Category Archives: Attachment

Pediatricians Screen for Child Trauma

To prevent childhood trauma, pediatricians screen children and their parents…and sometimes, just parents…for childhood trauma”
guest blog by Jane Ellen Stevens, Editor, and

Tabitha Lawson & kidsWhen parents bring their four-month-olds to a well-baby checkup at the Children’s Clinic in Portland, OR, Drs. Teri Petersen, R.J. Gillespie and their 15 other partners ask the parents about their adverse childhood experiences (ACEs).  [Tabitha Lawson of Portland, OR with her two children, who greatly benefited from the new program; more below]

When parents bring a child who’s bouncing off the walls and having nightmares to the Bayview Child Health Center in San Francisco, Dr. Nadine Burke Harris doesn’t ask: “What’s wrong with this child?” Instead, she asks, “What happened to this child?” and calculates the child’s ACE score.

In rural northern Michigan, a teacher tells a parent that her “problem” child has ADHD and needs drugs. The parent brings the child to see Dr. Tina Marie Hahn, who experienced more childhood trauma than most people. Instead of writing a prescription, Hahn has a heart-to-heart conversation with the parent and the child about what’s happening in their lives that might be leading to the behavior, and figures out the child’s ACE score.

What’s an ACE score? Think of it as a cholesterol score for childhood trauma.

Why is it important? Because childhood trauma can cause the adult onset of chronic disease (including cancer, heart disease and diabetes), mental illness, violence, becoming a victim of violence, divorce, broken bones, obesity, teen and unwanted pregnancies, and work absences.

The CDC’s Adverse Childhood Experiences Study (ACE Study) measured 10 types of childhood adversity: sexual, physical and verbal abuse, and physical and emotional neglect; and five types of family dysfunction – witnessing a mother being abused, a household member who’s an alcoholic or drug user, who’s been imprisoned, or diagnosed with mental illness, or loss of a parent through separation or divorce.  (There are, of course, other types of trauma, but those were not measured in this study. Other ACE surveys are beginning to include other types of trauma.)

Each type of trauma — not the number of incidents of each trauma — was given an ACE score of 1. So, a person who has been emotionally abused, physically neglected and grew up with an alcoholic father who beat up his wife would have an ACE score of 4.

The ACE Study found that childhood trauma was very common — two-thirds of the 17,000 mostly white, middle-class, college-educated participants (all had jobs and great health care because they were members of Kaiser Permanene) experienced at least one type of severe childhood trauma. Most had suffered two or more.

The more types of childhood trauma a person has, the higher the risk of medical, mental and social problems as an adult (Got Your ACE Score?). Compared with people who have zero ACEs, people with an ACEs score of 4 are twice as likely to be smokers, 12 times more likely to attempt suicide, seven times more likely to be alcoholic, and 10 times more likely to inject street drugs. Compared to people with zero ACEs, people with an ACE score of 6 have a shorter lifespan – by 20 years.

Twenty-two states and Washington, D.C., have done their own ACE surveys, with similar results.

The ACE Study is part of a perfect storm of research emerging over the last 20 years that is revolutionizing our understanding of human development. Brain research shows how the toxic stress of trauma damages the structure and function of children’s brains, which can explain their hyperactivity, inattentiveness, angry outbursts and other behavior. This affects their ability to learn in school, and leads them to use drugs, alcohol, thrill sports, food and/or work as coping mechanisms.

Biomedical researchers discovered that toxic stress experienced as a child can linger in the body to cause chronic inflammation as an adult, resulting in heart and auto-immune diseases, such as arthritis. And epigenetic research shows that the social and emotional environment can turn genes on and off, and childhood trauma can be passed from parent to child to grandchild.

Let’s put this another way: A huge chunk of the billions upon billions of dollars that Americans spend on health care, emergency services, social services and criminal justice boils down to what happens – or doesn’t happen — to children in their families and communities.


The pediatricians mentioned in this article know that, and they also know that if they intervene early enough to stop or prevent childhood trauma by building resilience factors in children and families, children won’t suffer, and they’ll have happier, healthier lives as adults.

Pediatricians aren’t just about sore throats and ear infections anymore, says Gillespie. “This is a culture shift. We’re here to support families.”

The profession is moving away from looking solely at healing a child, to healing a family and a community. For the last several years, the American Academy of Pediatrics has been helping pediatricians create medical homes where all needs of children and their families are met, including “specialty care, educational services, out-of-home care, family support, and other public and private community services that are important for the overall health of the child and family.”

Two years ago, the AAP encouraged pediatricians to also address adverse childhood experiences and toxic stress in early childhood. Last month, AAP President Dr. James Perrin launched a new initiative, the Center on Healthy Resilient Children, to “coordinate the academy’s response to the issue of adverse childhood experiences, the promotion of healthy development, and the prevention of toxic stress.”

Feeling overwhelmed…and someone to turn to

When Tabitha Lawson brought her four-month-old son in to the Children’s Clinic in Portland, OR, they both were having a hard time. Unlike her 6-year-old daughter, he wasn’t an easy baby. He had colic, and Tabitha and her husband were under stress from his long bouts of crying.

“I was feeling overwhelmed,” she recalls. “I had no breaks. I work full time. From my job to my house is five minutes, where I’d go into my other life mode, and every evening, the scream-outs.”

She filled out a survey with 10 questions about her adverse childhood experiences (ACEs)…  click here to READ MORE…

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Fire Up the Right Brain

Dan Siegel Website PicWhen we last left Stewart the 92-year-old lawyer in Dan Siegel’s office June 25,  “the presenting problem was:  his wife got sick, and he became more socially withdrawn… losing himself in his books,” Siegel said. “Rather than confronting what the illness of his wife of 65 years brought up in him, this unbelievable sense of vulnerability which he wasn’t prepared to sit with, he withdrew into his law books.”  [FN1]

Stewart could handle and remember lots of facts, like his or others birth dates, a left brain function.  But he had little or no emotional response, nor could he recall much about his fleshed-out lived experiences, like what he did on his son’s first birthday, a right brain function.  Pure dissociation.  “I think you’re living with half a brain,” Siegel told him.

So Dan set out to grow Stewart’s right brain.

“Our right human hemisphere is all about this present moment,” says brain scientist Jill Bolte Taylor. “Information, in the form of energy, streams in through all of our sensory systems, then it explodes into an enormous collage of what this present moment looks like, what this present moment smells like and tastes like, what it feels like and sounds like.” [FN2]

Here’s what Dan did: “I told Stewart that I thought if we could drive energy and information flow through the right hemisphere of his brain, over a three to four month period, I believed we could stimulate neuronal activation and growth: we could get new synapses to form in the right brain that had never formed before.”

Dan gave Stewart a series of exercises which only the right brain could handle, so the neurons in Stewart’s spectacularly developed logical left brain would have to just stop firing awhile.  His right brain would have to step up. [FN3]

Fire the Right Brain Neurons

Brain_superior-lateral_viewFirst, Siegel said, the right hemisphere specializes in non-verbal responses, facial recognition and imitation, and other mammal to mammal relational expressions and body language – as distinct from verbal language and logic which are left brain actions.

So Dan started miming emotions with his face and body, only — no words. And Stewart had to try to mimic back his face and body motions — no words. “I would make a face, and he would imitate it—not name it because that would be bilateral integration, ” said Dan. “We wanted to get his right hemisphere going, and the right specializes in non-verbal response and facial recognition.”   Stewart watched while Dan demonstrated an emotion non-verbally, with face, with hands and body, and gradually Stewart found he could make his own face, hands and body imitate Dan — all without logic or speech.

Then Dan reversed it, having Stewart mime something without words, while Dan tried to imitate him. “It kind of became fun actually, like a game,” Dan said. “For homework, I would have him watch television with the sound turned off, so that his left hemisphere, which does language, wouldn’t get stimulated. The right hemisphere had to start watching the shows, and he had to get his right hemisphere to work.”

Second, Dan knew that emotions, as the word implies, arise  first as bodily sensations — motion in the body parts — which is communicated as raw data via body nerves to the brain, and finally analyzed and interpreted by the mind as “feelings.” But emotions, like most bodily data, are shunted to the right side of the brain for interpretation, as Dr. Jill Bolte Taylor describe the way incoming sensory data goes to the right brain, above.

Dan thought Stewart didn’t have that right brain function of assembling a map of how his body felt — which was why he didn’t have emotions. So he taught Stewart to create in his mind, an integrated map of his body, which only the right brain can do.

Dan taught Stewart to do “body scans,” in which attention is focused strongly and willfully (“mindfully”) on what is going on first in our head, then our face,  neck, chest, belly, legs, and so on, for prolonged periods of time — something Stewart had never spent 10 minutes on in 92 years. “He couldn’t check into his body to say, my heart is pounding, my stomach is churning, I’m breathing fast,” said Dan, so how could he know he was feeling an emotion?

Third, Dan gives Stewart autobiographical exercises. “I asked him, ‘before you came to the office, you woke up. How did you wake up?’  He said he got up, he had breakfast, and he got in the car. I said ‘Let’s back that up, which foot got out of the bed first?’  He had to go from factual memory, to having a sense-of-self in time. That’s a right hemisphere specialty. Obviously your sense of self, if you don’t have an autobiographical sense of self, is pretty thin.

