity; identifying potential risk factors and inter-
vening early can shift the short- and long-term
trajectories for the better.
Executive Function Is Built Into
Brain Architecture
The ability to regulate one’s emotions and behaviors is one
of the executive functions, all of which develop over time,
beginning in infancy and becoming more complex and
mature throughout childhood and adolescence and into
young adulthood.57 Executive functions include several
major skill areas: working memory, inhibitory control,
maintaining attention, and cognitive flexibility (Box 1-2).
They help us, for example, organize information, layer
more complex learning onto more fundamental learning,
self-monitor, modulate our behaviors, maintain attention,
and prioritize.
CTAR BOOK.indb 7
7
Box 1-2. Major Skill Areas of
Executive Function
1. Working memory, or the ability to hold information in mind
in the short term and use it
2. Inhibitory control, or the ability to sustain attention and
manage thoughts and impulses, to think before acting,
and to stay on task despite distractions
3. Cognitive flexibility, or the ability to adjust to changing
demands or priorities
4. Regulation of emotions and behavior
Executive function skills develop in our attachment rela-
tionships and then in other relationships as we mature.
Caregivers initially provide these functions for their infants
but then model and teach them to their children through
play and games, chores, and schoolwork. Adults help chil-
dren learn simpler tasks and skills and eventually allow
the child to engage in them independently; in the process,
children learn to layer more complex skills onto simpler
foundational ones over time. Children practice these func-
tions over and over so that by adolescence, they become
largely independent and able to organize, prioritize, and
manage a variety of tasks and activities.58–60 Once again,
more complex skills are layered or scaffolded onto less
complex skills as children mature.57
Since brain structures have to be built to realize specific
skills, a child’s experiences at each stage of development
should be appropriate to that stage. Experiences tailored
to age and stage of development have unique and powerful
impacts on brain growth and development.1 As children
mature, through exploration and play they may be able to
learn skills for which their cognitive and emotional devel-
opment is ready. Vygotsky described the “zone of proximal
development” of the child as the distance between achiev-
ing skills that they are “close” to mastering and those
requiring the guidance and encouragement of a skilled
partner—whether parent, caregiver, educator, or coach—
to learn.61 Ideally, a child’s experiences during early child-
hood are of sufficient quality to promote optimal brain
development based on their genetic blueprint. Early learn-
ing lays the foundation for later learning. Children learn
the ABC song and sequence long before they recognize let-
ters and their sounds; later they learn to write and string
letters together to form words. Just like reading, the ability
to engage in more sophisticated and varied experiences and
learning later in life is built on early developmental skills.62
One of the major implications for educators and caregivers
is the importance of engaging children in a variety of activ-
ities that stimulate and balance cognitive, language, social,
and emotional development.57 Since specific brain circuits
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 8
CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
develop at relatively specific ages, activities that promote
development of specific skills should be age appropriate.
The developmental trajectory for executive functions is
long, and the development of these skills remains possible,
if more challenging, well into adulthood. This creates
opportunities at each age and stage of development, even
into adulthood, to provide specific age-appropriate activi-
ties to develop these executive function skills.57 Reading
out loud, peekaboo, and hiding games are appropriate for
infants and merge into conversations, imitation games,
storytelling, and songs with gestures in toddlers. By the
preschool years, children are able to engage in imaginary
play, tell stories, match and sort, and do increasingly com-
plex puzzles. Children 5 to 7 years of age can engage in
board games, play that requires turn taking and quick
responses, early sports activities, and logic and reasoning
games. Children 7 to 12 years old are capable of engaging
in music lessons and in games involving strategy and
planning ahead, organized sports, and brainteasers. In
adolescence, setting goals; planning; self-monitoring;
engaging in sports, music, and art of greater complexity;
and organizing tasks and events are among the many
activities that build executive function skills.
Attention to executive function as a set of learned skills
is very important since these skills can be modeled,
taught, practiced, and celebrated throughout childhood
and adolescence. While familial trauma is associated
with poorer child performance on a battery of executive
function tests compared to that of similar children who
experienced either trauma that occurred outside the family
setting or no trauma,63 executive function skills can con-
tinue to be taught and developed even in those who have
endured early childhood adversities and trauma.21
Because the brain is highly integrated, changes in one
pathway will likely affect other neural circuits. In early
childhood, large areas of the brain responsible for higher-
order functions, such as executive function, have barely
begun to mature, so there is substantial opportunity to
change the course of child development. However, some
plasticity of neural circuits persists throughout life, allow-
ing for some recovery of brain capacities, even in adults.1
Any such recovery requires an intentional focus on skills
to reactivate the key neural circuits.14
CTAR BOOK.indb 8
Summary
Brain development proceeds from simple to complex, based
on our genetic blueprint and in response to our experiences
and environment. Different brain circuits develop at vari-
ous ages in a predictable sequence, beginning with sensory
systems. Circuits that are used continue to develop and
grow and make connections. There are sensitive periods,
when specific circuits are rapidly maturing, when appro-
priate inputs are necessary for typical development. Once
a circuit matures, it may remain somewhat malleable but
require more intensive inputs to adapt. Early childhood,
puberty, and adolescence are times of rapid brain growth,
connectivity, and development and therefore times of
both great opportunity and great vulnerability. Some
brain structures and related functions (social-emotional
regulation and executive functions) mature throughout
childhood and adolescence and even into adulthood.
On the basis of what we know about the importance of
brain development, the implications for early care and
nurturance of children are clear. Children need safe, stable,
nurturing, responsive caregiving in their young years and
throughout childhood and adolescence along with expo-
sure to a variety of age-appropriate typical activities and
resources to achieve optimal brain development. As pedia-
tricians, we can promote responsive, nurturing parenting
and exposure to typical activities; screen early and often for
achievement of age-appropriate developmental milestones,
including social-emotional development; and encourage
involvement in high-quality child care and early childhood
education. For children falling behind a typical develop-
mental trajectory, we can refer for early developmental
support services as soon as we identify an issue.
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13. Kuhl PK. Early language acquisition: cracking the speech code.
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14. Knudsen EI. Sensitive periods in the development of the brain and
behavior. J Cogn Neurosci. 2004;16(8):1412–1425 PMID: 15509387
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16. Pascalis O, de Haan M, Nelson CA. Is face processing species-specific
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23. Brennan PA, Pargas R, Walker EF, Green P, Newport DJ, Stowe Z.
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24. Gunnar MR, Quevedo KM. Early care experiences and HPA axis
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26. Smyke AT, Koga SF, Johnson DE, et al; BEIP Core Group. The
caregiving context in institution-reared and family-reared infants
and toddlers in Romania. J Child Psychol Psychiatry. 2007;48(2):210–218
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27. Daw NW. Critical periods and strabismus: what questions remain?
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28. Giedd JN, Rapoport JL. Structural MRI of pediatric brain
development: what have we learned and where are we going? Neuron.
2010;67(5):728–734 PMID: 20826305
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29. Sowell ER, Peterson BS, Thompson PM, Welcome SE, Henkenius AL,
Toga AW. Mapping cortical change across the human life span.
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30. Sowell ER, Thompson PM, Tessner KD, Toga AW. Mapping
continued brain growth and gray matter density reduction in dorsal
frontal cortex: inverse relationships during postadolescent brain
maturation. J Neurosci. 2001;21(22):8819–8829 PMID: 11698594
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31. Giedd JN, Snell JW, Lange N, et al. Quantitative magnetic resonance
imaging of human brain development: ages 4–18. Cereb Cortex.
1996;6(4):551–559 PMID: 8670681
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32. Blakemore SJ, Burnett S, Dahl RE. The role of puberty in the
developing adolescent brain. Hum Brain Mapp. 2010;31(6):926–933
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33. Supekar K, Musen M, Menon V. Development of large-scale
functional brain networks in children. PLoS Biol. 2009;7(7):e1000157
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34. Gogtay N, Giedd JN, Lusk L, et al. Dynamic mapping of human
cortical development during childhood through early adulthood.
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35. Goddings AL, Mills KL, Clasen LS, Giedd JN, Viner RM, Blakemore SJ.
The influence of puberty on subcortical brain development.
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https://doi.org/10.1016/j.neuroimage.2013.09.073
36. Whittle S, Dennison M, Vijayakumar N, et al. Childhood maltreatment
and psychopathology affect brain development during adolescence.
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37. Xie X, Mulej Bratec S, Schmid G, et al. How do you make me feel better?
Social cognitive emotion regulation and the default mode network.
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38. Stevens MC, Pearlson GD, Calhoun VD. Changes in the interaction
of resting-state neural networks from adolescence to adulthood.
Hum Brain Mapp. 2009;30(8):2356–2366 PMID: 19172655
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39. Callard F, Margulies DS. What we talk about when we talk about
the default mode network. Front Hum Neurosci. 2014;8:619–631
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
40. National Scientific Council on the Developing Child, Center
on the Developing Child at Harvard. Children’s emotional
development is built into the architecture of their brains.
Working paper 2. 2004
41. Thompson RA. Development in the first years of life. Future Child.
2001;11(1):20–33 PMID: 11712453
https://doi.org/10.2307/1602807
42. Denham S. Emotional Development in Young Children.
Guilford Press; 1998
43. Fogel A. Developing Through Relationships: Origins of
Communication, Self, and Culture. University of Chicago Press; 1993
44. Yale Center for Emotional Intelligence. RULER. Accessed
February 22, 2021.
https://www.rulerapproach.org
45. National Research Council, Institute of Medicine Committee on
Integrating the Science of Early Childhood Development. From
Neurons to Neighborhoods: The Science of Early Childhood Development.
Shonkoff JP, Phillips DA, eds. National Academies Press; 2000
46. Davidson RJ, Lewis DA, Alloy LB, et al. Neural and behavioral
substrates of mood and mood regulation. Biol Psychiatry.
2002;52(6):478–502 PMID: 12361665
https://doi.org/10.1016/S0006-3223(02)01458-0
47. Posner MI, Rothbart MK. Developing mechanisms of self-regulation.
Dev Psychopathol. 2000;12(3):427–441 PMID: 11014746
https://doi.org/10.1017/S0954579400003096
48. Bluhm RL, Williamson PC, Osuch EA, et al. Alterations in default
network connectivity in posttraumatic stress disorder related to
early-life trauma. J Psychiatry Neurosci. 2009;34(3):187–194
PMID: 19448848
49. Marshall AD. Developmental timing of trauma exposure relative to
puberty and the nature of psychopathology among adolescent girls.
J Am Acad Child Adolesc Psychiatry. 2016;55(1):25–32.e1
https://doi.org/10.1016/j.jaac.2015.10.004
50. Busso DS, McLaughlin KA, Brueck S, Peverill M, Gold AL, Sheridan
MA. Child abuse, neural structure, and adolescent psychopathology:
a longitudinal study. J Am Acad Child Adolesc Psychiatry.
2017;56(4):321–328.e1
https://doi.org/10.1016/j.jaac.2017.01.013
51. Egger HL, Angold A. Common emotional and behavioral disorders
in preschool children: presentation, nosology, and epidemiology.
J Child Psychol Psychiatry. 2006;47(3–4):313–337 PMID: 16492262
https://doi.org/10.1111/j.1469-7610.2006.01618.x
52. Belsky J, Pluess M. Beyond diathesis stress: differential susceptibility
to environmental influences. Psychol Bull. 2009;135(6):885–908
PMID: 19883141
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53. Pluess M, Belsky J. Differential susceptibility to rearing experience:
the case of childcare. J Child Psychol Psychiatry. 2009;50(4):396–404
PMID: 19175816
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54. Bouvette-Turcot AA, Fleming AS, Wazana A, et al; MAVAN Research
Team. Maternal childhood adversity and child temperament: an
association moderated by child 5-HTTLPR genotype. Genes Brain
Behav. 2015;14(3):229–237 PMID: 25688466
https://doi.org/10.1111/gbb.12205
55. Teicher MH, Samson JA, Anderson CM, Ohashi K. The effects of
childhood maltreatment on brain structure, function and connectivity.
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56. Strathearn L, Giannotti M, Mills R, Kisely S, Najman J, Abajobir A.
Long-term cognitive, psychological, and health outcomes associated
with child abuse and neglect. Pediatrics. 2020;146(4):e20200438
PMID: 32943535
https://doi.org/10.1542/peds.2020-0438
57. Activities guide: enhancing and practicing executive function skills with
children from infancy to adolescence. Center on the Developing Child at
Harvard. Accessed February 22, 2021.
www.developingchild.harvard.edu
58. Best JR, Miller PH. A developmental perspective on executive function.
Child Dev. 2010;81(6):1641–1660 PMID: 21077853
https://doi.org/10.1111/j.1467-8624.2010.01499.x
59. Bunge SA, Wright SB. Neurodevelopmental changes in working memory
and cognitive control. Curr Opin Neurobiol. 2007;17(2):243–250
PMID: 17321127
https://doi.org/10.1016/j.conb.2007.02.005
60. Casey BJ, Getz S, Galvan A. The adolescent brain. Dev Rev.
2008;28(1):62–77 PMID: 18688292
https://doi.org/10.1016/j.dr.2007.08.003
61. del Río P, Álvarez A. Inside and outside the zone of proximal
development: an ecofunctional reading of Vygotsky. In: Daniels H,
Cole M, Wertsch JV, eds. The Cambridge Companion to Vygotsky.
Cambridge University Press; 2007:276–304. Accessed February 22, 2021.
https://psycnet.apa.org/doi/10.1017/CCOL0521831040.012
62. Center on the Developing Child at Harvard. Building the brain’s
“air traffic control” system: how early experiences shape the
development of executive function. Working paper 11. 2011
63. DePrince AP, Weinzierl KM, Combs MD. Executive function
performance and trauma exposure in a community sample of
children. Child Abuse Negl. 2009;33(6):353–361 PMID: 19477515
https://doi.org/10.1016/j.chiabu.2008.08.002
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 CHAPTER
2
Promoting Resilience
Relationships Are Essential
The definition of resilience has evolved over time but is now
perhaps best understood as “the capacity of an individual
or family (or system) to adapt successfully to challenges
that threaten its function, survival or future development.”1
Human resilience, instead of being viewed as a static trait,
is best viewed as a dynamic, evolving process that develops
over time and, while rooted in genetic potential, is pro-
foundly responsive to caregiving, culture, experiences, and
other environmental factors. The capacity for adaptation
develops over time and is greatly influenced by the avail-
ability of supportive relationships in the environment at all
stages of development, even though some innate capacities,
such as cognitive abilities and persistence, promote positive
adaptation. For the newborn and infant, the most immedi-
ate relationship is that with their parent or other caregiver,
and the most immediate environment is their home. How-
ever, parents are also individuals, with their own resilience
skills, who depend on their relationships and the environ-
ments they navigate every day. Resilience is thus complex
and dynamic; it is ever-changing as we grow and develop
and our environments shift and new challenges and sup-
ports arise. Familiarity with resilience promotion through
the ages and stages of childhood creates a framework for so
much of the work we as pediatricians do with families and
children; it is the foundation of trauma-informed care
because its focus is on relationships, hope, and building
self-efficacy and self-regulation.
Ordinary Magic
Resilience research actually began in earnest shortly
after World War II, as researchers explored why certain
individuals had good outcomes despite highly traumatiz-
ing experiences. However, in their search for traits that
11
CTAR BOOK.indb 11
bestowed apparent “invulnerability” on such individuals,
researchers instead discovered that resilience does not
result from extraordinary traits or talents. Rather, research
on early brain development, attachment, and resilience
demonstrated that resilience is the typical way of things for
a child when certain promotive and protective factors are
in their environment. In fact, in Masten’s sentinel paper,
“Ordinary Magic,”2 she says that, for children, resilience
develops in the give-and-take of safe, stable, and nurturing
relationships that are continuous over time, beginning with
the first relationship between newborn and parent immedi-
ately after birth and growing through play, exploration, and
exposure to a variety of normal activities and resources.
Thus, she coined the term “ordinary magic” to describe the
positive power of everyday relationships and experiences
on human development.
Researchers have, over decades, compiled a brief list
of resilience factors that are common across cultures
and countries for children, although there are nuances
in how different people and cultures nurture and pro-
mote resilience.3 Fortunately for us pediatricians, they
are factors that we are familiar with and promote in our
practices every day (Box 2-1) and they overlap with those
promotive and protective factors described independently
by researchers in developmental psychology.1,6,7
Researchers have described individual, family, and
community factors associated with the development
of resilience in individuals.4 While secure attachment
to a safe, stable, nurturing caregiver is the foundation,
it is important to consider other factors that can also
be strengthened to improve the probability of resilient
outcomes. These characteristics are summarized in
Box 2-1.
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide

Box 2-1. Characteristics, Conditions, and

THREADS
Supports That Favor Resilience1,4,5 We have rearranged the individual-level resilience factors
Individual characteristics and developed the acronym THREADS (Figure 2-1) to
• Temperament: is easygoing, evokes positive responses represent the elements that weave together the fabric of
from others
a resilient human being.
• Innate intelligence

THREADS
• Secure attachment to safe, stable, nurturing caregiver
• Self-reliance, self-efficacy; can take positive action in own life
• Self-regulation
• Optimism, hope, faith Elements of Resilience
• Self-concept: has sense of self and of self in relation
with others Thinking and learning brain
Good coping skills
Hope
• Good health Regulation or self-control
• Internal motivation Efficacy
• Mastery of age-salient developmental tasks Attachment
Positive family conditions Developmental skill mastery
• Authoritative parenting style: supportive, warm, responsive,
firm, rational, consistent
Social connectedness
• Stimulating environment
• Safe, stable, responsive caregiver
• Maternal (caregiver) expression of positive emotion
• Family structure
• Family cohesion
• Supportive parent-child interactions
• Stable and adequate income
Effective community supports
• Early prevention and intervention programs
• Neighborhood safety
• Support services relative to needs in community
• Recreational facilities, libraries and similar programs
• Access to adequate health services
• Religious and spiritual organizations
Figure 2-1. THREADS represents the elements of resilience.
• Effective culture
• Economic opportunities for families
Attachment: The Warp THREAD on the Loom
The fundamental underlying foundation of the resilience
factors for any child is having a safe, stable, nurturing
relationship with at least one caregiver who is continuous
over time in their life.5,8–10 This is described in the litera-
ture as the child’s primary attachment relationship and
creates the foundation and context in which all the other
resilience factors or skills emerge over time. In fact, the
primary attachment relationship is so vital to healthy
child development that it should be thought of as the warp
thread on the loom—that is, the thread shaping and pro-
viding structure and pattern to the final product. We
discuss the role of attachment relationships more fully
in Chapter 3, Attachment, and consider in later chapters
how we as pediatricians can support and nurture primary
attachment relationships to prevent, ameliorate, and treat
the impact of trauma on children and their caregivers.

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Cultural Considerations
Even though the resilience factors highlighted in the
THREADS acronym are common across cultures and
countries, we must bear in mind that cultural variations
affect their actualization. While having a safe, nurturing
caregiver who is continuous over time is vital to every
child, culture defines the details of how families provide
that nurturance and care, their expectations for child
behavior, the relative roles of primary caregivers in car-
ing for the child, and how children are socialized to adapt
to and fit into their culture. (See Chapter 5, Cultural
Connections.)3 For pediatricians practicing in a multi-
cultural world, it is important to partner with families to
understand the meaning of parenting and attachment in
their culture and lives, their strengths, and how they, in
and through their culture, nurture a child’s resilience.
Three Basic Questions of Resilience Research
Resilience research has been shaped over time by 3 core
questions. The first is What are the risks or challenges the
individual has faced or is facing that threaten survival or
well-being? Early resilience research was focused on risk
factors and identified trauma, maltreatment, neglect,
poverty, war, family or neighborhood violence, hospitali-
zation, and natural disasters as some of the major risks
threatening resilience.11,12 The Adverse Childhood
Experiences study identified cumulative intrafamilial
adversities, including various forms of maltreatment and
family dysfunction, that can lead to poor outcomes in a
dose-dependent manner throughout the life course.13,14
The dose of adversities (severity, frequency, and timing)
accruing in the short or long term matters. Risk factors for
poor outcomes also usually occur in bundles (eg, poverty
and neighborhood violence). The available buffers, or
protective and promotive factors and positive childhood
experiences, also matter.15,16
A crucial feature of adverse childhood experiences (ACEs)
is that the adversities are all intrafamilial; that is, child
maltreatment, impaired caregiving, and family violence
are threats occurring in the child’s immediate and most
important environment, their family. In this way, they
are traumas occurring within the primary attachment
relationship, breaching the most fundamental protective
factor any child has. This type of trauma is sometimes
referred to as “relational trauma” to differentiate it from
other single-event or extrafamilial traumas.17 Other
stressors have been found to be as impactful as the
original ACEs, including felt discrimination, being
CTAR BOOK.indb 13
13
Part I—Chapter 2. Promoting Resilience
bullied, having a foster care history, and being exposed to
community violence.18 Foster care history may not only be
a marker for prior childhood trauma but also reflect the
additional trauma of removal from family and the familiar,
as well as the endemic uncertainty and further disruptions
that often occur in foster care. Some populations are at
higher risk of experiencing adversity and trauma (eg, those
who experience discrimination because of racial/ethnic heri-
tage, immigration status, poverty, LGBTQ identity, or foster
care status), but many still have good outcomes because of
adequate buffering in their home environment.19–24
The second question about resilience relates to how an
individual adapts to or is affected by stressors. Children’s
well-being is often described in terms of their develop-
mental abilities, physical health, growth, emotional and
behavioral health, academic functioning, and quality of
peer relationships. For adults, other measures such as
employment, educational achievement, socioeconomic
status, caregiving, health behaviors, intimate relation-
ships, and happiness are considered. Resilience, briefly,
is construed as adaptive success on selected measures
despite past adversities. Of course, children can be resil-
ient in some areas of adaptive function (eg, academics)
and less resilient in others (eg, social skills).17
Finally, research has focused on what factors support
successful adaptation to adversities, bringing us back
to the protective and promotive factors noted in the
THREADS acronym. Children are not born resilient
but develop resilience in the contexts of relationships and
experiences. The THREADS have been shown to explain,
at least in part, why some people recover and even thrive
after adversities. Supportive and positive family and rela-
tional characteristics, along with community, societal, and
cultural factors, are the basic adaptational mechanisms
that promote the development of individual resilience.
Neurobiological processes explain how unbuffered trauma
becomes biologically embedded, exerting its impact at
molecular, genetic, cellular, and organ levels, ultimately
leading to the body and brain symptoms we encounter in
individuals. Since resilience develops over time, it must,
like trauma, also become biologically embedded because
of protective and promotive factors leading to healthy or
typical human development.
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
Dose, Timing, and Genetic Potential
Five decades of research on resilience has demonstrated
that the cumulative dose and types of adversities matter,
and so, too, does the cumulative dose of protective and
promotive factors.3,5,7,25–27 This finding has tremendous
implications for pediatric care and public health.28–30 As
pediatricians, we often meet children and their families
shortly after birth (or even before) and, thus, have the
opportunity to understand what parents bring to child-
rearing, their risks and challenges, their burden of trauma,
their strengths and resources, and their goals for their
family.31 In the context of our relationship with parents,
we have the opportunity to guide and inform, to help
them build good caregiving skills, to provide insight
into their child’s development and behavior, and to
link them to needed supports.
The timing of adversities in a child’s development is
crucial, since there are windows of opportunity in which
brain development is more rapid and specific developmen-
tal skills emerge.5,16,32 This issue is explored more fully in
Chapter 1, Brain Development: Early Childhood Through
Adolescence. In 2012, the American Academy of Pediatrics
published a landmark policy statement on toxic stress,15
which provides pediatricians with a way to think about
the impact of stress and buffering by relationships. At one
end of the spectrum, the authors describe milder stressors
as being promotive of and even essential for learning and
healthy development. However, the frequent, intensive,
more prolonged traumas that occur in the absence of safe,
stable, responsive caregiving are defined as being toxic
because they can overwhelm a child’s capacities and under-
mine healthy development by altering the brain circuitry
supporting certain crucial skills. For example, maternal
depression may lead to less responsive caregiving at a
time when the brain is relying on an interactive “serve-
and-return” relationship between parent and child to
promote optimal development of certain neural pathways.
Unless other caregivers in the environment are able to fill
this need, or the mother receives appropriate treatment,
the infant’s inability to get their needs met stimulates a
stress response that manifests initially as increased crying
and irritability but that, unabated, can evolve into insecure
attachment behaviors and even failure to thrive if severe
enough. As pediatricians, we are developmental experts
and, thus, are well positioned to identify for parents what
children need at various developmental ages and stages.
For children, whose brains and immune systems are rapidly
growing and developing, the environment is crucial—from
the quality of caregiving to the stressors affecting and the
supports available to their family, from the safety of their
CTAR BOOK.indb 14
home and neighborhood to the quality of child care and
education, and from the access to clean water and healthy
food to the recreational resources.5,33 Some individuals
appear to have more genetic resistance to stress than
others. This is termed the differential biological sensitivity
to context.34 Children with more genetic resistance to
stress can do well in a variety of different environments,
while children who are more sensitive to stress may thrive
in enriched environments but wilt in more deprived or
hostile ones. Being more sensitive to context is not a
weakness, since, in a nurturing context, it can become
a “superpower.” But any child’s capacities for resilience
can be overwhelmed with enough stressors and a dearth
of buffering from caregiving adults, resulting in the symp-
toms we encounter when the THREADS of resilience are
FRAYED, a topic discussed in more detail in Chapter 7,
How Trauma Can Manifest in Children and Teens.
Implications for Pediatric Practice
Medical care has historically taken a problem-focused
approach in which the underlying question is “What is
wrong with you?” so the medical practitioner can help
heal or fix the problem. A resilience-informed perspective
on child health and well-being suggests instead a partner-
ing approach that understands the context of individual
families and children and identifies and reinforces child
strengths and talents and those of their caregivers and
families.30,35 It is an approach that nurtures promotive
and protective factors, while ameliorating risks and
mobilizing resources that can improve outcomes.36 It is
child focused, family centered, and relationship building.
As noted by Traub and Boynton-Jarrett,29 pediatricians
can promote resilience by increasing promotive and pro-
tective factors for children at every encounter. The Center
on the Developing Child at Harvard37 summarizes the
following 3 principles for improving outcomes for
children and families:
1. Prevention: Identifying and reducing risk factors;
however, prevention also involves identifying and
leveraging strengths.
2. Ameliorating the impact of trauma that has occurred.
3. Treating and managing symptoms in the pediatric
setting and/or engaging community and mental
health resources.
Prevention is a vital activity of pediatricians. We do it
every day as part of anticipatory guidance in primary care.
Resilience promotion requires an intentional focus on the
quality of the parent-child relationship and promoting
safe, stable, nurturing caregiving; positive parenting
skills; and child and parent resilience in each and every
5/16/21 2:54 PM

