It turns out that neglect can dramatically lead to brain damage in children who are exposed to the neglected care. Here you read more about what is happening and about how you can recognize and understand the children who have been exposed to neglect.

 Image: Dreamstime (with licence)



This article is based on excerpts from the training package prepared under the auspices of the Quality Municipality project in Region West, and which is aimed at kindergarten employees to strengthen their competence in detecting and measures in the event of neglect or for children at risk of neglect. 

How does the brain work?

The brain is use dependent. That is, the development of the brain largely depends on how it is used. It is about the brain sending signals through neurons, and that the "pathways" that are used a lot get stronger and stronger connections; while the "pathways" in the brain that are not used become weaker.

The pathways of the brain can be understood as establishing a path in the forest. In the start, no distinct path exist. But If you follow the same route over and over again, this path turn increasingly more distinct and eventually an established path. The places you never go, on the other hand, do not become a path - but grow, like forests do.  





During the first five years of life, the mass of the brain is tripled, and there is an overproduction of connections in the brain. In other words, a "major cleansing" of nerve pathways in the child's brain begins in the first years of life, and here the child's interaction with his surroundings plays a significant role in how the child's brain weaves together its experiences.

The brain is organized in a close interplay between the child's genetic predispositions and the experiences the child makes from "being in the world." Thus, it is never only the genes that determine how the child's brain development behaves, nor is it ever the case that only environmental influences determine the brain's development. On the contrary: it is in the interplay between heredity and the environment that the child's nervous system takes the development that it takes.

 





Theories and research on early care and brain development

A lot of research has been done which has clearly shown that brain development is closely related to whether or not a child receives sufficient good care. Here are some of the most important theories and research findings in the field.

  

Sensitive care: Mirroring and tuning-in to the child

Daniel Stern studied early affective interaction between mother and child, that is, the emotional contact and communication that takes place very early in the child's life between the child and its mother. He introduced the concept of "mirroring" - as a caregiver to be able to capture and tone down the child's emotional state, and in this way to give the child the experience of being mirrored, understood and regulated by his caregivers.

Daniel Stern believes that the basis for how the child's self-esteem is formed already in the first months of the child's life, and emphasizes that the close interaction between the caregiver and the child is important for teaching the child the ability to "self-regulate"; to be enabled to regulate one's own emotions in the face of life's joys and disappointments.

One of the key injuries often seen in children who have been exposed neglect is precisely the lack of ability to regulate the intensity of one's own emotions.

 

Still Face experiment

This video illustrates that children are extremely sensitive to how caregivers relate to it. In the video, we see how the child is in "share joy with me" moments, and that whining and complaining occur when the child experiences that it is not seen.

Now, of course, children do not need to be seen in this way all the time (it would be incredibly tiring for both the child and the parents), but the child needs repeated experiences with this form of interaction characterized by emotional toning. Then the child learn that a sensitive relationship with the parents is possible and available when needed.

How do you think it is for the child to never achieve this sensitive contact, for example due to parents being intoxicated most of the time?

 

An exercise to demonstrate mirroring

A simple group exercise has been made that can illustrate the effect of not being met with mirroring. Here is the exercise:

Divide the group into two-by-two. Let one person have the role of him/her that will talk about something (e.g. about how the morning was today), and let the other person have the role of the one who will listen.

Step 1: The listener should now be "normally interested" in the conversation. That is, he / she must listen and show proper interest in what the other person is saying. Duration: 20 seconds. Mark the transition with a single signal.

Step 2: The listener should now be unconcentrated and pay little attention to the speaker. Duration: 20 seconds. Mark the transition with a single signal.

Step 3: The listener should now take a "still face", i.e. he / she should now not show any kind of emotional expression, but be like an expressionless stone. Duration: 20 seconds. Cancel the exercise.

Afterwards there is a small group discussion: How did it feel to be the one to speak? How did it feel in the different phases? How did it feel to be the one to listen? How did it feel in the different phases?

Common reactions are that the speaker literally feels anxious, unconcentrated or angry when the listener clearly shows little interest. And this despite the fact that everyone knows that it is an exercise. It is also common for the listener to find it difficult to be so dismissive; many people start laughing because it "feels awkward".

This exercise illustrates that we are programmed to respond emotionally to being met with poor mirroring. It shows how the emotional brain can be activated in interaction with other people, and that this happens on a more basic level than what the thinking brain manages to override (read more under the section "the threefold brain" below).