“Now you would say: hold on, my left foot got up, and then I had breakfast. How? You didn’t fly to the kitchen…Well I went to the toilet first, then I washed my face, then I took a step, etc…  Then he would start making a map of what he experienced that morning…

“And over time, with autobiographical memory exercises, non-verbal exercises, bodily exercises, and starting to then name feelings, we would put on facial expressions of these feelings — and then he started to change.  It was actually quite startling.

“One moment is telling…  He had mentioned that his brother had lost his leg in a skiing accident, but it didn’t matter, you know, because of his dismissal of relationships. He knew the facts of it, but not the feelings of it. A few months later, he was saying something about his grandchildren going skiing, and I thought there was something related to his brother, so I brought it up and he started to get tearful. I asked him if it was about his brother, he said no.

“I asked him what he was feeling and he looked at me and said that he couldn’t believe that I had remembered what he’d said, and that I really knew him. He said, ‘I can’t believe you remember who I am.’  And there was this shift of the feeling of his presence in the room.  He began to be able to articulate that he felt sad, that he could feel heaviness in his chest, that he was aware of his body in new ways.

“It was a moment of connection with him that didn’t exist before. And from that time onward the feeling in the room was like I had a whole person with me. There was this natural unfolding.  Once you allow these areas to be differentiated and honored, they can naturally find a linkage often.  And that’s what happened with Stewart.

“Empathy became something he did. With the right hemisphere focused on his interior, it also naturally began to focus on the interior of other people — me, his wife, his friends.  And that Presence you have when you’re interested in the interior world of other people, is a totally different way of being on the planet.

“His son reported that his presence around his grandchildren really changed. There was even one time Stewart came in and told me that I wasn’t going to believe what happened. He said they were saying goodbye to some people, and his wife put her hand on his shoulder, and he told her it felt good. Then she asked him if he wanted a back massage because in 65 years of marriage, he never let her do that. So she gave him a shoulder massage, and he said it felt fantastic. I asked why he’d said no for 65 years, and now at 92, he said yes.

“He said that he had been so terrified his entire life of needing anyone because he was never able to need anyone in his childhood, and that now he felt as if he could be that vulnerable to his wife and he could say that he needed her.

“His wife actually called me and asked me if I had given him a brain transplant because he had become a different person.  It wasn’t just that he was more present with relationships; internally, he felt this sort of playfulness. So, that’s how we could tell that something shifted with him.

“It was incredible and I have to say if it were just Stewart, I’d feel really nervous about reporting such a thing in a book, but I’ve worked with a lot of people with avoidant attachment histories, who as adults have dismissed attachment with the same paradigm, and it comes out the same way almost every time. [FN5]

“Now I get these beautiful cards from Stewart every winter. The last one said, ‘Dan, you cannot believe how much fun I’m having. Thank you’.”


Next Friday August 15:  Special guest blog on how the ACE Study is finally being put to good use in pediatrics


Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

Bio, website, and more of Dan’s books in Footnotes at end of

FN1    Siegel, Daniel J., MD, “The Developing Mind,” National Institute for the Clinical Application of Behavioral Medicine (NICABM), Apr 6, 2011 p.20-22 Apr 6, 2011 p.20-22

FN2   Jill Bolte Taylor,  “My Stroke of Insight,” Ted Talk of Feb. 2008,

FN3   Siegel, Daniel J., MD, “How Mindfulness Can Change the Wiring of Our Brains,” NICABM,; 2010 Webcast; my first NICABM webinar, downloaded March 31, 2011; rebroadcast October 11, 2011. and

FN4   Siegel, Daniel J., MD, “The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are,” (Guilford, 1999).  How attachment in infancy and childhood creates the brain and the mind.

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Dan Siegel: Creating a Joyful Brain

Dan Siegel Quote on EmotionI’ve got some great short videos here by Dr. Dan Siegel, MD  — and even his friend comedienne Goldie Hawn makes an appearance.

I’ve also had a lot of demand for my book — but it’s not done. I’ve been too wrapped up in my fascination with brain science and lots of great networking resulting from that. Now I need to chain myself to my book files, so I’ll be blogging only every other Friday.

As reported the last few weeks, Dr. Siegel details how often we feel lousy because actually our brains are wired wrong from childhood. And now Siegel has shown we can actually heal that and rewire our brains. A fun and heartwarming video by Dan which elaborates this theme “How you can change your brain” is here:

We often get sad-wired with attachment trouble as kids while the brain’s forming, due to implicit — body-only — memory created before we reach age 3, before we can think and remember. Two videos by Dan on this topic are here:
and here:

In coming weeks, I’ll be blogging on how Siegel actually healed the split-up brain of a 92-year-old lawyer.  The gentleman had great cognition, but couldn’t feel anything at all. It’s an amazing story.   To prepare, check out this video by Dan called “On Integrating the 2 hemispheres of our brains”  at

Dan on “Being” Versus “Doing” With Your Child – This video really helps show how poor Stewart the lawyer got so messed up as a child, because of lack of emotional connection in his birth home.  My blog introducing Stewart is at

Stewart was taught as a kid to think about facts, but he couldn’t feel a thing.  It’s all in the development of our right brain vs our left brain.  Click here for Dan’s video:

Dan Siegel & Friend Explore the Brain: Mindfulness and Neural Integration at TEDx.  Dr. Siegel shows more on how mindfulness and meditation can help rewire our brains. Then a school kid walks on camera, and you’ll love what happens next.  Click here:

Dan Siegel with Goldie Hawn at TEDMed 2009:  The comedienne explains her hunt for the “science of happiness” and how she teamed up with Dr. Dan.  Now they make school kids happy by helping them harness their brain power and grow mindfulness. It does turn out to create great joy — and better grades.  Click here:

Mindfulness meditation has become an increasingly popular way for people to improve their mental and physical health…New research from Carnegie Mellon University shows even brief mindfulness meditation practice – 25 minutes for three consecutive days – alleviates stress.  Go here for more:

I promised to blog on how Siegel actually healed poor Stewart’s split-up brain; I will, in Dan Siegel Part 5 (available here on Friday Aug. 8).


Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.


For Dr. Dan Siegel’s biography, website, books and more: see Footnotes at bottom of

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Dissociation Nation: Half a Brain

Dan Siegel Podium w. BrainDan Siegel’s webinar “How Mindfulness Can Change the Wiring of Our Brains,” which I found by accident in March 2011, insisted that we can re-wire our brains. Siegel actually used neuroplasticity and “mindsight” (see July 11 blog) to re-wire the brain of a ninety-two year old lawyer code-named “Stewart.” [FN1]

Stewart was an extreme case, but it’s how most of us live these days.  We live in “head talk” in our frontal cortex, pretty much in dissociation from the emotions in our mammalian limbic brain. Stewart existed entirely in his thinking brain, but said he didn’t know what feelings were.  He had almost no use of his emotional brain.  “He’s a good example of a need for bilateral integration,” as Siegel put it.

Emotions?  We think the objective is to get rid of ‘em, just “grow up” and be rational like Spock on Star Trek.  “Too many Americans are spurred to achieve (business, academia, etc.) rather than to attach (to other human mammals), warn three top psychiatrists in the key book “A General Theory of Love.”  We’ve been taught that our performance is our identity, so we over-perform, thinking non-stop. That leaves almost no hours for “face time” to simply “be” with and be present with live human beings.

Yet in fact emotions are sanity and mental health, not the reverse.  And that’s not an endorsement of road rage.  But we need secure attachment as kids, while our emotions first develop, to learn to govern (regulate) emotions by sharing them with our human mammal living group so we don’t go nuts.  Yet sharing emotions is far out of style these days, and  in the last census, “one third of American households were one person,” as Dr. Bruce Perry notes.  Having no social option, we dissociate from our emotions.

Stewart began acting strangely when his wife of sixty five years took ill, so his son brought dad to see Siegel. “Stewart comes in and his son says that he thinks his dad might be depressed,” Siegel said. “Stewart was withdrawn and cantankerous, but the feeling I got wasn’t that he was sad or depressed, but that there was something just kind of vacuous and disconnected about him.  When I got to talk to Stewart alone, he still didn’t seem depressed.  He seemed more aloof than anything else.”

Stewart’s thinking brain was in great shape; “his cognition at ninety-two was totally intact—excellent memory for facts,” said Siegel, and his legal business was  successful.

But when Siegel checked on Stewart’s emotions, the gent drew a complete blank.

Living with Half a Brain

Jill Bolte Taylor Brain Halves Crop, Ted 2-08And Stewart drew the biggest blank when Siegel asked him about his emotions during childhood.

“I did a brief Adult Attachment Interview (AAI) assessment, which I do with most of my patients,” Siegel said. (See my all-new blog on the AAI here; finally got the story.) The AAI shows how emotionally close the adult interviewee got to their parents as a child.