encounter (see Chapter 4, Parenting).28,38 As an example,
we can, in addition to screening for developmental mile-
stones, screen for or ask about assets, strengths, and resil-
ience. Messages, of course, must be tailored to the child’s
age and stage of development. For example, we can
explain “serve and return” and its importance in infant
brain development to parents of newborns, and we can
discuss attuned, attentive, reflective listening with parents
of adolescents. We can encourage at least short periods of
parent time-in with their child each day that is focused
on a child-led activity. We can explain the links between
child behavior, emotions, and thinking because behaviors
tell us something about thinking and emotions. We can
identify risk factors that might adversely affect caregiving
and/or child development and alert parents or link families
to resources that might reduce the risk (ie, quality child
care, early childhood education). Resilience promotion is
prevention, and it is the foundation of care even after
risks have been identified, exposure to trauma has
occurred, or symptoms have developed.
Many children have risk factors or trauma exposure but no
symptoms, while others have mild symptoms that can be
managed in the pediatric primary care setting. Secondary
prevention, ameliorating the impact of childhood trauma
after exposure, is an important pediatric intervention. In
addition to resilience promotion as described earlier in
this section, we will need to identify when exposure has
occurred (see Chapter 10, Surveillance and Screening),
understand the impact of trauma on the developing child
or adolescent (see Chapter 7, How Trauma Can Manifest in
Children and Teens), and provide simple psychoeducation
to the child and/or family regarding the impact of trauma.
Some of the work we do is to support the caregiver in build-
ing their own resilience and regulation so they can be more
available to their child. An empathic, motivational inter-
viewing style coupled with using the family’s language to
explore issues can create the emotional safety that families
and children need to share concerns if and when they arise.39
We will be able to treat some families in the practice
setting, while others, depending on symptom severity,
may benefit from referral for trauma-informed mental
health or evidence-based treatment, if it is available.
Finally, some children will manifest more concerning
symptoms after trauma exposure, depending on a variety
of factors: the nature, severity, and frequency of the trauma;
baseline resilience; age and stage of development; caregiver
support; and family stressors. Managing childhood trauma
symptoms includes a variety of strategies that are discussed
in much further detail in Part 3, Promoting Recovery From
Trauma. We address the language we use to explain the
impact of trauma, in order to reassure the child that they
CTAR BOOK.indb 15
15
Part I—Chapter 2. Promoting Resilience
will get better and that their reaction to trauma is a normal
response to one or more abnormal experiences. We discuss
how to help parents understand their child’s response to
trauma in ways that provide the parents with simple30 yet
important things to do to help their child; for example,
reassure the child that they are safe, establish routines,
and co-regulate with the child (see Chapter 11, Pediatric
Management). We discuss ways to build on protective
factors by supporting the attachment relationship, improv-
ing the quality of parenting, and building on self-efficacy
and self-regulation. We offer approaches to focusing on
family and child strengths by mobilizing community and
other resources to meet basic needs such as having food
and housing, having access to child care, engaging with the
school, and others. And we discuss evidence-based treat-
ment and trauma-informed mental health care, which are
tertiary prevention (see Chapter 14, Integrated Care).
Ultimately, trauma-informed care requires consideration
of how we train health care professionals, design health
systems, and pay for health care to build the infrastructure,
skills, and care that can improve outcomes for children and
families. Trauma- and resilience-informed care is primary,
secondary, and tertiary preventive care that can improve
the trajectories of families and children before, during,
and after trauma. If we can reduce the impact of adversity
on children, the cost savings in health care alone will be
substantial and will be augmented by improved outcomes
for children, families, and society. The path to improved
health outcomes later in the life course begins with invest-
ment now in childhood, adolescence, and families.
Summary
Understanding the basics of resilience can provide pedia-
tricians with the framework we need to nurture healthy
development, even in the face of adversity and trauma.
Overall, pediatricians are perfectly positioned to prevent,
identify, ameliorate, and initiate treatment of childhood
trauma. We can play a major role in translating the science
of resilience into the lived experience of children and fami-
lies in ways that support safe, stable, nurturing relationships
and, thus, promote a child’s healthy development, their
sense of self-efficacy, and their regulation of emotions and
behavior. We can also advocate in our communities for
programs that we know reduce and mitigate stressors,
promote child and family resilience, and ameliorate the
impact of trauma when it occurs. As we hone our own
knowledge and skills, we can educate the next generation
of pediatricians about this important work. Finally, we
must impress on payers and government entities the
importance of this work and the potential cost savings
to the individual, families, payers, and society as a whole.
5/16/21 2:54 PM
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
References
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resilience: past, present, and future research. Ann N Y Acad Sci.
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13. Felitti VJ. Adverse childhood experiences and adult health.
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15. Garner AS, Shonkoff JP, Siegel BS, et al; American Academy of
Pediatrics Committee on Psychosocial Aspects of Child and
Family Health; Committee on Early Childhood, Adoption, and
Dependent Care; and Section on Developmental and Behavioral
Pediatrics. Early childhood adversity, toxic stress, and the role of
the pediatrician: translating developmental science into lifelong
health. Pediatrics. 2012;129(1):e224–e231 PMID: 22201148
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16. Shonkoff JP, Garner AS, Siegel BS, et al; American Academy of
Pediatrics Committee on Psychosocial Aspects of Child and Family
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The lifelong effects of early childhood adversity and toxic stress.
Pediatrics. 2012;129(1):e232–e246 PMID: 22201156
https://doi.org/10.1542/peds.2011-2663
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17. Treisman K. Working With Relational and Developmental
Trauma in Children and Adolescents. Routledge; 2017
18. Finkelhor D, Shattuck A, Turner H, Hamby S. Improving
the Adverse Childhood Experiences study scale. JAMA Pediatr.
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https://doi.org/10.1001/jamapediatrics.2013.420
19. Linton JM, Green A; American Academy of Pediatrics Council on
Community Pediatrics. Providing care for children in immigrant
families. Pediatrics. 2019;144(3):e20192077 PMID: 31427460
https://doi.org/10.1542/peds.2019-2077
20. American Academy of Pediatrics Council on Community
Pediatrics. Poverty and child health in the United States.
Pediatrics. 2016;137(4):e20160339
https://doi.org/10.1542/peds.2016-0339
21. Trent M, Dooley DG, Dougé J. The impact of racism on child
and adolescent health. Pediatrics. 2019;144(2):e20191765
https://doi.org/10.1542/peds.2019-1765
22. Baams L. Disparities for LGBTQ and gender nonconforming
adolescents. Pediatrics. 2018;141(5):e20173004 PMID: 29661940
https://doi.org/10.1542/peds.2017-3004
23. Maclean MJ, Sims S, Bower C, Leonard H, Stanley FJ, O’Donnell M.
Maltreatment risk among children with disabilities. Pediatrics.
2017;139(4):e20161817 PMID: 28264988
https://doi.org/10.1542/peds.2016-1817
24. Szilagyi MA, Rosen DS, Rubin D, Zlotnik S; American Academy
of Pediatrics Council on Foster Care, Adoption, and Kinship Care;
Committee on Adolescence; and Council on Early Childhood.
Health care issues for children and adolescents in foster
care and kinship care. Pediatrics. 2015;136(4):e1142–e1166
https://doi.org/10.1542/peds.2015-2656
25. DuMont KA, Widom CS, Czaja SJ. Predictors of resilience in
abused and neglected children grown-up: the role of individual
and neighborhood characteristics. Child Abuse Negl.
2007;31(3):255–274 PMID: 17386940
https://doi.org/10.1016/j.chiabu.2005.11.015
26. Ioannidis K, Askelund AD, Kievit RA, van Harmelen AL. The
complex neurobiology of resilient functioning after childhood
maltreatment. BMC Med. 2020;18(1):32 PMID: 32050974
https://doi.org/10.1186/s12916-020-1490-7
27. Khambati N, Mahedy L, Heron J, Emond A. Educational and
emotional health outcomes in adolescence following maltreatment
in early childhood: a population-based study of protective factors.
Child Abuse Negl. 2018;81:343–353 PMID: 29793149
https://doi.org/10.1016/j.chiabu.2018.05.008
28. Vu C, Rothman E, Kistin CJ, et al. Adapting the patient-centered
medical home to address psychosocial adversity: results of a qualitative
study. Acad Pediatr. 2017;17(7)(suppl):S115–S122 PMID: 28865642
https://doi.org/10.1016/j.acap.2017.01.014
29. Traub F, Boynton-Jarrett R. Modifiable resilience factors to
childhood adversity for clinical pediatric practice. Pediatrics.
2017;139(5):e20162569 PMID: 28557726
https://doi.org/10.1542/peds.2016-2569
30. Hassink SG. Reclaiming the patient encounter. Acad Pediatr.
2017;17(7)(suppl):S12–S13 PMID: 28865643
https://doi.org/10.1016/j.acap.2016.08.008
31. Bethell C, Gombojav N, Solloway M, Wissow L. Adverse childhood
experiences, resilience and mindfulness-based approaches: common
denominator issues for children with emotional, mental, or behavioral
problems. Child Adolesc Psychiatr Clin N Am. 2016;25(2):139–156
PMID: 26980120
https://doi.org/10.1016/j.chc.2015.12.001
32. Blair C, Raver CC. Poverty, stress, and brain development:
new directions for prevention and intervention. Acad Pediatr.
2016;16(3)(suppl):S30–S36 PMID: 27044699
https://doi.org/10.1016/j.acap.2016.01.010
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33. Bowlby J. A Secure Base: Parent-Child Attachment and Healthy
Human Development. Basic Books; 1988
34. Belsky J, Bakermans-Kranenburg MJ, van IJzendoorn MH. For
better and for worse: differential susceptibility to environmental
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https://doi.org/10.1111/j.1467-8721.2007.00525.x
35. Marsac ML, Kassam-Adams N, Hildenbrand AK, et al. Implementing
a trauma-informed approach in pediatric health care networks.
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36. Hagan JF Jr, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for
Health Supervision of Infants, Children, and Adolescents. 4th ed.
American Academy of Pediatrics; 2017
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37. Cohen SD. 3 Principles to Improve Outcomes for Children and
Families. Center on the Developing Child at Harvard University;
2017. Accessed February 23, 2021.
http://developingchild.harvard.edu
38. Shah R, DeFrino D, Kim Y, Atkins M. Sit Down and Play: a preventive
primary care-based program to enhance parenting practices.
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https://doi.org/10.1007/s10826-016-0583-6
39. Miller WR, Rollnick S. Motivational Interviewing: Helping People
Change. 3rd ed. Guilford Press; 2013
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 CHAPTER
3
Attachment
In Chapter 2, Promoting Resilience, the attributes of resil-
ience were organized into the THREADS (Thinking and
learning brain, Hope, Regulation or self-control, Efficacy,
Attachment, Developmental skill mastery, and Social
connectedness). Even though attachment is in the middle
of the THREADS list, it is the warp thread on the loom—
the fundamental thread that is the context in which all
the other resilience factors develop over time. A secure
attachment relationship with at least one safe, stable,
nurturing caregiver over time enables the development
of all the other resilience factors.1–3 In fact, without it,
the others are very difficult to achieve.
What Is Attachment?
Attachment theory was first developed by John Bowlby,
who described attachment as a “lasting psychological
connectedness between human beings.”4 In trying to
understand separation anxiety in infants, he observed
that attachment of infant to caregiver involved a desire
for closeness to the caregiver, distress after separation,
and joy upon reunion.5 Attachment theory holds that a
competent, responsive primary caregiver enables the child
to develop a sense of security so that the infant comes to
view the caregiver as dependable. The caregiver essentially
creates a secure base from which the infant can begin to
explore the world, knowing that the caregiver will be
there, able to comfort them in times of distress. Bowlby
eloquently stated that the “infant and young child should
experience a warm, intimate and continuous relationship
with his mother (or permanent mother-substitute) in
which both find satisfaction and enjoyment” because it
is essential to the child’s mental health.4 A secure attach-
ment relationship with a safe, stable, nurturing caregiver
also underlies and promotes typical development and
healing from trauma.6–8
A child’s primary attachment figure is almost always their
parent or parents. The attachment relationship of child to
caregiver begins at birth as the newborn and parent make
eye contact, and the newborn hears the voice of, is fed by,
and experiences the gentle, soothing touch of their parent.
The parent holds the infant, gazes at them, coos at them,
19
CTAR BOOK.indb 19
and smiles. The infant initially gazes back but eventually
begins to make sounds and smile back. We call this back-
and-forth that develops “serve and return,” the beginning
of the dyadic “conversation” that is formative in building
the child’s sense of self and forming the template for future
relationships. The primary attachment relationship is the
“secure base” from which the child explores the world,
including the world of relationships.9 It evolves over time
but is constant in that the parent “keeps the child’s mind
in mind” and the child at the center of their relationship
in ways that nurture the child’s internal security.6 Parents
who are emotionally available, attuned, and responsive to
the child’s needs are likelier to have a child who is securely
attached and can move forward to build positive relation-
ships with peers and other adults. The secure attachment
relationship of an infant with a safe, stable, nurturing care-
giver is the context in which sense of self, developmental
mastery, a healthy thinking and learning brain, self-
regulation, and self-efficacy develop and are achieved.10,11
In other words, the primary attachment relationship is the
context in which the other THREADS of resilience are
built and woven together into a resilient human being.
The attachment relationship, in providing care and protec-
tion, helps the infant begin the long process of developing
self-regulation skills.9,12–14 Think about the image that pops
into your head when you encounter the word attachment.
It may be of a caregiver holding or soothing an infant.
When an infant is distressed, they turn to the caregiver.
In healthy relationships, the caregiver responds with
empathy appropriate to the distress and needs of the child.
The responsive caregiver effectively provides the child a
sense of security, shutting down the child’s physiological
stress response and restoring emotional regulation during
times of distress.
Another way of explaining what the caregiver does
is attunement, which literally means “bringing into
harmony.” Feldman and others describe the biological
underpinnings of “bio-behavioral synchrony” through
which the biology (autonomic reactivity, affiliative hor-
mones like oxytocin, and activation of brain circuits)
underlying and affecting parent behaviors (eg, sensitivity
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
to infant cues) promotes physiological changes that underly
responsive attachment behaviors in the infant. Researchers
have measured the variable physiological changes that occur
in mothers and infants when comparing care by synchro-
nous, intrusive, and depressed mothers in mother-child
dyads.15 For synchronous mothers, the caregiver is “in tune”
with the child, whether or not the child is distressed, and
provides support that matches the child’s needs in tempo,
rhythm, and volume. In contrast to synchronous mothers,
researchers note that intrusive or depressed mothers are
only intermittently in tune with their infants and do not
consistently support or respond to their child in ways
that match the child’s needs.
In the care of synchronous caregivers, the child learns
over time to expect an empathic, in-tune response from
their caregiver and to trust that their caregiver is predict-
able and will take care of their needs. The child begins
to develop internal working models of self and the world
through this ongoing interaction with a responsive, nur-
turing caregiver.13 The mental health literature refers to
this as “psychological holding,” an image mirroring the
physical act of cradling, protecting, and providing secu-
rity.16 We can also think of this as the caregiver’s capacity
to mentalize, or hold the child’s mind in mind.6 As Allen
writes, “security in attachment relationships is the best
means of regulating emotional distress.”6
The caregiver’s ongoing predictable compassionate avail-
ability ultimately leads the infant to form a secure attach-
ment relationship with their caregiver and teaches the
infant that their caregiver and the world are predictable.
Ironically, dependence on a caregiver begins the process
of fostering effective independence in the child.
Role of the Caregiver as a Secure Base
In a secure attachment relationship, the child attaches to
a caregiver who is stable in the child’s life over time and
offers responsive nurturance. The caregiver provides safety
and predictable compassionate availability to the child, and
the child comes to view the caregiver as being predictable
and trustworthy. Caregivers soothe the distressed infant
and meet their needs for protection, nutrition, and inter-
action. Caregivers become the secure base from which the
infant learns to explore their world and relationships.6,9 It is
not the infant’s role to calm the caregiver’s stress response
or to provide the caregiver with a sense of security. In fact,
when caregivers confuse those roles and seek comfort from
their child, the relationship is an unhealthy one and may
result in a child who becomes adept at meeting the emo-
tional needs of others but who never learns how to identify
and/or meet their own needs.6
CTAR BOOK.indb 20
Children can form different types of attachment relation-
ships with the caregivers in their lives.17 If one caregiver
is safe, stable, and nurturing and the other is chaotic and
unpredictable, the infant may develop a secure attachment
to the former but an insecure attachment style with the
latter.6 (See Chapter 13, Supporting the Caregiver.)
By using animal models, Bowlby9 and others propose
that the attachment system has been naturally selected
by evolution because it favors the survival of the child
and promotes typical human development, while, in
caregivers, the brain’s universal reward circuits are acti-
vated.7,10,13,18–20 Animal models are beginning to elucidate
the neurobiology of attachment, indicating that the quality
of caregiving in combination with the individual genetic
makeup of offspring can determine stress response system
function through epigenetic mechanisms. Thus, good
enough parenting in a stable attachment relationship
can “program” adaptive mechanisms, such as the stress
response system, in ways that promote physical and
mental health and social well-being.13
Secure Attachment
Secure attachment is the most critical baseline skill for
building or rebuilding resilience. All the other resilience
skills develop in the context of secure attachment to a
competent caregiver and the supports the attachment
relationship provides. Resilience skills come on line as
the child matures; this process extends beyond early child-
hood into early adulthood for some skills, such as executive
function and emotional regulation. The foundation of
resilience begins with secure attachment to a competent
caregiver and builds over time. We can envision the devel-
opment and sustainment of resilience as a series of upward
steps, with attachment as the first step on the staircase of
resilience (Figure 3-1). These skills can be challenged and
reinforced throughout life in day-to-day activities, relation-
ships, and challenges. Thus, children and adults move up
and down these stairs to some extent every day, but attach-
ment is the base supporting all the others. Even as adults,
we turn to our attachment relationships whenever our
own resilience is challenged.6,11,21
We shall now look at how resilience is built a step at a time.
5/16/21 2:54 PM
 21
Part I—Chapter 3. Attachment