 

Attachment between child and caregiver

John Bowlby was another important theorist. He studied children who had been exposed to neglect, and he developed what is later known as attachment theory.

Central features of the theory are that attachment is an invisible, emotional bond that arises between the child and the adult. All children are biologically prepared to form attachments to their caregivers. Children form a connection with their caregivers even when the caregivers expose them to neglect. This means that a strong attachment between children and parents does not have to be a safe attachment.

 

Disorganized attachment style

This film explains what a disorganized attachment style is and how it arises. In short, children can develop a disorganized, chaotic pattern of behavior when the caregiver is the source of fear.

Thus, children who are exposed to violence, abuse and neglect often has a strong attachment to their abusers, but also an insecure attachment.

 

Understimulation and being abandoned

A key idea in attachment theory is all children seek a caregiver who is bigger, stronger, wiser and good. But what happens when this care fails, and a child miss a caregiver who offers the child security and comfort?

Harry Harlow performed a series of animal experiments that examined how outright neglect could create lasting damage. He studied monkey babies who were robbed of their great-grandmothers in their first months of life.

He found that the monkey babies were anxious, hyperactive and socially maladapted - even after being put in contact with other monkeys at a later date. The neglect that the monkeys had experienced left lasting traces, and meant that they had extensive problems with "self-regulation" even in adulthood. The monkeys had a permanent impaired social functioning, which never recovered.

 

Animal studies of neglect

Video: Harry Harlow - Animal studies of neglect

 

Neuroaffective developmental psychology

Neuroaffective developmental psychology is a relatively new direction within psychology. The theory tries to link attachment theory to neurobiology (research on brain development). Susan Hart is a major contributor to the theory, writing the book "The Sensitive Brain."

A key premise in neuroaffective developmental psychology is that the brain develops in the interaction between child and caregiver, and that the quality of the interaction is important for how well or poorly the child develops the ability to self-regulate.

A consequence of the theory is then that achieving good and supportive interaction between children and caregivers can provide lasting, positive brain changes in the child, by using new skills in the interaction with the caregiver (e.g. that it is possible to be met with understanding even when I myself lose control).

Through repeated experiences that "it is safe to be me", "I am valuable", and "the adults wish me well", paths and tracks are created in the brain, which will increase the child's opportunities for mastery later in life. It is, so to speak, an increasingly strong thinking brain that takes hold, and which increasingly gains experience that it is possible to take on a captain role / managerial role over the ever-changing sensory and emotional impressions.

  

What is good enough care?

An important question in relation to the topic of neglect and neurobiology is what characterizes good enough care, what can be characterized as a care in the risk zone, and what characterizes a neglect situation. There are different ways to approach these questions.

 

What is neglect?

Important parental qualities are the ability to have empathy with the child, to see the child as it is, to engage positively emotionally in the child, and to have realistic expectations for the child's development (NOU 2009: 8). 

Neglect may include the following:

 

  1. Malnutrition or "passive physical abuse" entails a lack of satisfaction of children's physical needs such as severely deviant nutrition, a lack of protection against physical dangers, a lack of hygiene and clothing that does not suit the weather and temperature.

  2. "Passive mental abuse" or "mental neglect" includes gross understimulation and indifference and lack of consistency and comprehensibility in upbringing to such an extent that it inhibits the child's development.

  3. "Active physical abuse" includes aggravated violence against children in the form of beatings, burning, starvation and the like.

  4. "Active mental abuse" means that the child's caregivers show a hostile attitude that is expressed through disparagement, ridicule, threats of punishment, etc.

  5. "Sexual abuse" is defined as sexual activity between an adult and a child, where the adult exploits the child's dependence and immaturity for his or her own sexual satisfaction, and this is also obviously a form of neglect.

According to Kari Killén, different ways of exercising neglect are not mutually exclusive, and children in neglect situations are not necessarily exposed "only" to one of these forms of abuse, mistreatment or neglect. Killén also points out that in all forms of neglect, there are common elements that apply with varying strengths. These elements relate to lack of recognition of and respect for the child's needs; to rejection and indifference; and to not prioritizing the child's most basic needs over their own.

 

The attachment system

According to attachment theory, children develop attachment strategies that are based on experiences of how caregivers respond to the child. The attachment strategies are based on an inner "working model" that the child forms, which is primarily unconscious and which tells the child how he / she must act to have his / her needs taken care of, how far one feels valuable to his / her caregivers, how far difficulties can be handled. , and how to seek support and help when you feel insecure.