But that just annoyed Stewart. “He thought it was absolutely a moot point that I was reviewing his relationship with his parents almost 90 years ago…

“ ‘You’re out of your mind’ Stewart said,” Siegel laughed. “He insisted that ‘relationships didn’t matter,’ his son said; ‘he’s always had that attitude.’ ”  Stewart’s wife had more data.  “She said that his parents, as Stewart had also factually stated, were ‘the coldest people on the planet.’ They lacked the ability to see the internal world. Everything was about managing Stewart’s behavior and his physical externals—his food, his shelter, his schooling — but nothing was focused on feelings or thoughts, or the meaning of  things.”

Siegel pushed back, telling Stewart that they had to look into his childhood because “synaptic connections get formed early in life.” And then it came out that Stewart couldn’t remember much about his childhood experiences at all; he only remembered logical facts such as dates. This showed “a big difference between the left and right hemispheres of his brain,” said Siegel. Stewart could handle lots of facts with his left brain, but lacked recall of fleshed-out experiences, which are more an emotional phenomenon in the right brain.

Then Siegel gave Stewart the bottom line; he said that likely Stewart’s wife’s illness “had made him go more into withdrawal from relationships.”  He also said that his tests of right and left hemisphere functioning showed that Stewart’s right brain “wasn’t very developed.”

“I said, ‘I don’t think you’re depressed. I think you’re living with half a brain.

“And… I just want to offer you the idea that you did the best you could in childhood, but the lack of focus on you internal world didn’t develop that part of your brain, so you’ve lived a life dominated by one side and not the other.”

The photo above shows the actual normal separation of the two halves of a human brain, connected only at bottom by the corpus callosum, displayed by Jill Bolte Taylor in “My Stroke of Insight” on Ted Talks in February 2008.

“And when I asked how it felt when I said that, he paused and said he didn’t know what that question meant. He said that for his whole life, people have asked him how he felt, and he had no idea what they were talking about,” Siegel went on.

“Then, he paused again and said, ‘Maybe before I die, I can learn what that question means.’

“So then we went on a journey together,” Siegel said, “and the idea is this: if a part of your brain is underdeveloped, not destroyed, but underdeveloped, it can be changed. And even if it’s destroyed maybe you can sometimes get around that, as in abuse. I want to make sure to say that. Neuroplasticity, as you’ll see in Stewart’s case, exists throughout the lifespan.”

Next Friday August 1: More current news and videos from Dan Siegel and his collaborators.

Next blog Friday August 8:  Siegel and Stewart’s journey… not forgetting Jill Bolte Taylor.


Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.


For biography, website, books and more: see Footnotes at bottom of

FN1   Siegel, Daniel J., MD, “How Mindfulness Can Change the Wiring of Our Brains,” National Institute for the Clinical Application of Behavioral Medicine (NICABM),; 2010 Webcast and my first NICABM webinar, downloaded March 31, 2011. Rebroadcast October 11, 2011. and

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Bruce Perry: No Empathy, No Survival

Dr. Bruce Perry, MD, “Born for Love:
“Why Empathy is Essential – and Endangered”
Address to The National Council for Behavioral Health
Washington, DC, May 4, 2014  – Click link or photo for video

“Empathy is what makes us human,” says brain scientist Dr. Bruce Perry, MD  –  but this has not sunk in for Americans.  If simple kindness isn’t enough, what about the minor fact that it’s brain science?  Or that by ignoring this basic fact, we’re violating biology, so we’re dying as a species?

To let Dr. Perry make his point, today I’ve just got a few quotes from his May 4 Washington DC address, to provoke you to watch the video kindly posted by the National Council for Behavioral Health.

”From birth, we seek intimate connections, bonds made possible by empathy — the ability to love and to share the feelings of others,” Perry begins. But “our  policies routinely violate the biological reality of empathy, and that’s destructive…

“For example, we pass on to the next generation explicit choices that we’re going to teach math — but not music…We don’t care if everyone learns to read and perform music or not, but they’ve got to do arithmetic…  We have extensive rules for all the things everyone has to learn to drive a car… but we don’t do the same for raising a child!  We don’t make any systematic recommendations, or ensure that everybody who’s about to have a child has the fundamental knowledge of what’s necessary for the child…

“We’re exposing our children to levels of violence as a problem solving technique, at rates that are at least 50 times greater than alternate methods of problem-solving…

“We have invented ourselves into a corner with technology… into models of child rearing, education, and building communities that is fundamentally disrespectful of two of the greatest (biological) gifts our species has:  the fundamental malleability of the human brain in early life, and the fundamental relational (empathic) nature of human beings…. As a result we are much more vulnerable to mental health, social health, cognitive health, and physical  health  problems.

Humans Need Humans Around to Live

Perry another headshot“Human beings are biological creatures with genetic gifts… The only way we survived was by forming relationships, collaborative relationships…  Human beings are neurobiologically meant to be connected to others: to live, work, hunt, play, invent, and die in groups.

“We use the word ‘independent’ a lot — but the truth is there’s not a single human on this planet, ever, that’s been independent.  All of our physiology is designed to connect to others, we have huge parts of our brain designed purely to respond to the non-verbal cues of others… it’s in the way our face is oriented, our facial configuration is forward, looking at people… We have sensory apparatus on our skin that’s meant to be touched… so that we can feel somebody caress us…

“Our brain is a social organ; we are social animals. We don’t have any natural body armor, camouflage, stinging other things. We form groups!  Human beings are ‘meat on feet’ to the natural world!  The only way we survive is by forming collaborative groups, by sharing what we hunted and what we gathered with everybody else in our group.  And the typical living group was a developmentally heterogeneous, multi-family, multi-generational group: 40 to 50 people.

“And in that group…  the ratio of developmentally more mature individuals who cared for you, protected you, nurtured you…  was four to one.  But now, we think it’s an incredibly enriched early child care environment if there’s one caregiver to six kids!  That’s 1/24  the relational density the brain benefits from…

“Today, the whole organization of society flies in the face of this… In the last census, one third of American households were one person.

“On top of which, now… the typical American spends 11 hours a day interacting with digital devices, and not with fleshy objects!  And I want to talk about the consequences of this for how we end up expressing our ability to be compassionate (or not)…. You see it all the time, complaints in the psychological literature about the disconnectedness of multi-tasking constantly with our phones… but we do it ourselves…  You’re talking to someone, then your phone will vibrate — and it pulls you away from them.

” It breaks the rhythm of social contact, of empathic engagement– and the truth is: those things are physiologically meaningful.”

Again, click here for video:

Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

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Allan Schore: What is the “Self”?

Allan Schore 2In March 2013, I was standing unknown in a crowd of professors and therapists at a UCLA conference, and noticed a quiet gentleman on my right.  I’d seen his photo online.  “Dr. Schore?” I asked.  “Yes,” said Allan Schore, turning calm eyes on me.

“I’m so grateful for all you’ve done to show that babies can’t control emotions, that’s the mother’s job to model, and emotions are ok,” I blurted,  suddenly in tears. “I’m writing a book on what it feels like on the inside, when we don’t get that as an infant.”

Dr. Schore didn’t flinch; his eyes grew wide with empathy. He got it.  He got a total stranger, right by the conference stage, got that I had walked through a hell of emotional pain to study this. He got that I was feeling love for him because he’s shown there’s a scientific reason for the pain.  He got that “emotions are ok” and only emotions from a caring other can heal this, so he gave me emotions: presence and compassion. On the spot. “We see it every day,” he said.

Just sayin’: he walks the walk.

UCLA professor Allan Schore is a world leader in Attachment Theory. He’s known as “the American Bowlby” after British psychiatrist John Bowlby who first wrote about attachment in the 1950s. [FN1]  Schore was among the first to put together the latest brain science on how an infant’s brain forms biologically (“developmental neuroscience”), with the early psychology of the infant mind (“developmental psychoanalysis”).

Dr. Schore’s 9-28-14 Oslo speech “The Most Important Years…the Right Brain and Its Importance” is a must-see to understand infant developmental trauma. He calls it  “trauma in the first 1000 days, conception to age two.”  Schore reviews how the theories he’s published since the 1990s are being proven to be hard science by today’s brain scan technologies (content starts minute 8):

Schore is known for documenting the “origin of the self”– what, scientifically, is the “Self”?  What is it that makes me, Me?

He calls it “the origin of the early forming subjective implicit self.” It’s entirely subjective; each infant has a different experience.  It’s “implicit memory” because the self forms in infancy when memory is only subconcious. It all happens years before we have thought and conscious “explicit memory” at age two or three.

This isn’t mere geek-speak; the mental, emotional, and physical health of all humans depends on it. We can’t remember what happened before age 3 when our self was formed, but the experience had massive impact. It’s all still “down there,” driving our feelings and behavior big time for the rest of our lives.

When the self is damaged during formation in early infant and childhood, a person can feel miserable all their life. The ACE Study shows this often leads to biological disease and premature death.