Case Example

Donna is a pediatrician in a busy and
chronically underserved area. Most days,
she finds the interactions with her patients
to be rewarding and the stressors of billing,
charting, and keeping up with administra-
tive issues to be intense but manageable.
She is the mother of 4 active and healthy
children ranging in age from 9–16 years
old, and her spouse has a busy career (not
in medicine) as well. After a particularly
stressful day, one including having to admit
a teen for suicidal ideation, having to con-
tact child welfare about belt marks she
found on a 4-year-old, and being told by
her administrator that she was not meet-
ing “meaningful use” criteria in 3 areas
of her electronic medical record (EMR)
charting, she arrives home 2 hours later
than she had planned. She feels wiped
out, overwhelmed, and frustrated.
At this point, the resilience skills of hope
and optimism have been challenged by the
traumas of her patients and the seemingly
unending demands of the EMR that day.
That loss of hope then raises questions for
Donna about her own efficacy, or ability
to influence her patients’ lives or practice
effectively. Without her usual sense of hope
and efficacy, she feels powerless and dys-
regulated. When her 16-year-old asks,
“What’s for dinner?” Donna snaps back,
“Really? I left all the ingredients for tacos
out and no one could have thought about
getting those done? That’s my job too?”
Donna has fallen down the steps on the
staircase of resilience. Her spouse, coming
in just at that moment, would not be wise
to suggest that Donna clearly needs to read
a book about the EMR or child abuse to go
back up the steps of resilience at this point.
It would be much more effective to provide
the attachment supports of safety and
predictable compassionate availability,
look at the situation with Donna’s mind
in mind, and remain calm, helping Donna
re-center herself. Her spouse suggests
that she must have had a long day and
that the kids and he would be happy to
work on getting dinner ready while she
goes for a run. Feeling supported and
able to discharge some of the frustra-
tion with a run, Donna returns in a more
regulated state. After eating and telling
the family about some of the day’s events,
she feels she can manage to change how
she charts in the EMR and can think again
about the more hopeful visits she had
this week with other patients. With the
support provided by her spouse, her
primary attachment figure, Donna has
been able to regulate, use her thinking
and learning brain to develop more
efficacy, and recover her hope and
optimism for the future.

Attachment, the bottom step, supports the development mastery of developmental tasks ensues, leading to a sense
of all the other resilience factors. Early regulation or self- of self-efficacy so that one comes to view the future with
control (the next step) skills are learned in the attachment a sense of hope. The primary attachment relationship is
relationship, in which the caregiver initially soothes the also the template for future relationships because within
child and then co-regulates with the child. When the stress this relationship, we first develop a sense of self in relation-
response is dampened, cognitive development and the ships with others. This then becomes the foundation for
social connectedness,
which can be thought
of as the railing on the
staircase. As we form
other positive attach-
SS ment relationships with
DNE HOPE
TE extended family and with
NEC
N friends and neighbors, we
L CO
CIA develop a social network.
SO
EFFICACY
• Developmental skill mastery
• Thinking and learning brain

REGULATION

ATTACHMENT

Figure 3-1. The staircase of resilience. Attachment is the foundational step in building resilience.

CTAR BOOK.indb 21 5/16/21 2:54 PM

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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide

Secure attachment results when a caregiver provides some
very specific emotional supports in their relationship with
their child. We can summarize these aspects of competent
parenting that promote secure attachment, typical develop-
ment, resilience, and healing from trauma in the acronym
SEAM (Table 3-1). SEAM stands for Safety, Emotional con-
tainer, Availability that is predictable and compassionate,
and Mind in mind. We return to the SEAM concepts over
and over again in this book as we discuss how pediatricians
can nurture the attachment relationship to promote
resilience and healing from trauma.
The foundation of resilience is secure attachment to a care-
giver who is able to provide safety and security, provide
predictable compassionate availability, be an “emotional
container” during times of child distress, and keep the
child’s mind in mind. This relationship provides care that
enables the child to build self-regulation skills, build a sense
of self-efficacy, and understand the self and the self in rela-
tion to others. SEAM, as illustrated in Figure 3-2, supports
the child’s attachment to their caregiver.

Table 3-1. Using SEAM to Promote Secure Attachment

SEAM Competent caregiving behaviors
Safety The caregiver provides physical and psychological safety for the child through responsive care,
supportive words, establishing routines, flexibility, soothing, and reassurance.
Emotional container The caregiver is able to remain calm and focused on the infant’s/child’s needs when
they are distressed. The parent in effect is helping dampen the child’s stress response
and helping them regulate. This implies that the caregiver has good self-regulation.
(See Chapter 13, Supporting the Caregiver.)
Availability The caregiver is consistent and predictable, yet flexible, warm, responsive, and empathic toward
(predictable compassionate availability) the infant/child so that the child knows what to expect and that care is dependable.
Mind in mind The caregiver is able to “hold the child’s mind in mind,” to essentially “psychologically hold” the
child. This mentalizing is the foundation of “serve and return,” the responsive, caring back-and-
forth between an attuned caregiver and an infant/child that helps the child understand their own
emotions. Moreover, when the child is distressed, the caregiver can identify the child’s distress
and respond accordingly.

Regulation

Secure attachment because

caregiver provides
• Safety and security
• Emotional container
• Availability (predictable
compassionate availability)
• Mind in mind
Figure 3-2. SEAM supports the development of secure attachment of the
child to the caregiver.

