Meeting Children Where They Are: The Neurosequential Model of Therapeutics

Perry’s Sequence of Engagement is guided by the understanding that when the lower brain is not regulated, well-organized, and efficient the higher brain regions such as the cortex cannot function optimally. When kids are dysregulated or upset, they have little access to the cortex's logic, insight, and reason. Youth with complex trauma histories often struggle with poor behaviors related to low-brain dysregulation, particularly in the areas of sensory integration and self-regulation. In traumatized kids, over-reactions to sounds and touch, hyperactivity, or an inability to smoothly change activities and make transitions are all common behaviors. The NMT helps us recognize these behaviors for what they are: the result of the child’s low-brain dysregulation and sensitized stress response system. Unfortunately, when children are in distress and even in full-on meltdown mode, most parents, teachers, and even therapists are trained to view these behaviors as deliberate choices and respond with “top-down” cognitive approaches. These techniques put us squarely against the brain’s natural survival functions, and more importantly, they just do not work. No amount of talking, reasoning, or reminding a child of the rules ends a meltdown. Until the child is regulated, they cannot reason.

When my son was a preschooler, he had a particularly ugly meltdown in the grocery store. As he lay kicking and screaming in the cereal aisle, I used every parenting technique I had been taught. I redirected, ignored, counted to 10, calmly explained the consequences of his actions, firmly explained the consequences of his actions, then angrily told him he was making me sad and that I was very, very disappointed in him. Nothing worked. I finally picked him up, and we left the store. The next day as I described the situation to his therapist, complaining that my 4-year-old child with a history of neglect and food insecurity, "Just didn't respond to reason," the gentle and wise clinician placed her hand on top of mine and replied, “Yes, that’s true, but remember, you can’t teach a drowning child how to swim.” She explained that what I saw as a defiant meltdown after being told no to sugary cereal in the grocery store was my son's sensitized stress response system reacting to the fear of not getting his needs met. My lectures, well-thought-out explanations, and attempts to convince him through the threat of consequences would never work. To have full access to the logical, rational parts of the brain, the low brain must be regulated.

When we use the NMT as our guide, we focus foremost on regulation through the body and the senses. Engaging with kids through sensory activities like snuggling under a weighted blanket or swinging in a hammock or through movement such as taking a walk or jumping on a trampoline is vital to regulation. Patting my son's back in a slow yet steady rhythm, removing the sensory stimuli of the bright and noisy arcade—these regulate him. Lecturing him about the consequences of his “bad choices” and asking him to reflect on how his behavior impacted me in the grocery store only escalated him.

First, we regulate, then we relate. Relationships are vital in creating a sense of safety and security in children with trauma histories. Adult regulation in the face of the child’s distress and misbehavior is critical. It is easy to become frustrated, irritated, and angry with youth who appear defiant and non-compliant. Yet, it is imperative for adults to maintain a calm, regulated presence in these moments. An angry expression, loud voice, or threatening body posture do not create a sense of safety or positive behavioral change but will typically increase the child’s fear and agitation, leading to even more escalation.[3] Building co-regulation, a state where the adult’s calm, caring presence helps soothe the child, is integral to healing interactions with traumatized kids.

It is only after regulation and relationship that we can begin to reason. This means kids (and adults) must be calm, regulated, and feel safe before they can start the process of learning from or reflecting on their behavior. Only when the child is in this state can they think about what they did, attempt to understand why they did it, repair the mistakes, and reflect on how to avoid these situations in the future. In the reason state, the child can think and talk about what happened, noticing—like my son at the arcade—how emotions, sensations, or the environment may have played a role in their behavior. It took a lot of time to build a strong, healthy relationship and a great deal of commitment to finding the most effective regulation techniques for my son, but his healing, growth, and tenacity were apparent that June day, as The Sequence of Engagement unfolded in real time.

Dr. Perry’s 6 R’s

The 6 R’s are a framework for creating the rich developmental experiences needed to heal trauma. Deeply weaving these tenants into our teaching, treatment, and parenting gives us the decision-making tools to support and strengthen development and mitigate adverse experiences.