The Self and Emotions : Secure Attachment

brousblog4c Claire+MosesBabies are born with a massive level of emotions. Schore reports that they are  overwhelmingly dependent on the mother to show them how to handle it all. An infant’s brain doubles in size “from the last trimester of pregnancy through the second year,” he says. “At birth, there are hardly any cortical (conscious thinking brain) areas that are myelinated and online… so it’s impossible for the baby to regulate its own emotions…

The mother is the regulator of that baby,” he says, and this shapes the development of its entire brain. “Over the first year… the mother’s interactions are shaping the very wiring of those higher regulatory centers… Attachment communications which are emotional are forging the connections in the early developing right brain… The right brain literally is imprinted by these attachment relationships while it is being created…”  FN2

It’s all subconscious. With “secure attachment,” when a baby cries, the mother “attunes” to it. An “attuned” mother doesn’t say “think” or “ought to.”  She feels a strong, emotional urge to comfort her baby; she subconsciously intuits whether her baby cries because it’s hungry, wet, or tired. “The mother is able to pick up the baby’s communications,” Schore says. “She is not doing this by language, there is no thinking or language before age two.  She is picking up bodily-based nonverbal communications:  facial gestures, auditory tone of voice, and tactile expressions.  The attachment communication is more than between the mother and the infant’s minds; it’s between their bodies…

“She is psychobiologically attuning to the internal rhythms… of the baby’s autonomic nervous system and central system arousal…  It’s an attunement of mind and body. In doing so, she is regulating the baby’s rhythms and allowing the baby to create different emotional states that are associated with these different rhythms. This is not a matching of behavior; it is more of an intuitive matching of the internal rhythms of the baby.

“The baby is expressing these internal rhythms through the emotional communications it is sending back to the mother, in the prosody of the baby’s voice, or in the cry, or in the expression on the baby’s face, or in the gesture.  They are matching each other’s subjective state. Now, when two people match their subjective states, there is a sense of empathy, there is a sense of a bond; a sense that ‘someone’s body is exactly resonating with my body.’  When that occurs there is an amplification of arousal, and this amplification of arousal leads to things like joy states.”

Infants also have no sense of self.  Instead, Schore adds, there’s a “mother-baby continuum” for at least the first six months of life where the “dyad” (mother and child) often don’t know (and don’t care) where one person ends and the other begins.

We begin life as a sea of emotions, and then mom models for us again and again, that she can comfort our wild emotions. Unconsciously we pick up that skill. After we cry and mom comforts us for the millionth time, one day we feel our way to stop crying because we’ve “internalized” mom’s comfort. We subconsciously learn to manage emotions, to both enjoy good emotions, and also–very important–to tolerate and be able to fully feel negative emotions. Without fearing or repressing them.

This is also called “Emotional Object Constancy.”  Mom was an external object, but now we’ve taken her image inside us, so we feel loved and emotionally secure 24×7, even when we’re alone.

Our “self” begins when we first start to “regulate” our own emotions (“affect”) this way. When we realize we can feel our emotions and also modulate them, without screaming for someone else to do it for us? That’s when we first realize that we are not merely part of mom. We’ve got some independent “self.” “Essentially, one’s self-concept is focused around a positive sense of emotionality in the self,” says Schore.

Insecure Attachment and Trauma

Still Face Experiment 2Or not.

Back to how all babies are born with a massive level of emotions. We’re all supposed to receive all that attuning above, then we’re fine.

Or not.

What if we’re an “Or Not” baby?  What if we cry but no one comes?  Or what if someone comes, but they don’t have the neural equipment to attune, or they’re too distressed to attune?  “That baby learns that there is no comfort, that emotions are terrifying, and the world is a scary place,” Dr. Schore says. His colleague Dr. Ed Tronick shows this graphically in the “Still Face Experiment”– click for video.  [FN3]

That baby often does not develop much of a self.  To the extent no one showed it how to manage emotions, the day could not come when it could “regulate like mom.” It can’t regulate, so it can’t individuate.

That is really uncomfortable; it’s what’s behind the feeling that “I have a hole in me.”

All the above leave deep damage, even just passively.

Plus, on top of that: what if we cry, someone comes, and then there’s active aggression; we’re yelled at or physically maltreated?

A whole lot can and does go wrong for a baby. I call that a lot of Adverse Infant Experiences (AIE). “Aaiiee!” Double ouch.

Schore says this is the root of developmental trauma.  “In trauma there is an intense negative state about the sense of self,” he says, with “extremely high states and low states of arousal, an inability to internally regulate their state or to use other people to help them regulate their state and bring them into a sense of comfort.”

With insecure attachment, he says, “there are problems that the caregiver is having emotionally…  There is anxious insecure attachment, where the mother is preoccupied or unpredictable… There is also avoidant insecure attachment, where the mother is mostly cold…

“And there is ‘mind blindness,’ so to speak. There are some mothers who cannot read the tone of the baby… depressive mothers have problems reading facial expressions, especially the facial expressions and gestures of the baby. You see inter-generational transmission of these deficits…”

Schore first showed this scientifically in his three blockbuster books Affect Regulation and the Origin of the Self (1994), Affect Dysregulation and Disorders of the Self, and Affect Regulation and the Repair of the Self.  FN4

“Affect regulation” means we can freely feel our emotions without being emotionally blocked, we can enjoy our emotions–yet also be “on top”of our emotions, so they don’t feel overwhelming, painful or frightening.  If not, we suffer “affect dysregulation ” i.e., some level of painful emotional chaos.

We all know people who either can’t or won’t access their emotions, or others whose emotions go out of control to where they and those around them feel miserable.  Others  swing to both extremes, but never simply enjoy their emotions without freaking out or hurting people.

The good news is: there is repair, as Dr. Schore’s third book lays out in detail. At a support group, Al Anon meeting, therapist’s office, or with friends, repair means we find other humans to do exactly what Schore did for me on the floor of that conference: be present emotionally with another emotionally-attuned human being.

If we can sit for an hour and attune to another human willing to share our emotion state and help us learn to gradually shift and modulate it, we learn to “regulate.”  Brain scans now show that we can literally repair the neural circuits which remained painfully out of tune when we didn’t receive human attunement as kids.

It takes time, perseverance, courage, and real human beings like Allan Schore.  I’ve met them–they’re out there.  Find them.


Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.


FN1  Bowlby, John, “The Nature of a Child’s Tie to His Mother,” British Psychoanalytical Society, London, 1958; “Attachment and Loss,” New York, Basic Books, 1969

FN2  Schore, Allan N., PhD, “Affect Regulation and Mind- Brain-Body Healing of Trauma,”   National Institute for the Clinical Application of Behavioral Medicine (NICABM), June 15, 2011
Schore, Allan N., “The right brain implicit self lies at the core of psychoanalysis,” Psychoanalytic Dialogues  21:75–100, 2011
Interview with Allan Schore – ‘the American Bowlby,’  by Roz Carroll, UK ;  The Psychotherapist, Autumn 2001,

FN3  Dr. Ed Tronick of the U Mass Boston’s Infant-Parent Mental Health Program did his first “Still Face Experiment” work in 1975; his 2007 video  has over 1.3 million hits.  First a mother and child play in a responsive, attuned way, so the baby learns to interact with the world. Then she suddenly stops attuning. Video at:

FN4  Norton Textbook Series on Interpersonal Neurobiology:
Schore, Allan N., “The Science of the Art of Psychotherapy,” April 2012; 480 pages
Schore, Allan N., “Affect Regulation and the Origin of the Self,” Norton textbook May 2003; first edition 1994; 432 pages

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What Trauma-Informed Care Means to Me

IMAG3258 James, kid, bike“Rider for Change” James Encinas arrived by mountain bike at San Diego’s Cherokee Point Elementary May 2 to the delight of some hundred students, and visitors from around southern California. James, a career LA school teacher, is riding 3,000 miles from Sacramento to Philadelphia. He’ll take the southern route through Texas and Louisiana, then follow the Underground Railway by which African Americans escaping slavery crossed north to freedom.

James is riding to draw national attention to the need for “trauma-informed schools,” key to the movement for “Trauma-Informed Care (TIC)” in education, health, and all public systems. But what is Trauma-Informed Care, and what’s a trauma-informed school ?  (Hint: all the pix in this blog are from Cherokee Point).

“In medicine, a patient is sent to hospice when all medical procedures have failed, and they’re going to die. That says: we give care and comfort only when nothing else works,”notes Dr. Christopher Germer, psychology prof at Harvard Medical School and co-editor of Mindfulness and Psychotherapy.  Pretty crazy right there, if you consider. Been in a hospital lately? Often you’re a widget; they take your clothes away, don’t tell you what’s happening, and so on. [FN1]

IMAG3250 James, Dana Mom w. FoodBut when treating the real human being, “Care Equals Cure,” says Dr. Germer. If a therapist doesn’t care, he’s not going to cure his client. But it’s also true in any dealings with humans. “Care IS the practice of non-resistance to suffering which dismantles emotional suffering,” says Germer. “It means opening to emotional pain more fully, instead of trying to bypass it. Compassion opens the heart, reveals inner suffering, and makes the suffering available for transformation.” (Above: James and activists carry food donated for kids.)