CTAR BOOK.indb 22 5/16/21 2:54 PM


Let us now look at each aspect of SEAM in a bit more detail.
Safety (physical, emotional, and psychological) and
a sense of security are primary features of the secure
attachment relationship.6,9,13 The caregiver’s ability to
soothe the infant in times of distress effectively shuts down
the infant’s stress response. The attachment figure protects
the child from predators or the things that would harm the
child. Grief on separation causes the child to cry and alerts
the caregiver to return to protect the child. The safe harbor
a child experiences in a predictable relationship creates
a secure base from which they can explore their world.
Picture the toddler in a playground moving away from the
caregiver to investigate their surroundings but occasionally
turning to check back. Sometimes they venture a bit farther
but then return to the caregiver for reassurance, before once
again returning to play, perhaps calling out to the caregiver,
until the day of play is done. The Circle of Security,22,23 first
described in 2006, is an intervention shown to improve
child attachment security by increasing caregiver attune-
ment and improving parenting capacities.
Emotional container is a term used to describe how care-
givers with good self-regulation skills and the ability to
empathize with their child (or keep their child’s mind in
mind) understand that a display of strong emotions by
their child is usually not about them as a caregiver, even if
directed at them. Such caregivers are able to remain calm
in the face of a child’s storm—to essentially serve as an
emotional container to hold the child’s distress. In tolerat-
ing the child’s strong emotions, caregivers are helping the
child regulate. In infancy, the caregiver soothes the child,
which dampens the infant’s stress response and, in the
process, models regulation as the caregiver contains the
child’s emotions.24 As the child matures, the parent con-
tinues to use these skills to co-regulate with the child, help-
ing them identify and modulate emotions. The caregiver
provides the child words for emotions, offers empathy, and
problem-solves with the child. Eventually, the child learns
to identify, modulate, manage, and express their feelings
as their emotional self-regulation skills mature. At the
other extreme, a dysregulated adult finds it very difficult to
hold the child’s mind in mind and serve as the emotional
container for the child, leaving them at a disadvantage in
developing this skill set.6,25 (See the larger discussion of
caregiver self-regulation in Chapter 13, Supporting
the Caregiver.)
Availability of the caregiver that is predictable and
compassionate (or what is termed predictable compassion-
ate availability in the literature) describes the measured,
consistent responses reliably provided by a caregiver who
is able to look at the world from the child’s perspective
and interpret the world for the child, while keeping their
CTAR BOOK.indb 23
23
Part I—Chapter 3. Attachment
mind in mind. The caregiver is attuned, responsive, and
predictable and able to recognize and respond with com-
fort to a child’s distress. By anticipating empathy from the
caregiver, the child becomes confident in turning to their
caregiver for comfort in times of distress.
As Allen explains, mind in mind describes the abilities of
a safe, stable, nurturing caregiver to attune to the child.6
As the caregiver offers empathy to the child and reflects
their feelings and emotions back to them, the child develops
a sense of self. Just as we learn to speak by being spoken to,
we learn to understand ourselves and our emotions by hav-
ing responsive caregivers attune to our emotions in a caring,
compassionate manner. A child essentially develops their
sense of self and comes to know their own mind because
caregivers define it for them in the attachment relationship.
Because the mother is holding the child’s mind in mind, she
is able to integrate compassion and caring into an empathic
expression of sadness, while using a soothing voice and
gentle holding to calm the child. A mother does not just
mirror a child’s frustration but overlays it with empathy and
understanding, by showing the infant what they feel, not
what their mother feels; in turn, the infant comes to learn
what the emotion is and is soothed as their needs are met.
In fact, the ability of the caregiver to keep the child’s mind
in mind is critical to all the steps in resilience building.6
Attachment Styles
Secure Attachment Style
In the attachment relationship, the child develops internal
working models that are essentially maps of the self and
others. These representations, like maps, can be more or
less accurate or they can be distorted.6,26 In the context of
a safe, nurturing caregiver who is stable over time in the
child’s life, the child comes to view the caregiver as being
loving and dependable and themselves as being lovable and
worthy of care. The secure attachment relationship is one
in which the caregiver displays sensitive responsiveness,
warmth, and affection and is attuned to signs of the child’s
distress. Feldman15 notes that parents promote newborn
attachment through their behaviors and attunement, by
using the modalities of gaze, affect, touch, and vocalization.
The parent who is in synchrony with the infant interprets
the child’s affect and emotions accurately and responds
appropriately, promptly, and predictably. The caregiver
engages in their child’s activities in ways that are coopera-
tive and helpful, without interfering. The child perceives
the caregiver as being predictable and nurturing. In the
context of a responsive, attuned, stable caregiver, the
child learns how to regulate their emotions, which enables
their thinking and learning brain to develop; mastery of
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
age-appropriate developmental tasks ensues. The secure
attachment relationship is one in which the bottom
stair of the staircase of resilience is solid and secure.
(See Figure 3-3.)
However, if the caregiver is unpredictable in their responses,
overtly hostile, inconsistently available, or rejecting, the
child lacks a secure base for exploration. Unless there are
other caregivers in the child’s environment who can provide
the safe, stable nurturance the child needs, the child is likely
to develop one of 3 insecure attachment styles: ambivalent
(or ambivalent resistant, also described in the literature as
“anxious”), avoidant, or disorganized attachment style.
This has profound implications for development and future
relationships with peers, romantic partners, and one’s
own children.
When caregivers display unpredictable or inappropriate
responsiveness, children respond in one of 2 ways. They
can try harder to get what they need from the caregiver
who is inconsistent, which potentially leads to an ambiva-
lent (or anxious) attachment style, or they can just give
up, which leads to an avoidant attachment style.
Ambivalent Attachment Style
In ambivalent (or anxious) attachment, the child’s efforts to
communicate their needs to their caregiver are met with
inconsistent responses. The child keeps trying but only
Regulation
Secure attachment because
caregiver provides
• Safety and security
• Emotional container
• Availability (predictable
compassionate availability)
• Mind in mind
Figure 3-3. The development of secure attachment. A solid, dependable
bottom stair allows the child to climb to the next step of skill building.
CTAR BOOK.indb 24
sometimes elicits the support they need, and often un-
predictably.6,26 In the face of an inconsistently responsive
caregiver, such as a caregiver with substance use disorder
who lacks psychological attunement, a child may intensify
their signs of distress and angry protests (tantrums) to
force attention and responsiveness. The infant becomes
increasingly insistent, a demanding strategy that works
only sometimes. The attachment style becomes ambiva-
lent because the desire for care is frustrated by an incon-
sistently available caregiver. Both the caregiver and the
child develop resentment. The caregiver, preoccupied
with their own needs (if using substances or focused else-
where because of mental health issues such as depression
or overwhelming stress), comes to resent the child for
their seemingly intrusive demands. The child, frustrated
by and angry with the inconsistent, preoccupied caregiver,
eventually comes to resent them for not caring enough. If
you consider our stair analogy, the bottom step is shaky.
Children are not sure whether support will be provided
when needed, because it sometimes is and sometimes
isn’t. It is consistently inconsistent. (See Figure 3-4.)
Avoidant Attachment Style
The avoidant attachment style most often develops when
caregivers are rejecting. The rejecting behavior may be
subtle or overt; caregivers may even try to suppress how
they feel toward their child. Caregivers with mental illness
or substance use disorder may be averse to body con-
tact, irritated by the child’s demands, rigid, or compul-
sive. They may not want to be interrupted by the infant;
they may become frustrated quickly when the infant
does not adhere. Avoidance is a response to the care-
giver who is consistently emotionally unavailable or
to the caregiver who feels irritable and communicates,
“Don’t bother me with your needs.” The child’s efforts
to regulate are unsupported, and the child is forced to
regulate alone, by depending on their own resources.
In the stair analogy, there is no bottom step, so there
is no one but oneself to turn to for regulating.6,26
(See Figure 3-5.)
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Part I—Chapter 3. Attachment

Regulation

Ambivalent attachment:
caregiver intermittently
supportive
• S : Unpredictably responsive
• E : Inconsistent self-modulation
• A: Inconsistently available and
compassionate; unpredictable
• M: Unpredictable, empathy limited
Figure 3-4. Ambivalent attachment style. The bottom stair is shaky and unable to
support the child, who will have a difficult time making it to the next step on the
staircase of resilience.

Regulation

Avoidant attachment:
caregiver rejecting or
not available to child
• S : Child feeling unsafe,
no secure base
• E : Parent rigid or rejecting
• A: Caregiver not attuned,
available, or compassionate
• M: Lack of attunement
Figure 3-5. Avoidant attachment style. With a missing bottom stair, the child has
no clear path to the later steps.

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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
Disorganized Attachment Style
Finally, in some cases of parental mental illness and/or
child abuse, the caregiver is either frightened or frightening
and misreads the child’s cues, which leads to disorganized
attachment. The caregiver may be overwhelmed or overly
intrusive or hostile so that the child is fearful and tries to
escape the caregiver. This fear is always superimposed onto
another predominant attachment style (secure, avoidant, or
ambivalent). In these relationships, the most basic strategy
children usually use for reducing fear, seeking the care-
giver, only exacerbates the fear, so the child then has no
way to resolve their fear. Disorganized attachment is
described as “fright without solutions.”6,26 The caregiver
not only responds inappropriately to the child but causes
the child fear, making relationships something to actively
reject. The term “attachment trauma” is sometimes applied
when the trauma occurs in the attachment relationship
and undermines the child’s capacity to develop a secure
attachment relationship and is most often applied to chil-
dren with this attachment style. In our stair analogy, the
attachment step (ie, the caregiver) is present but dangerous
and injurious and the relationship is to be avoided and/or
sabotaged. (See Figure 3-6.)
Regulation
Disorganized attachment:
caregiver frightening or
dangerous
• Safety and security
• Emotional container
• Availability (predictable
compassionate availability)
• Mind in mind
Figure 3-6. Disorganized attachment. The bottom stair, or attachment
figure, is a hazard to the child, severely affecting their ability to form a
secure attachment relationship.
CTAR BOOK.indb 26
Impact of Childhood Attachment Styles on Later
Adult Relationships and Caregiving
The various attachment styles that develop in response
to caregiving styles have implications for a child’s relation-
ship with their caregivers, for their development, for their
future relationships as adults, and, ultimately, for how they
will parent their own children.3,6,12,27,28 (See Table 3-2.)
However, it is wise to bear in mind that attachment styles
are associations, not destiny.
Parallel Processing: How Pediatricians Promote
Secure Attachment Relationships
Sandra Hassink, MD, describes the power of engaging the
caregiver and/or youth in a relationship as the beginning
of healing in pediatric encounters.29 It is in an “optimal
encounter,” characterized by attuned listening, compas-
sion, a dyadic and strengths-based approach, mutual com-
munication, and alignment, that we have the opportunity
to make positive change. The core of trauma-informed care
is in fact relationship-based care that promotes caregiver-
child attachment by modeling it and intentionally promot-
ing and supporting parenting behaviors that reinforce the
child’s sense of safety and secure attachment behaviors.
In this model of care, the pediatrician provides a secure
base for the stressed caregiver to help them modulate their
own emotional distress so they can in turn help their child.
In this process of mentalizing, the pediatrician holds the
caregiver’s mind in mind, in turn helping the caregiver
do the same for the child.6 Zuckerman further describes
a process of promoting parental self-insight and self-
understanding to nurture the parent-child relationship.30
Infants quickly become astute observers of their care-
givers’ behaviors and respond accordingly. Not all parents/
caregivers are “naturals” at parenting, because of a host of fac-
tors (eg, their own experiences as children, life stressors
that may overwhelm and distract them, chronic illness,
use of medications or substances that impair judgment
and responsiveness). Thus, part of our job as health pro-
fessionals, whether at the front desk or in the exam room,
is to attune to the caregiver and child to create a safe zone
in which we can help caregivers assess and explore their
own parenting and their relationship with their child.
This is essentially a parallel process in which we model
the secure base that we hope caregivers will provide their
children. The provider-parent “attachment” relationship
is the most powerful tool we have to promote wellness in
the parent-child relationship. We discuss this further in
relation to helping children and families heal from
trauma in Chapter 8, Engagement.
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Part I—Chapter 3. Attachment

Table 3-2. Child Attachment Styles and Their Potential Consequences in Childhood and Adulthood
Attachment Impact on Impact on relationships Impact on
type child development in adulthood caregiving
Secure • Good self-regulation of emotional Forms secure attachments • Sensitively responsive
distress with others and on own • Comfortable in • Consistently emotionally
• Easygoing relationships available
• More socially competent • Comfortable with
• Empathic and caring depending on partner
and having partner
• More positive relationships
depend on them
• Curious and persistent in
problem-solving
• Seeks help when needs it—achieves
effective dependence
Ambivalent • More anxious and easily frustrated As an adult, forms preoccupied Displays ambivalent behavior
(or anxious) • Passively helpless and excessively attachments toward offspring
dependent • Fears rejection from partner • Inconsistent
• Difficult to soothe • Strong desire to maintain • Varies in emotional regulation
• Less able to perform well in novel closeness • Inconsistently available and responsive
situations • Overreacts to ordinary • Poorly attuned
events
Avoidant • Most isolated As an adult, displays dismissive Displays rejecting or avoidant
• Tends to direct attention away from behavior behavior toward offspring
parent to environment • Low levels of closeness, • Rejects infant’s attempt to seek
• Tends to be hostile and emotionally affection, and commitment comfort when infant is distressed
insulated; rejects help • Cuts self off emotionally • Unemotional with infant
• May bully and exploit ambivalent from others; self-sufficient OR
children loner
• Intrusive, controlling, and
• Lack of emotional awareness • Low expectations of others overstimulating
• Most disliked
Disorganized: • Disorganized behavior that can be As an adult, displays Displays disorganized behavior
superimposed onto short-lived and hard to discern; may disorganized behavior toward offspring
one of the 3 dominant cling to parent while avoiding parent’s • Fears intimacy or • Frightened or frightening behavior
styles; most often gaze; may shrink from parent in fear vulnerability
encountered when
• Dissociative states
• Dissociated, dysregulated, or • Little empathy for others • Hostile intrusiveness (mocking infant)
parent is maltreating dramatically contradictory
or neglectful behavior
• Does not understand or fearful withdrawal (being silent)
boundaries • Emotionally overwhelmed by
• Extreme rage or anger child’s distress
responses • Role confusion and contradictory
• Can be controlling cues (encouraging closeness while
physically withdrawing)
• Disabled caregiving or abdication
of care
Derived from Allen JG. Restoring Mentalizing in Attachment Relationships: Treating Trauma With Plain Old Therapy. American Psychiatric Publishing; 2013.

Promoting secure attachment relationships is work that is
part and parcel of pediatrics.29,31,32 It permeates everything
we do, although we may not think of it in that context.
We begin at the prenatal or newborn visit by teaching
parents what to expect. We remind them that their new-
born is born ready to engage and learn. Pediatrics is a
two-generation approach rooted in the sciences of attach-
ment, child development, and resilience. We create an
emotionally and physically safe setting characterized by
empathy and partnership. We strive to understand the
context of the child and family, including their culture.
No matter the issue, we offer hope for improvement or
recovery in support of children and families. While we
offer this same approach of care to all families, some care-
givers need little from us, while others require us to be
more intentional in assessing their needs and their rela-
tionship with their child and in approaching their care.
This dyadic approach is true for children and families
facing virtually every type of stressor, from small to over-
whelming. Indeed, for some families, even an apparently
small stressor has a large impact.