Important parenting characteristics that may be important here are:

 

  1. How sensitive are the parents of the child?
  2. Are the parents able to read the child's needs in a good way?
  3. Do the parents share joy and give positive attention to the child?
  4. Do the parents protect the child when he/she feels insecure?
  5. Do the parents comfort the child?

In short, children can develop a secure attachment, which implies an inner conviction that the caregiver is always there for me, available, responsive, and able to help and protect me; or one can develop different variants of and degrees of insecure attachment, which then implies a lack of reassurance that the caregiver is always there for me, available, responsive, and able to help and protect me.

Attachment is both related to the re-establishment of security after something stressful has happened (comforting, helping, calming down, finding solutions), and to share positive emotions in general (sharing joy with the child, enjoying the child, creating commitment and zest for life ).

It is important to know that children's attachment strategies can change. It is possible to progress towards a secure attachment in children who have had a difficult start. There are no parents who are perfect, and it is not about giving perfect care - but about giving "good enough" care, which over time provides the child security in their attachment to other people. 

 

Affect regulation

Through a good interaction between child and caregiver, the child strengthens his or her ability to regulate affects (emotions).

Development of affect regulation is related to the extent to which caregivers help the child to minimize unpleasant feelings, and also to share and reinforce pleasant feelings.

Psychologist Day Nordanger explains that sensitive care strengthens the regulatory functions of the brain. By giving children good affect regulation in a safe and predictable interaction, the child's competence in gaining control over emotions is strengthened, in giving the thinking brain (see section below) experiences of mastering affects and emotions that arise, and the brain's regulatory functions are through such repeated mastery experiences strengthened.

 

The sensitivity scale

Tools have been developed to be able to measure and assess how good care competence parents show in relation to their children, and "Care Index" is one such tool.

The following observations about the parents' interaction with the children give indications of "good enough" interaction:

 

  1. 14–13 points: mutual joy, joy over each other; a dance
  2. 12–11 points: soft, pleasant interaction, playful, common positive feeling
  3. 10–9 points: quite satisfactory, no problems, but no dancing
  4. 8–7 points: adequate play, but clear periods of dissynchrony (controlling or passive)

Scores below seven are described as types of interaction where there is a need for parents to get help:

 

  1. 6–5 points: inadequate / rigid / awkward («inept»). Clearly unresolved issues

The following types of interaction are considered to be compatible with neglect:

 

  1. 4–3 points: clear lack of empathy, lack of playfulness, yet some weak (insufficient or unsuccessful) attempts to respond to the child
  2. 2–0 points: total lack of perception of or attempt to alleviate the child's anxiety; no play

 

Interaction: Good enough - at risk - neglect

In the article "Early mother-child interaction in Norwegian families", Kari Kiléen describes three examples of interaction between caregiver and child who each fell into their own category of the above.

 

  1. Good enough interaction

    Child 3 months: The child stands on the changing table and smiles at the camera while the mother undresses it. Mom says "Mom is here, you see". The child leans against the mother and turns to her. Sits down. The mother finds a tube and gives it to the baby. She bends down at the height of the child, and they smile warmly at each other. The child turns to the camera and watches for a while while the mother gently strokes it on the left leg. The child turns to her again, and they smile at each other. They look at each other for a long time, and the child reaches for the mother, who helps him to get up again. Looking at the mother's face. Both smile. They start playing a little by shaking their heads. The child laughs. Suddenly they bark at each other and both stop in horror. Mother says "now we are going, did it go well?". She looks at the child, who quickly smiles at her again. The mother lays the child down and gives it back to the tube. The child laughs. Mom strokes it on thighs and abdomen. The child looks at the camera, smiles and laughs when the mother bends down and makes noises. Mother continues, and the child laughs happily.