“So the message is:  Stop fixing,and start caring,” Dr. Germer concludes. In fact, it’s brain science. Comfort, care, compassion reduce so much of a human’s fight-flight reflex, even in major medical pain, that this has been shown to heal surgeries faster. Pain and bodily trauma create enough fight-flight that the brain stem often shuts down the immune system, for one.  Compassion helps it come back online. “Let a wounded soldier talk to his mom and he’ll require 50% less pain meds,” says Dr. Bruce Perry, MD.

But could it be necessary or work well in schools?

History of Trauma-Informed Care (TIC)

IMAG3253 Dana w. Youth LeadersTIC goes back to 1994 when the federal Substance Abuse and Mental Health Services Administration (SAMHSA) began to study the remarkably high rate of women in the mental health system with histories of physical and sexual abuse trauma. It became clear that, since such clients came in already pre-traumatized, providers should be mindful lest their own practices and policies put the women in danger, physically or emotionally, or lead to re-traumatization. (Activist Dana Brown with youth leaders.)

These and related studies next showed high rates of earlier life trauma in clients seeking services for substance abuse, domestic violence, child welfare and many other areas. In 2005 SAMSHA created the National Center for Trauma-Informed Care (NCTIC) to assist all public programs to implement Trauma-Informed Care, not only in mental health, but in all services including criminal justice and the education system. [FN 2]

“NCTIC seeks to change the paradigm from one that asks, “What’s wrong with you?” to one that asks, “What has happened to you?” says SAMHSA. “Trauma includes physical, sexual and institutional abuse, neglect, inter-generational trauma, and disasters that induce powerlessness, fear, hopelessness, and a constant state of alert…often resulting in recurring feelings of shame, guilt, rage, isolation, and disconnection.”

It’s impossible to successfully  treat human beings in that condition without recognizing this and at least following the principle of “Do No Harm.”  “When a program becomes trauma-informed, every part of its organization and service delivery system is assessed… to include a basic understanding of how trauma affects the life of an individual,”  SAMHSA notes.

IMAG3271 Kids Raise HandsSchools are key, since all Americans are supposed to spend 13 years there. “If fixing school discipline were a political campaign, the slogan would be ‘It’s the Adults, Stupid!’,” says Jane Stevens, founder of ACEsConnection;  “More than three million kids are suspended or expelled each year” in the U.S., 3.4  million in 2006 according to the National Center for Education.  “But punishment doesn’t change behavior; it just drops hundreds of thousands of  kids into a school to prison pipeline.” (Above: Kids ask James questions.)

“Instead of waiting for kids to behave badly then punishing them,  trauma-informed schools are creating environments in which kids can succeed,” she says. It’s about re-training the adults to drop their fears and assume that kids are basically good, but something traumatized them, so they act out. Bad behavior isn’t accepted and it is corrected – by a dialog with kids to hear what’s hurting inside, and show them how to address it. “Focus on altering behavior of teachers and administrators, and kids stop fighting and acting out in class. They’re more interested in school, they’re happier and feel safer,” Stevens says. [FN3]

See the Grade or see the Person?

As SAMHSA began trauma studies in 1994, the Adverse Childhood Experiences (ACE) Study (1994-98) documented a shocker:  about 50% of Americans have significant child trauma. The 17,421 HMO clients studied were privileged to be mostly college-educated, have jobs and good health care. Yet more than half had two of ten types of childhood trauma: physical abuse; sexual abuse; alcoholic or drug addict parent; family member in jail; battered mother; parent with mental illness; loss of a parent; physical neglect, emotional neglect;  or verbal/emotional abuse.

The ACE Study compared their childhoods, to whether they later developed life-threatening physical conditions and/or addictions.  “It found that those 10 types of severe and chronic childhood traumas up the risk of adult onset of major diseases. But it also  increases the chances of being violent, a victim of violence and becoming chronically depressed,” Stevens reports in a terrific post on  Cherokee Point El.  “Brain research revealed one reason: the toxic stress of trauma damages the structure and function of a child’s brain. Kids get anxious and can’t sit still; get depressed and withdraw; get angry and fight; can’t focus and stop learning. They cope with anxiety, depression, anger by drinking, smoking, drugs, fighting, stealing, overeating,  and/or becoming overachievers on their way to being workaholics.”

What about not-so-privileged kids?  Child trauma and its mortal results must affect a far higher percentage of kids in low-income areas with less access to nutrition, health care, and on and on.  A huge percentage of American children suffer trauma, bigger than 50% if we knew the real national average.

IMAG3293 Big GroupMeanwhile many of us privileged middle class kids grow up to be teachers,  administrators, and so on. If we’re traumatized ourselves, we can’t feel our feelings– so we believe that considering “feelings” is idiotic.  Instead, we set up schools as a place to tell kids things.  Because adults talked at us, we think it’s adult to talk at kids. We tell kids they are there to listen to information and repeat it back as we want it, ie. “get the grade,” or face trouble. Enough to put anyone into fight-flight. (James Encinas, left, with students, Principal Godwin Higa, activists.)

I’m from that privileged middle class. I often say, “Nobody beat me or raped me; what’s wrong with me?”

IMAG3306 Higa & Crane AOn Feb. 25 this year, I heard Ruth Beaglehole, founder of Echo Parenting and Education, address Echo’s annual Los Angeles meeting. Urging the 150 professionals present to get passionate about raising awareness of child trauma, she said,  “Kids have to live in the real world? Make the real world non-violent and trauma-sensitive!  What about creating places where children can seek safety, where children can come home to people who open their arms, attune to them, and say ‘Tell me what happened today’. ” (Above: Principal Higa helps Cherokee students make origami cranes for charity.)

“Some people define that as a report card and demand, ‘I want to see your grades.’  Enough of these bloody grades!” Ruth said, to audience laughter, including mine. “Why do we accept this?  Why do we accept that that’s the definition of a person — their grades?”

Suddenly out of nowhere I began violently sobbing at my table full of therapists, about 20 feet from the podium.  “I see you,” Ruth said, looking straight at me. “You don’t have to hold it back.” She saw the real person I am, she didn’t need me to fake anything. She was willing to simply be with me in the pain, as Chris Germer said: “Stop fixing, start caring.” Boy did that feel good. [FN4]

I knew I always hated having to go out and get that grade, and it better be above 90 “or else.”  So I did it, but I lived in fear.  They didn’t see me.  I was a widget who had to produce results or there’d be trouble.

Back story? On Feb. 8, 2011, I’d just heard I might have a thing called “attachment disorder.” Late one night I dragged myself to the sink to wash, listening to a CD by Dr. Henry Cloud. He joked about a lady who didn’t like her husband to go bowling: “She’s not old enough to be dropped off at school.”  But it wasn’t funny.  [FN5]

“That’s it: I wasn’t old enough to be dropped off at school,” I journaled, “I was just dumped off.”  Terrified, I slumped in a heap sobbing, clutching a stuffed dog and a soggy toothbrush.  Rising an hour later, I couldn’t even brush my teeth without holding the dog. “I’m really frightened because I don’t know if this hole under my feet ever ends,” I muttered into my pocket recorder.

I didn’t know last February but read later that Ruth was born in New Zealand to prestigious academic parents who didn’t see Ruth, either.  “I baby-sat since age 12, trying to give to vulnerable children what I didn’t get,” she says.  So she took a BA in early childhood ed, moved to LA, got a Masters in family therapy, and grew Echo Parenting into an agency of 23 staff that trains 100 professionals a year in service.

IMAG3308 Trauma SignWhat if Ruth’s right? What if a school’s whole mission were to look at each child and say “I see you”?  “I see you as a human being, I care how you’re feeling today, and I care what feelings and fears you’re bringing in the door.  I care if you feel threatened even before you walk in the door.  I want to get to know you, the real you who is.  That way we can make you feel safe to be here in school.  And then, you’ll really want to learn!”  (One of many posters students did for James Encinas.)

Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.


FN1  Christopher Germer, PhD, “Open Heart, Open Eyes: Self-Compassion,” speech to 20th Annual Conference on Psychology of Health, Immunity and Disease, National Institute for the Clinical Application of Behavioral Medicine (NICABM), Hilton Head SC, Dec.2008
Dr. Germer [ and ] is a founding member of the Institute for Meditation and Psychotherapy, a clinical instructor in psychology at Harvard Medical School, author of The Mindful Path to Self-Compassion, and co-editor of Mindfulness and Psychotherapy. His meditation MP3 are here:   “Why Self-Compassion is Becoming a Psychotherapist’s Best Between-Sessions Tool,” Dr. Chris Germer interview by  Dr. Ruth Buczynski, Sept 13, 2009 is at

FN2  The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. Websites on TIC: ;

FN3  Jane Stevens, and

FN4 Ruth Beaglehole, founder of Echo Parenting and Education, address to Echo’s annual Los Angeles meeting “Developmental Trauma: Changing the Paradigm,” Feb. 25, 2014

FN5  Dr. Henry Cloud, PhD, “Character Discernment for Dummies, Part 2,” CD, Dec. 6, 2010,

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Music Therapy and Child Trauma

Vienna Boys ChoirWant to heal developmental trauma in kids?  Create children’s choirs, I wrote last week.   Dr. Bruce Perry says “patterned, repetitive, rhythmic regulation” is what regulates the brain stem, and when it’s not regulated, we can’t truly reach the rest of a child’s brain.