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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
Provide Empathy to the Child and Caregiver
Empathy is the ability to see the world as the other sees it,
to see them as they see themselves, and to lay aside external
perceptions. Empathy implies positive regard, which is
acceptance, affirmation, caring, warmth, and the valuing
of another person as an individual. It is characterized by
congruence, or genuineness and authenticity. It involves
putting aside constrained professionalism and behaving
more naturally. Attuned, attentive listening is one way
we project empathy to the caregiver or patient, by helping
them feel “heard.” Empathy helps reduce caregiver and
patient distress. In the parallel processing framework,
we model the empathy the parent should provide for the
child.6,29 In pediatric settings, we often do this by validat-
ing how challenging parenting is, the caregiver’s obvious
concern for the child, and that the caregiver wants the best
for the child. We may also model empathy for the child.
For example, we may turn to and focus on the child, asking
what happened at school right before they became so upset.
We can use our attuned, attentive, empathic listening
skills to hear that another child called them a name. We
may then validate how much being bullied hurts and how
humiliating or degrading it is and affirm that the bully is
dealing with problems in their own life by creating prob-
lems for others. Then, we can work on some ways to handle
bullies, reinforcing that the child’s caregiver has to address
the bullying issue with the teacher and principal, who in
turn should ensure that the bullying child receives help and
the behavior stops. In responding empathically to both, we
model skills the caregiver can use to help the child.
Form a Partnership With the Caregiver and Child
Partnership involves recognizing that, while we are experts
in health, prevention, child development, and parenting,
the caregiver is the expert in their child and family. This
approach empowers the caregiver and, coupled with
empathy, enables us to form a care partnership with
the caregiver on behalf of the child.
Elicit Caregiver or Patient Concerns
We begin most visits with families by eliciting a chief
concern that the caregiver, or the child (if older), brings
to us. This should be done early in the visit because it
prioritizes the caregiver’s or child’s agenda, which is basic
to partnering. Using an open-ended, nonjudgmental inter-
viewing style characterized by attentive, attuned, reflective
listening helps create a safe space for caregivers and chil-
dren to share what has happened or is happening in their
lives. Through active, attuned, and reflective listening,
and guiding the conversation to explore concerns, we are
more likely to gain a genuine understanding of child and
CTAR BOOK.indb 28
family perspectives.33 While this approach is helpful for
any health issue, it is of profound importance—for both
the caregiver and the child—when we are addressing
childhood trauma and adversity. One of the ways we
can help caregivers and children feel heard is to reflect
back to them what we have heard them say by using their
words and verifying that we have heard them correctly
(ie, “reflective listening”).
Identify Strengths of the Caregiver, Child,
and Relationship
Every child and family, no matter how distraught, vul-
nerable, or challenging, has strengths. If we are to engage
caregivers and children on a journey toward healing, it is
incumbent on us to identify these strengths. One approach
is to simply ask the caregiver what strengths they see in
their family and child. Another is to actively notice and
Case Example
Two-month-old Kiran is in for a visit with her parents, who state
that they are a bit exhausted by Kiran’s crying. Both parents
are worried that there is something seriously wrong with Kiran
since she cries for hours every evening, even after being fed and
changed. Other times, she seems perfectly all right. After ask-
ing a number of questions, Dr Welby is fairly certain that Kiran
has colic. Dr Welby pauses, though, to say, “I heard you say that
you think there is something seriously wrong with Kiran.” The
parents both nod. “And I hear that you are exhausted, as any
parent would be after 6 weeks of having their baby screaming
in the evenings.” Dr Welby has now acknowledged their ex-
haustion, and normalized it, and, again, there is agreement.
“You also told me that Kiran seems perfectly all right except in
the evenings.” The parents by now feel “heard” because Dr
Welby has reflected back what she has heard and has conduct-
ed a careful examination that is normal in findings, comment-
ing, as she goes, on how healthy Kiran looks and how good her
interval growth and development are. Dr Welby has also noted
how loving and attentive the parents are and how well Kiran
is responding to them. The foundation has now been laid to
reassure the parents that Kiran has colic, in order to discuss
how challenging colic is since infants with it may not respond
to all of our soothing and calming measures. It is important to
emphasize that Kiran is doing very well because they are such
great parents and so attuned to her, to review what has
worked for the crying even if only momentarily, to suggest
ideas they may not have tried, to suggest some parental self-
care measures, to remind them they can call with concerns,
and to offer to follow up with them to make sure that the
crying abates over the next month as expected.
then comment on them. Sometimes, saying something
as simple as “I can see that you love your child and want
the best for them” can create the space for conversation or
healing to begin. The strengths or resilience factors we help
parents identify are the foundation that they, in partner-
ship with us and others, will build on to help their child.34
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Validate Concerns and Provide Confident
Expectation for Recovery
When a caregiver who has been up all night with a toddler
comes to the medical professional frightened and con-
cerned that there is something very wrong with the child,
the professional listens, validates the worry and challenges
of caring for a child in pain, examines the child, and
perhaps diagnoses an illness. Validation of the parent’s
concern is a key step that we engage in whether the prob-
lem is a physical, developmental, behavioral, or emotional
symptom. This is especially important for building trust in
our relationships with parents and children after trauma
has occurred and provides the context in which we can
then diagnose and offer advice and treatment.
We also offer parents our confidence in their abilities to
help their child and in the expectation their child will
recover. In the most recent case example, we expect the
2-month-old with colic to improve by about the age of
3 months and reassure the parents of that timeline. Our
confident expectation of recovery provides safety and
security for the caregiver, reducing their stress response
and allowing them to also feel confident that their child
will recover. The parent is then better able to manage the
child’s pain, distress, and fear and to calm the child. This
pattern applies to all sorts of diagnoses and is part of even
our simplest interactions with families. And we shall see
that trauma is no exception.
The medical professional has the opportunity to offer hope
and promote attachment at every visit. We can project to
the caregiver a confident expectation that they can do this
work and support their child. In the case of trauma, we will
intentionally use these same skills (promoting attachment
and confidently expecting recovery) to help caregivers help
the child recover. When this confident expectation for
recovery is supported, the caregivers can then project
it to the child.
Teach or Reinforce Specific Evidence-Based
Positive Parenting Skills
All evidence-based parenting education programs adhere
to similar major principles of parenting, all of which have
relevance to healing from trauma since healing has to
occur in a child’s attachment relationships. Evidence-
based parenting programs all promote competent parent-
ing skills, parental self-control (eg, emotional regulation,
emotional container), self-care, positive self-regard, and
having a support network. While skills building is often
focused on child behavioral management, these programs
CTAR BOOK.indb 29
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Part I—Chapter 3. Attachment
also promote viewing the world from the child’s perspec-
tive and building relationship skills. Effectively applying
these skills promotes a secure attachment relationship
between parent and child. For a more detailed discussion of
evidence-based parenting skills, see Chapter 4, Parenting.
We can reinforce positive parenting skills in a few power-
ful ways during each visit with families. First, we can
notice and say what is going well. Perhaps the mother of
a newborn, even while speaking with us, frequently turns
her face to regard her infant, whom she is holding tenderly.
Just noticing that the mother is behaving in this way
and commenting on her attunement and how her infant is
responding can reassure her and reinforce this crucial skill.
We can also remind the same mother that she knows her
child better than anyone and can probably already tell
when her child is sleepy, hungry, or ready to engage.
Another skill we can use in pediatric settings is offering
simple choices. For children who are old enough, we can
ask them which ear they would like us to examine first or
which arm they would prefer their immunization in. For
parents, we can offer them the choice of holding their tod-
dler or standing next to them at the exam table. This skill
supports partnering and reinforces a sense of self-efficacy.
In pediatrics, we are in general attuned to using such
teachable moments.35,36 While noticing and commenting
might seem very basic, it is reassuring to the caregiver and
creates an opportunity to use the moment for teaching. In
the instance of the attuned mother, we can talk about the
importance of serve and return—that beautiful, attuned,
responsive back-and-forth between mother and infant that
is building the infant’s sense of self, their trust in their care-
giver, the architecture of their brain, and templates for
healthy relationships. Teachable moments arise frequently
during encounters with families, while we are observing
the interaction between caregiver and child, taking the
history, and conducting the examination. After noticing
these moments, we can seize them as opportunities to
build the attachment relationship and reinforce parenting
skills. For example, to turn simple choices into a teachable
moment, we can say, “Offering simple choices is some-
thing you can do at home. It builds a child’s competence
and confidence.”
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CHILDHOOD TRAUMA & RESILIENCE: A Practical Guide
Summary
A secure attachment relationship develops in the care
of a safe, stable, nurturing, responsive caregiver who has
empathy for the child and is able to hold the child’s mind in
mind. It is in this relationship that all the other resilience
skills are built (hope, self-efficacy and autonomy, mastery
of developmental tasks, growth of a thinking and learning
brain, and self-regulation of behaviors and emotions),
along with the individual’s sense of self and an understand-
ing of self in relation to others. While we often think about
the importance of the primary attachment relationship for
the infant and toddler, this relationship remains a source of
security and safety for the child throughout childhood and
adolescence and into young adulthood. Understanding the
elements of secure attachment and how we promote it in
encounters with families to promote optimal child develop-
ment is fundamental in pediatrics. We already do a lot
of this every day in practice. In upcoming chapters, we
come to understand that the attachment relationship is
the context in which healing from childhood trauma has
to occur and how our intentional dyadic approach to pro-
moting secure attachment reduces the impact of trauma
on the child and parent and promotes recovery.
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Another random document with
no related content on Scribd:
 Toujours, il pensait à ce fils que sa femme ne lui donnait pas, à
ce fils qu’il désirait si obstinément pour que son nom se perpétuât,
pour que la famille continuât de régner sur la Maison.
Lorsqu’il parlait maintenant de cet enfant, ce n’était plus, comme
naguère, avec attendrissement, mais avec nervosité, irritabilité. Très
vite, il devenait amer et même, parfois, proférait une menace :
— Je te dis que je veux un garçon, un Rabier… et que je
l’aurai !… De toi ou d’une autre !… Si tu ne te décides pas, un de ces
jours, j’en fais un à la première venue… et je le reconnais ! Alors, on
verra bien !…
Mme Mireille était meurtrie. Mais, se rappelant ce que lui avait
prédit Casi en regardant palpiter la flamme de la bougie, elle restait
inébranlable dans sa décision de n’accepter jamais plus la maternité.
Et ce n’était pas tout : une fois encore, les affaires périclitaient.
Si l’on ne pouvait dire que cette situation fût imputable à M.
Adolphe, du moins s’expliquait-elle par la présence constante d’un
grand mutilé dans la Maison dont, peu à peu, à cause de cette
présence, notables et civils riches s’étaient écartés.
Beaucoup d’entre eux, qui, étant d’âge à être mobilisés, avaient
pourtant réussi à passer à travers les mailles des filets qu’aux
applaudissements des vieillards sanguinaires on traînait alors
périodiquement sur la France afin d’y pêcher tout ce qui jouissait
d’assez de jeunesse, de force et de santé pour mériter d’être envoyé
au carnage, beaucoup d’entre eux éprouvaient un malaise, lorsque,
venant au 17 dans le dessein de s’y dissiper, ils se trouvaient face à
face avec M. Adolphe.
Ce colosse, vêtu de gabardine, qui, lui, connaissait l’enfer loin de
quoi ils avaient réussi à se tenir, où il avait troqué ses yeux contre
une médaille et une croix, et qui, après avoir étonné par sa sérénité,
se montrait souvent taciturne et parfois irascible, se dressait
maintenant comme un reproche devant ses hôtes.
Même silencieux, il leur disait que, là-bas, sur des kilomètres, la
terre était farcie, fourrée, bourrée de morts, que, dans des centaines
d’hôpitaux, des hommes qui, en réalité, n’avaient pas plus de
raisons qu’eux-mêmes d’être des suppliciés, souffraient et
mouraient, que, sur toute l’étendue du territoire, une multitude de
victimes pleuraient pour leurs membres perdus, leurs corps
désarticulés par la mutilation ou ruinés par la maladie.
Et, lorsqu’il parlait, racontait ce qu’il avait vu, — du temps qu’il
pouvait encore voir ! — le son de cette voix leur était insupportable.
— Il nous embête, celui-là, avec ses croix et ses discours,
pensaient-ils. On ne vient tout de même pas au bobinard pour y
recevoir des leçons !
Ils vidaient rapidement leurs verres et se retiraient.
D’autres, dont les fils ou les gendres étaient au front et qui
allaient chercher au 17 l’oubli de leurs angoisses paternelles, en
ressortaient, aussitôt qu’ils avaient aperçu M. Adolphe, avec l’effroi
d’apprendre un malheur, lorsqu’ils rentreraient chez eux.
Hommes jeunes ou déjà sur l’âge, qui avaient participé à la
démonstration de sympathie dont le héros de la rue des Trois-
Raisins avait été l’objet lors de son retour ou s’y étaient associés par
la pensée, tous, maintenant, désertaient l’établissement où, seul,
l’élément militaire continuait de fréquenter.
Sans pouvoir s’en expliquer la cause, M. Adolphe constata ces
désertions. De même, il constata le fléchissement des recettes.
— Il y a quelque chose, disait-il parfois à Mme Mireille, quelque
chose qui ne va pas.
Mme Mireille ne savait que trop ce qui n’allait pas et pourquoi, en
dépit du sacrifice qu’elle avait fait, dans le dessein de la fixer, la
fortune, une fois encore, se détournait d’eux. Pour ne point le dire ou
éclater en sanglots, elle se mordait les lèvres.
Souvent, il ajoutait :
— Et puis, tu ne surveilles pas ton monde. Je suis sûr que tu te
laisses gruger.
Malgré l’injustice du reproche, elle ne répondait pas. Mais, loin de
l’apaiser, ce silence irritait son mari dont l’humeur, si égale naguère,
s’aigrissait au point que, parfois, il lui arrivait de molester ou d’injurier
les clients.
— Si ça continue, nous ne reviendrons plus, lui avait dit une fois
l’un d’eux.
Sous un tel outrage à sa personne, à sa qualité de mutilé, à son
nom, à sa Maison, M. Adolphe s’était dressé terrible : front livide,
lèvres tremblantes, mains crispées.
— Mais foutez donc le camp tout de suite, nom de Dieu, foutez le
camp !… Tous !… Tous !… Tous !…
Pour le faire taire, pour le calmer, Mme Mireille s’était jetée sur lui
qu’elle croyait devenu dément. Il l’avait saisie par les poignets et,
visage contre visage, lui avait crié :
— Toi !… Toi !… Je commence à en avoir assez, tu sais ! Je finirai
par te crever !…
Mme Mireille avait blêmi, ces dames avaient échangé des
regards, le salon s’était vidé.
 XIV

Un lundi matin, M. Adolphe dit à sa femme :

— Le piano est faux, il faut commander l’accordeur pour cet
après-midi, vers quatre heures.
Le garçon, par qui Mme Mireille envoya chercher l’homme de l’art,
rapporta sa réponse : occupé toute la journée, il ne pouvait venir que
le lendemain ou le surlendemain.
M. Adolphe réfléchit, compta sur ses doigts.
— Qu’on y retourne, ordonna-t-il d’une voix impérieuse, et qu’on
lui dise que je l’attends sans faute jeudi à la même heure. Je ne
veux de lui ni demain, ni après.
Mme Mireille n’avait jamais discuté aucune des décisions de son
mari. Elle dépêcha de nouveau le garçon.
Cette fois, la réponse fut conforme au désir du maître.
— Nous réglerons donc cette affaire-là jeudi sur le coup de
quatre heures, prononça-t-il.