1. Relational (safe)

The importance of relationships in healing early trauma and broken attachments cannot be overstated. It is only in the context of relationships that a child’s most critical developmental skills are learned. This is readily apparent when we think about how children learn language. It is only through the relational interaction of a parent talking to them or hearing conversation between adults that infants learn how to speak. Children with histories of maltreatment, neglect, chaotic caregiving, or broken attachments often struggle to feel safe, trust others, or participate in healthy relationships.[4] Because of this, it is critical for adults who care for and work with traumatized children to prioritize relationships. Only when children feel safe and connected can they can learn new skills, grow, and heal.

Tips for building strong relationships:

• We all long to be seen, heard, and understood. Even when kids are misbehaving or dysregulated, adults can engage with empathy, validating their feelings and assuring them that they are not alone in their distress.
• Approach challenging behavior with curiosity, not judgment. Asking a child how you can help or what they need gives us valuable insight into their behavior. Judging behaviors often leads us to assumptions about the child’s motivations or character.
• Be aware of your facial expressions and tone of voice. Children who have been abused and neglected often perceive neutral faces as angry and demonstrate poor recognition of the meaning of facial expressions overall.[5]
• While traumatized kids crave relationships, the intensity of emotional closeness can often be overwhelming or triggering, causing them to shut down or even lash out. When seeking relational opportunities with youth, adults should allow them to have as much control as possible. While we often think connection means looking each other in the eye and sharing our most profound truths, this kind of interaction can be incredibly overwhelming for children with attachment challenges or trust issues. Being side by side, sharing an experience, or completing activities in the same space, and offering, not forcing, interaction, can break down the barriers that children who have lived with trauma and neglect have built to protect themselves.

2. Relevant (developmentally matched to the individual)

Adversity and trauma cause children to have lagging skills in multiple developmental realms; for this reason, we must meet kids where they are. While it sounds simple, this is often incredibly frustrating for parents and professionals who feel children should perform at their chronological age level rather than their developmental age. Carefully observing, reflecting on, and recognizing a child's strengths and weaknesses helps adults have reasonable expectations and know the right times to challenge a child and stretch their skills. In his book What Happened to You? Conversations on Trauma, Resilience, and Healing, co-written with Oprah Winfrey, Dr. Perry states, "It really is never too late. Healing is possible. The key is knowing where to start the process. And matching the developmental needs of the person."[6]

Tips for creating developmentally relevant interactions

• Invest in a new way of thinking. When adults see misbehaviors as lagging skills, they are more apt to respond with kindness and support rather than anger and punishment. Parents, educators, and clinicians must focus their interventions on teaching and strengthening skills rather than shaming kids for their mistakes.
• Have flexible expectations. Remember that stress makes it more challenging to learn and perform. Drop rigid expectations and increase support, especially when children are in new environments, making transitions or among overwhelming sensory stimuli.
• Take note of your child’s lagging skills and strategize about what they might need for support. If you know that loud or chaotic environments or events with lots of relational expectations lead to meltdowns and misbehavior, make sure to plan carefully. Packing a go-bag of sensory tools like fidgets, noise-canceling headphones, crunchy snacks, and chewing gum; remembering to take plenty of breaks during challenging activities; and planning for a quick exit if things get rough can be lifesaving.

3. Repetitive (patterned)

Repetition is essential for creating changes in the brain. This neuroscientific principle is often expressed by the phrase, “neurons that fire together, wire together.” Patterned, repetitive experiences are the basis of all therapeutic and educational growth. Caring adults must provide many opportunities for kids to strengthen their skills and experience safe and healthy relationships. Repetition creates strong neural associations, so the more developmentally rich experiences we can create for our kids, the stronger and more resilient their brains become.

Tips for incorporating repetition:

• Make the child’s life predictable. Routines and consistency create safety and regulation. Have daily schedules, let your child know what's coming next, and provide structured activities that are not overly rigid but feel consistent and supportive.
• Repeat expectations often, even in situations that are common or familiar. For example, while parking the car before having dinner at a restaurant, remind children that they will need to remain in their seats and chat with the family, color or draw, or that they may ask you to take them for a walk while waiting for the food.
• Create multiple opportunities for youth to engage in positive relational interactions. Promoting healthy connections with teachers, coaches, community, and family members allows kids to create new beliefs about themselves, others, and the world. Relationships re-wire the brain.