The brain science studies have been done on yoga, meditation, EMDR and so on — not on Bach.  But is that only because those scientists were never given the chance to sing Bach?  Chalk it up to the decline of education.  What if Bessel van der Kolk had sung in the Vienna Boys’ Choir?  (Ok, so he’s from Holland…)  Or haven’t I seen the brain science studies on choirs?  Please leave me a comment!

Plus: there’s a lot of science that shows music helps shape babies in the womb — and keeps them alive when they need it.  Science shows this “medical music therapy” helps people of all ages.  Put this with the fact that children’s choirs have been a keystone of civilization since at least 700BC  [FNO] and we start to see a pattern.

The Music in Your Cells

What we do know is that everybody loves music because every body loves music.  Music is literally built into the human cells, especially brain cells from the hour of conception.  Our bodies physically need it. Infants and children know that instinctively.  “The first music encoded deep within your memory are the earliest vibrations that made you – the rhythms and tempos of your first cells,” writes Galina Mindlin, MD, Columbia University Professor of Psychiatry. [FN1]

“As your cells began to develop with the comforting rhythms of your mother’s heartbeat and the whooshing low frequency sounds vibrating through her placenta and your umbilical cord, these first musical scores began entrainment (two or more rhythms synchronizing into one) in your brain and orchestrating the essence of music for your entire being.  So from your first spark of life, your brain was already establishing the relationship for how music affects you today…

“Newborns can almost immediately show some memory of sounds they encountered in the womb… Before any of us is capable of speaking words, we can recognize changes in notes and rhythmic patterns… Throughout all this development, lyrical and comforting ‘motherese,’ the singsong way in which parents speak to their children, plays a significant role in instilling feelings of calm, safety, and love…

“By only their 14th week, children can distinguish their mother’s footsteps from anyone else’s, and discriminate between their mother’s voice and a stranger’s… At the beach on any given day, we can see a man or woman lying in the sand… listening to the whoosh of waves and the easy hush of wind, smiling like a baby…”

“Music in its most primodial form links our brain to vibrations we experienced as babies that have both long- and short-term effect on our brains’ circuitry.  The core characteristics of music – rhythm, harmony, synchrony, resonance, and dissonance – can affect frequencies in our brain and extend their influence on our hormones, neurotransmitters, and essential enzymes, and can ultimately affect our focus, feelings, moods, motivation” and more. [FN2]

Music Therapy Saves Preemies

Joanne Loewy Sings to BabyDr. Joanne Loewy, Director of the Louis Armstrong Center for Music and Medicine at New York’s Beth Israel Hospital, saves lives of premature babies (and other patients) using music to replicate the auditory environment in the womb. I haven’t asked Dr. Loewy about choirs, but to me this work says worlds about what singing can do to regulate the physiology and thus the brains of kids.   Dr. Loewy sings to a newborn, above. [FN 3]

I first met Dr. Loewy by email shortly after the Beth Israel team she heads published a major study on medical music therapy for preemies  on  April 15, 2013.  First off, I was blown away to learn there exists a Louis Armstrong Center for Music and Medicine  at the top hospital in New York City.  It’s official: music is essential to humans!  [FN4]

I was also delighted when she invited me to see her for music therapy to heal my pre-concious anxieties from being an unwanted pregnancy.  Gosh, she trains music therapists worldwide and teaches  at the Albert Einstein College of Medicine. It was too long a commute from California.  But I started music therapy anyway and it sure works for me.

“By re-creating a womb-like environment through sound and music, music therapy has been shown to deepen infant sleep-state, support infant self-regulation, assist in the stabilization of breathing and heart rates, enhance parent/infant bonding, sooth irritability, re-enforce feeding/sucking rhythms and weight gain, and promote a sense of safety during painful procedures” faced by many preemies,” she wrote.

“Historically, we thought premature infants were best left alone in a quiet, closed incubator with no stimulation,” she told the press when the study came out. “But more recently, we’re seeing that the right kind of stimulation — particularly live, interactive music — can enhance babies’ neurological function and increase their quiet-alert state. . . . the more we can regulate the sound environment, the better they’re going to fare.”  [FN 5]

Dr. Loewy’s team studied  272 infants in 11 hospital neonatal intensive care units (NICUs). They found that live music matched to babies’ breathing and heart rates enhanced feeding and sleeping patterns. Parent-selected lullabies also seemed to promote bonding between parents and babies, easing the stress of the chaotic NICU environment.

The music also lowered parental stress, the study found — which is key, because anxious, fearful, clueless parents produce developmental trauma in their kids.  Parent-preferred melodies and entrained live rhythm and breath sounds enhanced quiet alert and sleep states, suck response, and oxygen saturation in premature infants and also  significantly reduce fear and anxiety perception in parents, they found.

Over two weeks, the 272 premature babies underwent several sessions of two instruments, singing and no music at all.  The instruments and lullaby singing style were intended to approximate womb sounds, said Dr. Loewy.  Two-tone heartbeat rhythms were played on a “gato box,” a rectangular wooden drum.  [Bruce Perry and Bessel van der Kolk speak  extensively on the primacy of the mother’s heart rate in determining fetal brain development. Dr. van der Kolk strongly recommends heart-rate variability regulating therapies for trauma. -kb]

Whooshing sounds [like those in the womb referenced by Dr. Mindlin and I suspect by numerous researchers] were produced by an “ocean disc,” a cylinder containing shifting metal beads.

For melody, parents were asked for a favorite song.  If it wasn’t a lullaby (one chose “I Heard It Through the Grapevine”; another, “Pick Up the Pieces”), therapists slowed it, changed meters to lullaby-like waltzes and adjusted lyrics.

“Lots of times you see parents bopping the baby up and down on their lap, and there’s no purpose to it,” Dr. Loewy said. “You don’t feel the music intention as much as if you have a song that a parent has chosen.”  If parents did not specify, researchers used “Twinkle, Twinkle, Little Star.”  Tempos were coordinated with babies’ vital signs, indicated not only by monitors but also by baby  eye movements and its chest’s rise and fall.

Researchers found that the heart beat gato box, the whooshing ocean disc and the  singing, all slowed a baby’s heart rate, though singing seemed most effective.  Singing also increased the time babies stayed quietly alert.  Sucking behavior improved most with the gato box. Breathing rate slowed most and sleeping was best with the ocean disc. Babies hearing songs their parents chose had better feeding behavior and gained more calories than those who heard “Twinkle, Twinkle, Little Star.” But the “Twinkle” babies had slightly more oxygen saturation in their blood.

“Many NICUs are noisy, or people put on random lullabies that are recorded,” Loewy said. “But it’s not just any recorded lullaby, it’s the power of the parent’s voice synchronized therapeutically . . . and the other two sounds can have a therapeutic benefit.”

Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.


FNO  Chorus members in Greek theater were trained in childhood from around 700 BC.  Greek theater always included a chorus, whose members also danced and spoke, but also sang:   Both boys and girls were trained to sing:
Greece and Rome founded many children’s singing schools:
The Schola Cantorum in Rome was formed in the seventh century to train boys in reading and singing.

FN1  Galina Mindlin, M.D., Ph.D is Assistant Clinical Professor of Psychiatry at Columbia University College of Physicians and Surgeons, and Supervising Attending Physician at the Department of Psychiatry in St. Luke’s Roosevelt Hospital Center.  She is Board Certified in psychiatry and neurology.  See also:

FN2  Mindlin, Galina MD, PhD, “Your Playlist Can Change Your Life: 10 Proven Ways Your Favorite Music Can Revolutionize Your Health, Memory, Organization, Alertness,”  Sourcebooks, Inc., Naperville, IL, 2012

FN3  Joanne V. Loewy, DA, LCAT, MT-BC,  is Director,
Louis Armstrong Center for Music & Medicine,
Beth Israel Medical Center, New York, NY  Websites: and
She is also Co-Editor-in-Chief, “Music and Medicine”

FN4  “The Effects of Music Therapy on Vital Signs, Feeding, and Sleep in Premature Infants,” Joanne Loewy,  Kristen Stewart, Ann-Marie Dassler,  Aimee Telsey,  Peter Homel
Online April 15, 2013; hard copy in May 2013 Pediatrics.
Full Text in PDF:
What’s Known on This Subject:
Recorded music, parent voices, and sung lullabies have been shown to increase oxygen saturation, nonnutritive sucking, and weight gain in premature infants.
What This Study Adds:
Parent-preferred melodies and entrained live rhythm and breath sounds can enhance quiet alert and sleep states, suck response, and oxygen saturation in premature infants and significantly reduce fear and anxiety perception in parents.

FN5  Pam Belluck, “Live Music’s Charms, Soothing Premature Hearts – Preemies and Sound,” New York Times, April 15, 2013,
Maureen Salamon,  “Lullabies Soothe Preemies, Parents Alike,” Philadelphia Inquirer, April 15, 2013 [webpage removed]

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Bruce Perry and Children’s Choirs

Cantoria1 Youths larger della_robbia_02I’ve reported Dr. Bruce Perry’s in Washington May 4 to talk on healing trauma at the National Council.