L’accordeur fut exact.

Il prit possession du tabouret que M. Adolphe lui céda, mit un
diapason entre ses dents et commença d’éprouver chaque note.
Ponctuel comme s’il se fût agi d’une affaire de service, le
capitaine William-George Ellis, dont c’était le jour, survint peu après.
 Déjà parée pour la soirée, c’est-à-dire vêtue d’une seule tunique
de gaze, très courte, sans manches, et de bas verts, la négresse
était assise, cigarette aux lèvres, devant un cahier de chansons
qu’elle feuilletait. En reconnaissant le pas de l’Anglais, elle se leva,
sourit et, selon le protocole établi, monta avec lui.
M. Adolphe n’écoutait plus les sons émis par l’instrument. Il
tendait l’oreille vers l’escalier dont chaque marche sonnait sous le
martèlement de la mule de Mme Bambou et gémissait sous la botte
de l’officier.
A l’étage, une porte s’ouvrit. Elle se referma. Tout bruit cessa.
M. Adolphe croisa les bras, emplit d’air sa poitrine et dit à
l’accordeur :
— Maintenant, jouez la Valse des Roses un peu forte, sans arrêt,
jusqu’à ce que je revienne… Et quoi qu’il arrive ne vous occupez de
rien. C’est pour faire une blague !
Il enleva ses bottes qu’il jeta sous une banquette, et, mains en
avant, traversa le salon en fredonnant :

Viens avec moi, pour fêter le printemps,

Nous cueillerons des lilas et des roses…

puis s’engagea dans l’escalier, dont il saisit fortement la rampe.

Opérant sur celle-ci des tractions successives, il touchait à peine
les marches qui ne craquaient pas plus que si un enfant allant pieds
nus les eût foulées.
M. Adolphe arriva sur le palier au moment que Mme Bambou le
traversait.
En apercevant ce colosse médaillé, aux paupières closes, qui
allait en chaussettes dans l’étroit espace où il avait réussi à venir, à
la manière d’un chat, elle accrocha ses ongles à ses dents qui se
heurtaient et s’aplatit contre une cloison.
Les yeux agrandis, les jambes tremblantes, elle haletait.
 Et son épouvante s’accroissait de cette circonstance : dans le
salon elle entendait jouer, comme si c’eût été par lui-même, la
langoureuse musique dont l’homme qui était là, devant elle, aimait à
bercer son inaction de l’après-midi.
Mme Bambou n’était pas très éloignée de supposer qu’il y avait
de la sorcellerie dans tout cela et que son patron, dont les mains, qui
continuaient de ramer, atteignirent le mur, glissèrent dessus et
s’arrêtèrent sur une porte, avait le pouvoir de se dédoubler.
Puis elle vit ceci :
M. Adolphe sortir un pistolet automatique de la poche de sa
vareuse, l’armer, chercher de nouveau la porte, la caresser jusqu’à
ce qu’il eut trouvé le bouton qu’il tourna et qui grinça.
Mais l’huis résista : le verrou avait été poussé à l’intérieur. Une
voix féminine, la voix de Mme Mireille, s’éleva courroucée.
— Qu’est-ce que c’est ?
M. Adolphe eut un rire muet.
— Qu’est-ce que c’est ? répéta la voix. Qui est là ?
Reculant d’un pas, puis faisant une flexion sur les jarrets, puis
donnant de l’épaule dans la porte qui céda sous la violence du choc,
M. Adolphe fut projeté plutôt qu’il n’entra dans la chambre.
— C’est moi ! dit-il.
Mme Bambou avait bondi dans l’escalier. Quatre détonations
qu’elle entendit coup sur coup précipitèrent son élan.
Sa tunique de gaze s’étant accrochée à un barreau, elle se crut
poursuivie, poussa un cri de bête traquée, arracha de son corps
l’étoffe légère, sauta les marches qui la séparaient encore du salon
où elle arriva nue, hurlante, les yeux fous, les cheveux en désordre.
Fidèle à la consigne qu’il avait reçue, croyant que la tumultueuse
entrée de cette négresse frénétique, vêtue de bas vert-pomme,
faisait partie de la blague annoncée, l’accordeur continuait de jouer

Nous cueillerons des lilas et des roses.

 Mme Lucie rentrait de la ville. Mme Bambou tomba dans ses bras.
— M. Adolphe vient de tirer sur Mme Mireille et sur l’Angliche, là-
haut, dans ma chambre.
Puis elle s’évanouit.
La cousine la poussa sur une banquette :
— Arrêtez donc votre musique à la noix, vous, nom de Dieu ! cria-
t-elle. Et occupez-vous de Madame.
Elle se précipita dans l’escalier.
L’accordeur comprit que, décidément, il devait se passer des
événements exceptionnels. Il termina la phrase commencée, rabattit
le couvercle du piano, fit pivoter son tabouret, enleva ses lunettes et
considéra le corps de bronze qui se tordait sur la peluche saumon
de la banquette.
— Encore que cette personne de couleur soit déparée par des
seins un peu flasques, elle est assez harmonieuse de formes,
remarqua-t-il.
Il était fort intéressé par le spectacle qui lui était offert, peu ému
et très perplexe quant aux services qu’il pouvait rendre à cette
femme dont les yeux étaient blancs, les mâchoires serrées, qui
émettait des cris stridents et se retournait les ongles en cardant de la
si belle peluche.
A tout hasard, il la gifla avec force cinq ou six fois et constata
qu’il éprouvait un certain plaisir à appliquer ce traitement.

— En voilà une brute !

— Il tape comme un sourd !
— Voulez-vous la laisser tranquille !
— Il va lui casser les dents, ma petite !
L’accordeur fit volte-face : huit femmes aux cheveux enguirlandés
de faux géraniums, de faux myosotis, de fausses capucines, et qui
étaient nues sous des tuniques de gaze, de mousseline ou de surah,
se trouvaient devant lui.
Au bruit des détonations, elles avaient quitté leurs chambres en
hâte et, se bousculant, étaient descendues au salon afin de
s’enquérir de ce qui se passait.
Bien qu’elles fussent de volumes, de teints, de types différents,
l’accordeur les estima également désirables et se félicita que la
saison de l’amour fût, depuis longtemps déjà, terminée pour lui, car il
eût été fort embarrassé s’il lui eût fallu élire l’une d’elles.
— Mesdames !… Mes hommages !… prononça-t-il en s’inclinant.
— On s’en fout de vos hommages, répliqua Mme Carmen qui
l’écarta pour s’occuper de Mme Bambou.
Il faut croire que l’intervention dont la négresse venait d’être
l’objet était parfaitement appropriée à son cas, puisque son corps,
raidi tout à l’heure, se détendait, puisque ses mains cessaient de
griffer et ses jambes de s’agiter, puisque, enfin, ses yeux avaient
perdu leur aspect effrayant et pris une expression de douceur et de
puéril étonnement pour regarder le visage de la compagne penchée
sur elle.
— Tu me reconnais, mon noiraud ? demanda Mme Carmen avec
sollicitude.
— Oui, répondit Mme Bambou en sanglotant à petits coups dans
la saignée de son bras replié. J’ai froid, ajouta-t-elle.
Elle grelottait.
Heureux de démontrer que, malgré les apparences selon quoi on
venait de le juger peut-être un peu légèrement, son âme n’était pas
tout à fait insensible, l’accordeur étendit avec beaucoup de soin son
pardessus sur la négresse.
Considérant tour à tour Mme Bambou et le vieil homme, ces
dames ne parvenaient point à établir une corrélation entre la scène
dont elles venaient d’être témoins et les détonations qu’elles avaient
entendues.
 Elles échangeaient des regards interrogateurs, des hochements
de tête, des haussements d’épaules, des gestes par quoi chacune
exprimait à la fois son ignorance et son désir d’entendre sa
compagne émettre une hypothèse qu’elle-même ne voulait pas
prendre la responsabilité de formuler.
— Qu’est-ce qui s’est donc passé ?… Qui a tiré ? Y a-t-il
quelqu’un de blessé ? demanda Mme Joujou à la négresse.
Mais celle-ci continua de pleurer et ne répondit pas.

Une sorte de hululement vint de l’escalier. Toutes les têtes se

tournèrent vers la porte.
Paupières gonflées, visage tuméfié et verni par les larmes,
poitrine secouée de sanglots, Mme Lucie parut.
On s’élança vers elle. Elle fit effort pour reprendre son souffle.
— Madame est morte, réussit-elle à articuler.
Ces dames comprirent. Toutes poussèrent le même cri suivi de
lamentations semblables à celles, qu’en Orient, les pleureuses juives
modulent sur les tombeaux.
— Et l’Angliche ? demanda Mme Andrée.
— Lui ? Crevé !
— Et M. Adolphe ?
— Il a jeté son revolver dans un coin et maintenant… maintenant,
il est étendu par terre, à côté des deux cadavres… Il pleure !
Mme Zizi apporta une chaise, Mme Lucie s’y laissa tomber. Elle
posa les coudes sur la table, cacha son visage dans ses mains.
Entre deux hoquets, elle disait d’une voix brisée ;
— Quand on pense qu’il l’a tuée !… Tuer une femme comme
ça !… Une femme qui a tenu la Maison tout le temps qu’il a été là-
bas… qui avait l’œil à tout… qui l’aimait comme on n’aime pas
quelqu’un !
 « Une femme qui était sérieuse et dévouée et toujours à
l’ouvrage… Qui ne savait qu’inventer pour augmenter les bénéfices,
même qu’elle avait trouvé le moyen de faire payer une taxe de luxe
aux clients !… Et maintenant, la voilà morte… elle qui aurait fait la
fortune de son mari et de sa fille… Pauvre Mireille !…
« C’est pas juste !… Non, c’est pas juste, car, par le fait, c’est
pour lui et pour la petite qu’elle avait repris le peignoir trois après-
midi par semaine. »
Elle suffoqua sous son chagrin et poursuivit :
— Mais aussi, pourquoi ne l’avait-elle pas prévenu ? Pourquoi ne
lui avait-elle pas fait toucher les billets qu’elle recevait… Il ne se
serait pas forgé des idées, cet homme… Il n’aurait pas cru que
c’était pour le plaisir de la chose…
— Trop bonne, dit Mme Andrée.
— Trop délicate dans ce qu’elle était, dit Mme Joujou.
— Voilà où ça mène, constata Mme Zizi.
— Sainte Mireille ! murmura Mme Carmen en joignant les mains.
Assises sur les chaises, les banquettes, les tables, elles
sanglotaient…
La nuit tombait dans le salon.
L’accordeur reprit son pardessus et, marchant sur la pointe des
pieds, se retira.
 XV

Vingt-quatre heures se sont écoulées. La Maison est fermée.