4. Rewarding (pleasurable)

The human brain is highly motivated by pleasure. We all understand that if an activity or relationship feels good, we want to do it. If it does not feel good, we are not likely to seek it out or may even actively avoid it. When children receive an intrinsic reward, they will typically return to the activity or relationship over and over, without the adult even prompting them. Reward leads to repetition!

Tips for creating rewarding developmental experiences:

• Set aside time for play. Play performs multiple essential roles in child development. It strengthens the imagination; allows children to explore relationships and learn social skills; and helps with problem-solving and physical development. For kids recovering from maltreatment, play can be a way to express big emotions and fears and a safe means to connect with adults. Think of play-time as a way to build your child's skills, form or deepen relationships, and stimulate growth after trauma. Simply adding five minutes of child-directed play to your daily to-do list can develop your child’s confidence, relationships, and resilience.
• Use children’s interests and preferences to provide opportunities for learning and connection.

5. Rhythmic (resonant with neural patterns)

In a 2018 interview, Dr. Perry said, “One of the most destructive effects of trauma is when the stress response systems of the brain become dysregulated...patterned, rhythmic, repetitive activity can restore regulatory balance.”[7] Patterned, repetitive activities get the body ready to learn by balancing and organizing the low brain. Remember, rhythm regulates.

Tips for incorporating rhythm in your interactions:

• One of the most common rhythmic regulation techniques is rocking and singing to an infant. While you may not rock an 11-year-old, you can listen to or make music with him. Creating calming playlists for your home, classroom, or office (songs with 60-80 beats per minute are recommended as they mimic the rate of the human heartbeat); choosing a transition song to play when shifting activities; or working together to create a chant, poem, or rap are some doable and straightforward examples of rhythm at work.
• Playing handclapping games or reciting poetry and nursery rhymes are great ways to spend long car rides or time waiting in lines.
• Do not wait until kids are dysregulated. Be proactive. Add planned rhythmic activities such as dancing, drumming, swinging, walking, and breathwork into the day to keep both children and adults regulated.

6. Respectful (of the child, family, and culture)

All trauma-sensitive interactions must be based on a deep respect for the child, family, and culture. Perry writes, "Marginalization is a fundamental trauma."[8] Dismissing or invalidating the experiences of an individual or group creates dysregulation and a lack of safety. Environments that foster respect for the whole child promote growth, healing, and resilience.

Tips for respectful developmental interactions:

• Remember that children’s emotions are real and valid. It’s easy to dismiss children’s feelings as silly or inconsequential, particularly if they are communicated in ways that feel irritating or over-the-top to adults. Relationships are strengthened when adults can co-regulate, actively listen, reflect the child’s thoughts and feelings, and communicate empathy.
• Be aware of the impact of race and culture on adopted children’s identities. Research indicates that raising transracially adopted children to be "colorblind" or ignore racial differences often causes them to feel “racially alienated with an unavoidable experience of racial stigma that was invalidated by parents."[9] Providing children with racial mirrors, initiating conversations about race, and learning from adult transracial adoptees is crucial for adoptive parents.

I spend far more time making dinner and driving kids to school than I do studying the inner workings of the human body, yet over the past decade I’ve watched my son’s brain grow. I’ve seen his sensitized stress response system become less reactive and more responsive through rhythmic, repetitive activities. I’ve watched his attachments grow as his relationships increased, both in number and in quality, and I’ve seen our family and this amazing boy make the leap from surviving to thriving. I’m a mom, not a neuroscientist, but the Neurosequential Model allows me to think like one, to meet my kids where they are, and to celebrate them as they heal and grow.

Further Resources to Explore

• Neurosequential Network
• Harmony Family Center’s Harmony@Home
• 31 Days of Sensory Play, Sensory Activities for Kids
• Healing in the Context of Relationships Tip Sheet