What’s that got to do with this sculpture of children singing in the Cathedral of Florence in 1436 to kick off the Renaissance?  Everything!

Dr. Perry says it’s brain science to regulate the brain stem with “patterned, repetitive, rhythmic regulation,” featuring yoga, meditation, deep breathing, and singing, principles so fundamental they go back to the dawn of man. [FN1]

Who can imagine life without singing?  In every culture, long before writing, the only way to pass down an idea was to sing it. Aryans have sung Vedas since 5,000 BC or before. Hebrews sang Psalms as far back as 2,500 BC, long before they were written down ca. 1400 BC. [FN2  ]

Want to regulate kids? Teach them to sing! Gathering children to sing in choirs was the core of the Greek educational system since at least 700 BC, and there were choir schools for kids in Europe at least since the 900s AD. [FN3]  Singing in choirs brings kids into organized personal connection with other living, regularly-breathing human beings.  Being connected and in harmony with other humans is what best regulates human beings – today brain scientists call it “limbic resonance.” [FN4]

Amira Willighagen 1Singing gives kids a voice!  Children have been known to sing gloriously even today. Watch 9-year old Amira Willighagen sing in Amsterdam last year.

She did it without any training.  Amira just went on the internet looking for songs, found this Italian aria, and learned it by imitating.  Clearly she found a terrific adult soprano – we can hear the inflections of a highly-experienced adult in Amira’s voice. [FN5]

St Thomas Choir1AOr take the St. Thomas Boys Choir of Leipzig. When J.S. Bach became music director in 1723, the choir school was already 511 years old. Click here for the boys singing a Bach “Gloria.”    [FN6]

Born to Sing

Cantoria2 Boys10-12 & Teens della_robbia22If a child can speak, he can sing; most kids can sing before they can speak. Training children to sing as young as possible is a principle of civilization. Electronic culture has forgotten it to our peril as our kids whack out on machine-made noise. We need a revolutionary approach as old as the hills.  We need children’s choirs on a mass scale.

These children singing on the “Cantoria” by Lucca della Robbia, sculpted 1431-36, were placed in the Cathedral as public ads, to urge parents to bring in their kids for training. This is the level of culture and education which later produced Bach, Haydn, Schubert and Beethoven. Was their genius just magic?  Why don’t we have composers today, who produce music on such a scale (and they did it all without electronic equipment) ?

Answer: Bach & co. were trained as children to sing harmonic, complex polyphony (4-6 different musical lines at once).  So complex, harmonic music was what they heard in their heads as little kids. They were bilingual; music was their second mother tongue.  To them, it was simple: as soon as they could hold a pen, they would just start to write down their musical ideas. That tradition continued in Europe until the end of the 19th Century.

And there’s another reason everybody loves music: it’s because every body loves music. Music is literally built into kids’ bodies from the hour of conception.  Our bodies physically need it. And kids know that instinctively, from infancy.

“The first music encoded deep within your memory are the earliest vibrations that made you – the rhythms and tempos of your first cells,” writes Galina Mindlin, MD and music therapist.

“As your cells began to develop with the rhythms of your mother’s heartbeat and the whooshing sounds vibrating through her placenta and your umbilical cord, these first musical scores began entraining (two or more rhythms synchronizing into one) in your brain… your brain was already establishing the relationship for how music affects you today…   Newborns can almost immediately show some memory of sounds they encountered in the womb… Before any of us is capable of speaking words, we can recognize changes in notes and rhythmic patterns…” [FN7]

The Mother of All  Trauma

Cantoria3 Boys 10-11 playing stringsWhat about trauma healing?  Consider this: from 1348-1350, the Black Death, the mother of all trauma, killed half the population of Asia and Europe. In Italy, Florence’s population was reduced from 120,000 in 1338 to 50,000 in 1351. Many thought civilization was finished. [FN8]

Then a handful of intellectuals devised the idea of a re-birth or “Renaissance,” a project to unite a new economics to feed the population, with the science, philosophy, and arts to uplift them.  Florence had a famous problem whose solution could inspire people with hope. At the city’s center lay the massive Cathedral of Florence, begun 1296 — but no one had any idea how a dome could be built large enough to cover such a space without collapsing. Work was also delayed by waves of plague for decades. The roof lay open for over a century as people prayed in the rain.

During 1402–1404, Filippo Brunelleschi and his friend Donatello visited Rome to study the ancient ruins and the Pantheon on which the Cathedral was modeled. They returned to build the first “classical” buildings in Florence. In 1420, Florentine banker Cosimo de’ Medici (1389-1464) bankrolled Brunelleschi to work  16 years to complete the first octagonal dome in history to be built without a wooden supporting frame. [FN9]

What did they do in that Cathedral? They brought in the children of the city and taught them to sing, to show there was hope for the future, that  the children could be saved from the jaws of death. These sculptures just above show that by the age of 9-11, kids were singing (and playing) complex four and six part polyphony.

Note the rounded mouths in all the sculptures (and in the St. Thomas boys). Vocal scholars can tell you what note they’re singing by how large of an egg-shaped mouth they’re making.

The dome was ready in time for the Council of Florence which opened in the Cathedral on March 25, 1436, the date often cited as the start of the Renaissance. Inside were featured these sculptures of children singing in the choir loft by Lucca della Robbia.  Flemish composer Guillaume Dufay and many of his colleagues were brought to Italy to teach advanced musical composition.  Dufay’s advanced motet Nuper rosarum flores was composed for the 1436 opening and sung from della Robbia’s choir loft by kids like these in the sculptures.

Cosimo de’ Medici and his grandson Lorenzo de’ Medici (1449-1492) also backed philosophers Marsilio Ficino and Pico della Mirandola. Pico’s 1486 “Oration on the Dignity of Man” stated the Renaissance Idea: each individual human soul is a divine spark of God, not a beast of burden as under feudalism.

Cantoria4 Boys 5-10 Sing-Dance1A webThese sculptures show that in Florence, the Dignity of Man began with the dignity of the children.  These kids have been taught to sing even younger, at 5 to 8 years.  Della Robbia did several sculptures of toddlers singing as well (more than I have space to show!).

Cantoria5 Infant singingEven infants sang, singing with their families perhaps while they learned to speak.This child is not much older than 2.  Kids who started this early acquired the experience it took to produce genius in many fields.

San Diego Trauma-Informed Renaissance?

I’ve seen this kind of singing of fine music in choirs make traumatized children happy.  Musicians who run children’s choirs will tell you that.

San Diego Childrens Choir1 earlyyears_collageThe San Diego Children’s Choir (right), founded 1990, now has 5 branches with  over 250 participants. It also has a neighborhood outreach program that spans many low-income areas full of traumatized children including City Heights and other areas.

City Heights is also where Principal Godwin Higa has been turning Cherokee Point Elementary into an advanced trauma-infomed school since 2008. Three professors at San Diego State and community organizers Dana Brown and Dorothy Zirkle worked with the City Heights community to develop a two-year $684,094 pilot project at Cherokee Point, the Wellness and Restorative Practice Partnership (WRPP), funded by the California Endowment.

I can’t be with Bruce Perry in Washington May 4, but I will be in San Diego May 2, talking to  my friend Dana Brown and other members of the San Diego Trauma-Informed Guide Team (SD-TIGT) about Bruce Perry, Bessel van der Kolk, and the brain science of trauma.  SD-TIGT is leading the way among county health and welfare institutions to implement trauma-prevention and trauma-healing practices in schools, medical, and social facilities.

If Principal Higa and Dana haven’t met the folks at the San Diego Children’s Choir yet, maybe I’ll be able to provoke something.  Even if they’ve met, maybe we can expand their forces. As a result of the economic crisis, San Diego just lost its opera company, the San Diego Opera.  The city must be full of struggling singers, school music teachers and private voice teachers who would jump at the chance to teach every child at Cherokee El to sing Bach.

Next step: find our Cosimo de’ Medici to pay these already financially-pressed musicians and educators, so they can put in the hours necessary every week at Cherokee El. Then stand back.

Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.



FN1  Lucca della Robbia, Cantoria (Choir Loft), shows children singing, dancing,and  making music to “praise the Lord” in the words of Psalm 150. Photos  at


FN3  Chorus members in Greek theater were trained in childhood from around 700 BC.  Greek theater always included a chorus, whose members also danced and spoke, but also sang. [ ]  Both boys and girls were trained to sing.  [ ]  Greece and Rome founded many children’s singing schools [ ] The Schola Cantorum in Rome was formed in the seventh century to train boys in reading and singing.
The Vienna Boys Choir, formalized in a 1498 letter by Maximilian I Habsburg, goes back to the year 957 when Bishop Wolfgang of Regensburg created his cathedral choir [  and ] The first choir school was founded at  St. Paul’s Cathedral, London in 1127, the second at St. Thomas’ Church, Leipzig in 1212. A boarding school for choristers at the Kreuzkirche in Dresden is mentioned in 1300, a choir known now as the Dresdner Kreuzchor. The Vienna Boys Choir received a solid musical education, many went on to become professional musicians such as Franz Schubert.
[ ].