Il pèse sur elle cette torpeur qui s’empare des logis où la mort
vient de passer. Mme Lucie qui ne peut, encore qu’elle le souhaite
sincèrement, se défendre de songer à son propre avenir et se
consacrer tout entière à la douleur, règne, dolente, silencieuse et
hagarde, sur ces dames.
Celles-ci, après avoir poussé tant de cris, versé tant de larmes,
échangé tant de réflexions, n’ont plus de pensées, ni de paroles.
Reprises par leur fatalisme, il semble même que la force d’avoir du
chagrin les ait abandonnées.
Inactives et sordides, elles errent, du salon à leurs chambres, où
elles s’occupent à réunir les quelques pauvres objets qui leur
appartiennent en propre, qu’elles ont apportés lors de leur entrée au
17 et qu’elles vont remporter puisque, demain, il leur faudra partir…
Hier, après le drame, la police, à qui Mme Lucie dépêcha son
frère dès qu’elle eut repris ses esprits, est arrivée. Elle a emmené M.
Adolphe, harcelé le personnel de questions, mis les scellés sur la
chambre de Mme Bambou après avoir fait réparer la porte par un
menuisier.
Puis, le soir, la foule ayant été chassée de la rue où, devant
chaque maison, les dames formaient des groupes bariolés et
commentaient l’événement, le corps de Mme Mireille fut chargé sur
une voiture de l’hôpital civil pendant que celui du capitaine William-
George Ellis était emporté par une ambulance automobile de
l’hôpital anglais.
Un peu plus tard, une infirmière de la Maternité, munie d’un ordre
du Maire, vint chercher la petite Aimée-Désirée qui, déjà, sommeillait
dans le berceau où, depuis un siècle, tous les bébés Rabier avaient
dormi et qui ne s’éveilla point.
Dès qu’elles furent avisées qu’un officier des Armées de Sa
Majesté avait été assassiné en un lieu où, à moins de vouloir
offenser tout l’Empire, nul ne saurait soutenir qu’un gentleman ait
jamais mis les pieds, les autorités militaires britanniques, concluant à
un guet-apens, exigèrent de mener l’enquête en même temps que la
police française.
Elles placèrent devant la porte du 17, avec mission de ne laisser
entrer ni sortir personne, deux gendarmes blonds armés du revolver
et de la cravache de cuir, vêtus de kaki et portant le brassard rouge
marqué des deux initiales noires M. P.
Aujourd’hui, toute la matinée, tout l’après-midi, des curieux, parmi
lesquels officiers et soldats anglais en grand nombre montraient, par
leur attitude, qu’ils partageaient l’opinion du Commandement quant
aux circonstances ayant entouré le meurtre du capitaine William-
George Ellis, ont continué de défiler dans la rue.
Regards levés vers les volets fermés, ils commentaient avec
passion l’événement. Les dames portières des autres maisons leur
fournissaient avec volubilité et abondance des détails dont ils se
montraient friands et que, grisées par leur propre éloquence, elles
inventaient du reste à mesure.
Maintenant, dans la rue des Trois-Raisins où règne la nuit, où les
lanternes grillagées plaquent, çà et là, des taches rouges, les
hommes se meuvent comme des ombres.
De cette foule enfiévrée monte un brouhaha confus, fait de
conversations, de bribes de chansons, de sifflets, d’exclamations et
d’appels lancés par la voix tentatrice des portières promettant mille
délices à ceux qui pénétreront dans les eldorados dont elles ont la
garde.
Un bruit de moteur et de ferrailles secouées couvre tous les
autres : un camion automobile de l’armée britannique, chargé de
soldats, vient de s’arrêter perpendiculairement à la rue de façon à en
obstruer l’issue.
Les hommes sautent sur le pavé où sonnent les fers de leurs
talons. Autant qu’on peut en juger, ils sont une trentaine.
Les voici alignés sur deux rangs. Un coup de sifflet déchire l’air.
Ils avancent lourdement dans la rue au pas cadencé.
Des cris de surprise, suivis de cris d’effroi, partent de la foule,
qui, dans un grand bruit de semelles cloutées raclant le sol, disparaît
comme si, d’une seule soufflée, un vent violent l’avait emportée
jusqu’à l’autre extrémité de la rue.
Les dames portières rentrent dans les maisons, poussent les
verrous. Les lumières s’éteignent dans les lanternes.
Les soldats continuent d’avancer. Sans un mot, sans un cri, ils se
jettent sur les deux M. P. en faction et les désarment.
Leurs rangs s’ouvrent. Huit d’entre eux qui portent sur leurs
épaules une poutre de chêne sont démasqués. Ils font face au 17.
Quelqu’un siffle, en deux temps, entre ses dents. Sur ce rythme,
le bélier frappe la porte blindée qui résonne, geint, craque, s’abat.
Des hurlements de démentes s’élèvent dans la maison où
soudain, on le discerne entre les lames des persiennes, les lumières
sont éteintes.
Un commandement :
— Light !
Quatre torches s’allument. Chaque homme tire une lampe
électrique de sa poche et la Maison absorbe les trente soldats de Sa
Majesté.
Quand ils paraissent dans le salon, ils sont accueillis par le cri de
« Vive l’Angleterre » poussé par un personnage qu’ils ne
s’attendaient point à trouver là.
Cheveux mêlés, teint cuit, barbe non faite, moustache tombante,
œil éteint, le quidam ricane, se dandine et, pour se maintenir en
équilibre, s’accroche à une table.
— Vive l’Angleterre ! répète-t-il avec difficulté. Vivent les soldats
de la noble Angleterre !
C’est, en personne, le frère de Mme Lucie.
Depuis des mois qu’il tient, dans la Maison, l’emploi de portier,
qu’il est soumis à la triple surveillance de sa sœur, de Mme Mireille et
de M. Adolphe, il n’a jamais pu boire à sa soif.
Il a donc profité du désarroi qui, depuis hier soir, règne au 17,
pour rattraper le temps perdu et consommer, en une seule fois, la
quantité de liquide dont il fut frustré.
— J’ai royalement bu ! murmure-t-il, sur le ton de la confidence.
Royalement bu !… Et ce qu’il y a de rigolo, c’est que personne ne
s’en est aperçu !… Un autre, à ma place, serait saoul… Moi pas !…
Il s’interrompt, paraît réfléchir, puis, se touchant le front comme
s’il venait de retrouver le fil de ses pensées :
— J’ai rudement sommeil !… Alors, je vous souhaite le bonsoir,
les gars !
Il pose l’index sur ses lèvres.
— Surtout n’allez pas raconter à Lucie que vous m’avez
rencontré… Elle me chercherait des raisons.
Ayant dit, il s’écroule et instantanément s’endort.
Les soldats le poussent sous une banquette et se mettent en
quête de ces dames.
Ils n’ont pas besoin de les chercher longtemps.
Il leur suffit de monter à l’étage, d’enfoncer les portes à coups
d’épaules ou de bottes pour les trouver pâles, tremblantes, claquant
des dents, debout devant leurs lits.
Qu’importe si, en cette nuit qui est pour elles nuit de chômage
forcé, elles ne sont ni lavées, ni peignées ? Qu’importe si elles ont
de gros bas de coton, des savates éculées, des peignoirs de pilou
constellés de taches ?
Les guerriers sont gens d’appétits robustes. Ceux-ci le
prouveraient s’il en était besoin.
Ils font magnifiquement leur métier d’hommes.
Mme Lucie qui, en sa qualité de cousine et de sous-maîtresse, a
essayé de leur résister, est la proie de quatre gaillards bien décidés
à lui faire payer cher son indocilité.
L’un a saisi à pleine main sa chevelure qu’il a roulée autour de
son poignet pour ne pas perdre la prise.
Deux autres lui tiennent les bras, le quatrième les jambes et c’est
ainsi qu’on la descend au salon où l’électricité a été donnée ainsi
qu’aux plus beaux soirs.
Entre les mèches qui pleurent sur son visage, elle voit toutes ces
dames, nues comme elle, aux mains de soldats qui les immobilisent
sur les banquettes pour permettre à leurs camarades, qu’ils
relèveront tout à l’heure, d’user d’elles.
Cris de triomphe, vivats, applaudissements et rires se mêlent aux
cris de douleur, aux exclamations rageuses, aux sanglots des
patientes.
Mme Lucie est assise sur une table. On l’y renverse. Par les
cheveux, les mains et les pieds, on l’y maintient. On danse, on
chante, on vocifère, on siffle autour d’elle. Et elle subit tant d’assauts
que, malgré son habitude et sa vigueur, elle s’évanouit.
On la fait glisser sur le marbre. Elle tombe sur la banquette.
Mme Andrée, puis Mme Carmen, puis Mme Bambou, puis Mme Zizi
subissent la même épreuve jusqu’à l’évanouissement.
Ces garçons ne sont-ils pas des sportifs ? Et, partant, ne
convient-il pas qu’ils s’amusent à établir laquelle de ces femmes
fournira la plus longue carrière avant de perdre connaissance ?
Honneur et gloire à la race blonde ! C’est Mme Joujou qui est
recordwoman.
 La meute bat des mains, trépigne, siffle, chante devant ce corps
blafard, aux monstrueuses boursouflures, devant ce corps inerte qui,
sur le marbre blanc, semble celui d’une bête morte, tuée pour la
boucherie et qu’on va dépecer.
— She is all right ! scande un des soldats.
Tous, détachant chaque syllabe du ban, répètent en chœur :
— She is all right !
— Who is all right ? interroge le premier.
— Djoudjou !
Alors, le chef de ban bat la mesure et, par trois fois, une
immense acclamation roule :
— Hipp ! Hipp ! Hipp ! Hurrah !… Hipp ! Hipp ! Hipp ! Hurrah !…
Hipp Hipp ! Hipp ! Hurrah !…
Le frère de Mme Lucie se réveille. Il réussit à se dégager, rampe
sur le sol, s’assied, jambes écartées, au milieu du salon, passe sur
son visage verni de sueur ses mains chargées de poussière.
Les soldats applaudissent.
Le succès qu’on lui fait le flatte. Il salue gracieusement, multiple
les sourires, envoie des baisers, et apercevant tout à coup les corps
des pensionnaires étendus çà et là, pousse des gloussements de
joie en se frappant sur les cuisses.
— Alors, les gars, alors les Alliés, c’est la nouba à ce que je vois,
la grande nouba, s’écrie-t-il.
Il demande à boire.
Comme on ne comprend pas, il fait le geste de porter un verre à
ses lèvres. On lui passe une bouteille. Il s’y abreuve avec avidité,
puis, aux applaudissements renouvelés de l’assistance que cet
intermède a divertie, il reprend son mouvement de reptation et
disparaît de nouveau sous la banquette en hurlant :
— Vive l’Angleterre !
La troupe compte un musicien. Il s’assied devant le piano, et
voici le God save the King et le Tipperary et le Rule Britannia.
 Un autre prend possession de l’étagère aux liqueurs. Il tend à
ses camarades des verres à bière pleins de rhum, de cognac, de
chartreuse, de kummel, de curaçao.
Trois sergents, qui ont exploré la cave, arrivent chargés de
paniers.
— Tchampeine ! crient-ils.
On les acclame. L’alcool contenu dans les verres est versé sur
les corps de ces dames. Les bouteilles passent de mains en mains,
comme des briques lancées par des maçons faisant la chaîne. Les
bouchons sautent. Le vin s’échappe des goulots. Des bouches le
happent.
Et quand le flacon est vide, on le jette dans une glace, dans le
lustre, ou bien on en martèle les touches du piano.
Car l’heure n’est plus à la musique, ni à l’amour, ni aux chants, ni
aux rires.
L’heure est à la force !
Comme s’ils obéissaient à un signal, les hommes se lèvent.
Beaucoup sont très rouges, quelques-uns très pâles. Ils chancellent.
Mais il leur reste assez d’équilibre pour gravir l’escalier à la course,
se répandre dans les chambres, en ouvrir fenêtres et persiennes,
faire passer dans la rue meubles, miroirs, literie, lingerie multicolore
et accessoires de toilette — tout ce qu’ils peuvent atteindre.
Ils redescendent dans le salon empuanti d’alcool, de fumée et de
vin, dans le salon où tout est détruit.
Tout ? Non ! Il y a encore le piano et les tables de marbre.
Un piano, ça se renverse. Et l’on danse dessus jusqu’à ce qu’il
éclate. Des tables de marbre ? Il suffit de les basculer sur le sol
carrelé pour qu’elles s’y brisent.
Voilà qui est fait ! Et proprement et rapidement fait !
Les vainqueurs quittent la Maison. Ils butent sur le tas de
meubles brisés et d’objets qu’ils ont jetés à la rue.
Une voix commande :
 — Oil !
Les deux conducteurs de camion surviennent, porteurs de bidons
de pétrole qu’ils éventrent à coups de couteau. Le liquide se répand
sur le bois, les matelas, la lingerie qu’une torche enflamme.
— Hurrah !
La vieille Angleterre qui, jamais, n’a pardonné une offense, qui,
jamais, n’a manqué de châtier durement ceux qui attentèrent à son
renom ou à ses biens, vient de venger le capitaine William-George
Ellis.
Rule Britannia !

Et maintenant ?…
Maintenant, M. Adolphe appartient à la justice.
Elle peut le frapper ou l’absoudre, qu’importe !
Privé de son Antigone, jamais il ne rentrera au 17 où, pendant
plus de cent ans, les siens ont si rudement peiné pour acquérir une
honnête aisance, où il était fondé à espérer que, grâce à la guerre
longue, il aurait l’orgueil, lui, premier de sa race, d’asservir la fortune,
où, enfin, un fils né de sa chair lui aurait succédé.
Les Rabier ont cessé de régner sur la Maison…

FIN
 ACHEVÉ D’IMPRIMER
POUR LA COLLECTION « ÉCHANTILLONS »
LE DIX SEPTEMBRE MIL NEUF CENT VINGT-CINQ
SUR LES PRESSES
DE L’IMPRIMERIE BUSSIÈRE
SAINT-AMAND (CHER)
*** END OF THE PROJECT GUTENBERG EBOOK MIREILLE DES
TROIS RAISINS ***

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