FN4  Lewis, Thomas, MD; Amini, Fari, MD; Lannon, Richard, MD; “A General Theory of Love”, Random House, New York, 2000.  Lannon interviews :

FN5  Amira Willighagen video:

FN6  St.Thomas Choir video:

FN7  Mindlin, Galina, MD, PhD, “Your Playlist Can Change Your Life,” Sourcebooks, Inc., Naperville, IL, 2012  More here:

FN8  The Black Death was one of the most devastating pandemics in human history, peaking in Europe between 1348 and 1350 with 30–60 percent of Europe’s population killed. It reduced world population from an estimated 450 million to between 350 and 375 million in the 14th century.

FN9  Walker, Paul Robert, “The Feud That Sparked the Renaissance: How Brunelleschi and Ghiberti Changed the Art World,” Harper Collins, 2003

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Perry: Rhythm Regulates the Brain

Perry another headshotDr. Bruce Perry, MD is taking his healing for trauma to Washington in a May 4 program for the National Council for Behavioral Health.

And the doc’s got rhythm.  In fact, he and other trauma experts are reporting revolutionary success with treatments using yoga, meditation, deep breathing, singing, dancing, drumming and more.

These principles are so fundamental to our brains they go back to the dawn of man; the Vedas were sung before 5,000 BC (likely with yoga and meditation.)  My book describes how yogic chant and meditation saved my life in 2010, before I ever read a word about brain science.

One California county is trying to cancel such programs, insisting on Cognitive Behavioral Therapy (CBT) which relies on the thinking brain.  But Perry and many experts say talk therapy alone can re-traumatize trauma survivors.

Perry says we need “patterned, repetitive, rhythmic somatosensory activity,” literally,  bodily sensing exercises. Developmental trauma happens in the body, where pre-conscious “implicit memory” was laid down in the primitive brain stem (survival brain) and viscera. Long before we had a thinking frontal cortex or “explicit memory” function. [FN1]

The list of repetitive, rhythmic regulations used for trauma by Dr. Perry, Dr. Bessel van der Kolk, Dr. Pat Ogden and others is remarkable. It includes singing, dancing, drumming, and most musical activities.  It also relies on meditation, yoga, Tai Chi, and Qi Gong, along with theater groups, walking, running, swinging, trampoline work, massage, equine grooming and other animal-assisted therapy…. even skateboarding. Click here for Perry’s web page on interventions.

“I am asked how hip hop and skateboarding can help a child with depression or ADHD,” reports Dr. Sarah MacArthur of the San Diego Center for Children. “Yet 70% of the children showed improvement in symptoms of depression, anxiety, and PTSD.” [FN2]

The Brain Stem Rules

Perry simpler 4 brain from web“The brain organizes from bottom to top, with the lower parts of the brain (brain stem/diencephalon aka “survival brain”) developing earliest, the cortical areas (thinking brain) much later,” Perry says. “The majority of brain organization takes place in the first four years.

“Because this is the time when the brain makes the majority of its “primary” associations… early developmental trauma and neglect have disproportionate influence on brain organization and later brain functioning… When a child has experienced chronic threats, the brain exists in a persisting state of fear… and the lower parts of the brain house maladaptive, influential, and terrifying pre-conscious memories… ”  [FN3]

“People with developmental trauma can start to feel so threatened that they get into a fight-flight alarm state, and the higher parts of the brain shut down,” says Perry. “First the stress chemicals shut down their frontal cortex (thinking brain).  Now they physically can not think. Ask them to think and you only make them more anxious.

“Next the emotional brain (limbic brain) shuts down. They have attachment trauma, so people per se seem threatening; they don’t get reward from emotional or relational interaction.

“The only part of the brain left functioning is the most primitive: the brain stem and diencephalon cerebellum. If you want a person to use relational reward, or cortical thought – first those lowest parts of the brain have got to be regulated,” Perry concludes.

We must regulate people, before we can possibly persuade them with a cognitive argument or compel them with an emotional affect.

“The only way to move from these super-high anxiety states, to calmer more cognitive states, is rhythm,” he says. “Patterned, repetitive rhythmic activity: walking, running, dancing, singing, repetitive meditative breathing – you use brain stem-related somatosensory networks which make your brain accessible to relational (limbic brain) reward and cortical thinking.

“Cognitive behavioral therapy (CBT) is great if you have a developed frontal cortex – but we’re talking about a five year old kid who’s so scared to death most of the time that it’s shut down his frontal cortex ’cause he just saw his mother get shot,” Perry told an audience of therapists. “You’re going to do 20 sessions of CBT and expect change? That’s a fantasy.”  [FN4]

6 R’s for Healing Trauma

Perry NMT Bar Chart from webDr. Perry does separate developmental “maps” of each person (left) using his “Neurosequential Model of Therapeutics” (NMT). Each individual is so unique that using NMT needs training;  this blog is meant only to point you toward it. For an overview of NMT, click here for Perry, B.D. and Hambrick, E. (2008), “Neurosequential Model of Therapeutics.  Click here for training in NMT and Somatosensory Regulation.

Trauma healing, says Perry, requires 6 R’s; it must be:
Relational (safe)
Relevant (developmentally-matched to the individual)
Repetitive (patterned)
Rewarding (pleasurable)
Rhythmic (resonant with neural patterns)
Respectful (of the child, family, and culture)

“To change any neural network in the brain, we need to provide patterned, repetitive input to reach poorly organized neural networks involved in the stress response. Any neural network that is activated in a repetitive way will change,” Perry explains.

“The rhythm of these experiences matter. The brain stem and diencephalon contain powerful associations to rhythmic somatosensory activity created in utero and reinforced in early in life. The brain makes associations between patterns of neural activity that co-occur.

“One of the most powerful sets of associations created in utero is the association between patterned repetitive rhythmic activity from maternal heart rate, and all the neural patterns of activity associated with not being hungry, not been thirsty, and feeling ‘safe’ (in the womb).

“Patterned, repetitive, rhythmic somatosensory activity… elicits a sensation of safety.  Rhythm is regulating.  All cultures have some form of patterned, repetitive rhythmic activity as part of their healing and mourning rituals — dancing, drumming, and swaying.

“EMDR and bilateral tapping are variations of this patterned, repetitive rhythmic, somatosensory activity… We believe that they are regulating in part because they are tapping into the deeply ingrained, powerful permeating associations created in utero.”  [FN5]

For each child, the NMT develops a unique, personalized “map” (see above) of what the specific neurological damage has been, how far development has come (or not), and where the child needs to go. Next it creates “a unique sequence of developmentally-appropriate interventions,” says Perry. “While many deficits may be present, the sequence in which these are addressed is important. The more the therapeutic process can replicate the normal sequential process of development, the more effective…

“The first step in therapeutic success is brain stem regulation… Start with the lowest undeveloped/ abnormally functioning set of problems and move sequentially up the brain as improvements are seen…

“An example of a repetitive intervention is positive, nurturing interactions with trustworthy peers, teachers, and caregiver… using patterned, repetitive somatosensory activities such as dance, music, movement, yoga,  drumming or therapeutic massage…  This is true especially for children whose persisting fear state is so overwhelming that they cannot improve via increased positive relationships, or even therapeutic relationships, until their brain stem is regulated by safe, predictable, repetitive sensory input.” [FN6]

Sound like your family doctor saying “Go calm down in the gym” ?  I thought so – until I tried it.  It works, big time.  My story is here: “Dr. Perry: Music Makes Your Case.”


Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.


FN1  Perry, Bruce D., MD,  “Born for Love: The Effects of Empathy on the Developing Brain,” Annual Interpersonal Neurobiology Conference “How People Change: Relationship & Neuroplasticity in Psychotherapy,” UCLA, Los Angeles, March 8, 2013 (unpublished).
Library of articles on interventions, trauma, brain development:
Training in NMT Method and Somatosensory Regulation, Power of Rhythm — Individual and Site Training Certification Programs, DVD/streaming training, and online training:
Dr. Perry’s latest research and key slides: “Helping Children Recover from Trauma,” National Council LIVE, National Council on Behavioral Health, Sept. 5, 2013 at  (scroll down to Sept. 2013.)
Dr. Perry’s YouTube channel with educational videos in depth:

FN2  MacArthur, Sarah,PhD., “Wellness Innovations Transform Children,” San Diego Center for Children, June 2013,

FN3  Perry, B.D. and Hambrick, E. (2008), “The Neurosequential Model of Therapeutics (NMT),” Reclaiming Children and Youth, 17 (3) 38-43;  and
Dobson, C. & Perry, B.D. (2010), “The role of healthy relational interactions in buffering the impact of childhood trauma in “Working with Children to Heal Interpersonal Trauma: The Power of Play,” (E. Gil, Ed.), The Guilford Press, New York, pp. 26-43
Both at:

FN4  Perry, Bruce D., “Born for Love,” op. cit. FN1

FN5  MacKinnon, L. (2012), “Neurosequential Model of Therapeutics: Interview with Bruce Perry,” The Australian & New Zealand Journal of Family Therapy, 33:3 pp 210-218,

FN6  Perry & Hambrick, op. cit. FN3

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