  2. Risk interaction

    Child 3 months: The child is lying on his back with his face facing the camera, smiling. The mother tries to make contact with the child by poking it a little on the cheek and drumming on the child's lips. The child does not react, but lies in the same position, with the same smile. The mother pushes her head down against the baby's stomach, but still no reaction. She tries to pull it in her arms, strokes it over her head and bends down so that they are face to face. The child turns further away. The mother lifts the child so that it has to look at her for a moment, but it quickly turns to the other side. The mother then takes the child's head and holds it firmly, at an angle to her and kisses it on the body and head. The child fights with his arms, turns away and looks at the camera, still with the same unchanging smile. Mom asks several times, "Aren't you going to look at Mom a little?" She then lifts the child up in a standing position and shakes and twists it, giggles. The child is like a rag doll. Mother takes the child and lifts it several times high in the air. Puts it down again. The child turns away quite quickly and makes some noises.

  3. Neglect interaction

    Child 7 months: The child lies on his stomach and explores a toy. The mother does not show interest in the play that the child is interested in. She looks for several toys in the basket and brings one by one to the child without showing or stimulating the child to engage in them. The child continues with his play, but is not allowed to rest. After one minute, the child loses balance, rolls over on his side and lies in an uncomfortable position. The child expresses this with whining sounds, without the mother doing anything to help. The child manages to roll back and lies on his back. After sitting passively and laughing to herself, the mother abruptly bends over the baby with her long hair covering the baby's face. The child fights uneasily with his arms, and sends small protest sounds. Mom laughs.

 

Brain systems that are affected by neglect

The brain is very complex and it is therefore difficult to give a complete description of how care or failing care affects the development of the brain. At the same time, it must be emphasized that it is in the interplay between heritage and the environment that the individual child develops with his or her strengths and limitations. It must therefore be warned against theories that simplify the view of why the individual child becomes exactly as he or she becomes.

However, some systems in the brain can be described here that have been shown to be highly relevant in relation to understanding children who have lived under severe inadequate care.

 

The fight-flight system

This video provides an explanation of what the fight-flight system is all about and how it works. It is a built-in system in the brain that enables us to survive in the face of acute dangers / threats, something we clearly demonstrate in the video with the man who just escapes being run over.

 

The fight-flight system is a built-in system in the brain that enables us to respond to danger and threats by mobilizing the body to go into fight or flight mode. Simply put, this system triggers the fear response. The fight-flight system is something that both animals and humans are equipped with, and it basically works the same way. When one perceives danger (through sensory impressions), the brain automatically turns on the body's "alarm system."

Adrenaline, norepinephrine and cortisol are then immediately excreted in the blood, and this initiates an enormous mobilization of energy in the body. It is perfectly normal to react to danger / threat with fear, and it is a sign that the brain is functioning properly. Normal symptoms that the fight-flight system is activated include sweating, palpitations, high heart rate, dizziness, the skin turns white, stomach ache, feeling of fear, numbness, feeling of unreality, and more.

The problem is when the "fight-flight response" does not turn off, that is, you can not calm down after the immediate danger or threat is over. It is also a problem when the alarm system turns on without understanding the reason for it.

When the fight-flight system does not shut down after an "acute crisis", but continues to keep the person in high activity, we can call it being in a "constant state of alert." This means that the level of cortisol in the blood remains high, which has a negative effect on, among other things, the immune system, and which can also seem to have negative effects on brain development in young children.

When children have a constant alertness, this is a sign that the child is not feeling well. It is a common symptom in various forms of neglect situations.

 

Trauma and brain "overload protection": Dissociation

Children who have experienced trauma, either as a result of neglect or for completely different reasons, may have experience with a phenomenon called dissociation. This is part of the brain's natural "overload protection" and is something that can happen in situations that are so frightening that it exceeds the person's ability to integrate the experience in a normal way.

 Dissociating means standing on the side of the situation one is in, and can be a form of "anesthesia". It is a sensible strategy that makes the extremely frightening events virtually tolerable. 

However, can dissociation create problems in different ways. By dissociating while experiencing something traumatic, this can lead to the memories being stored in the brain in a disorganized and disorderly way, which makes memories difficult to process - as they are "splintered" in various fragments of memory. Therefore, memories can come up again in surprising ways, for example by hearing a sound reminiscent of the traumatic, feeling a smell, or get a sensory sensation similar to the one you had when the traumatic happened.

Children who have experienced neglect will have experience with a number of trauma situations, and may have extensive problems related to dissociation. Many such children have sudden mood swings, and it can happen as "lightning from clear skies". They often have difficulty putting into words what they are experiencing, and this can take the form of outbursts of rage or extreme anxiety attacks. 

Simply put, it can be explained by the fact that the fight-flight system is activated without any real danger - but that it is the brain that plays the child a trick. 

 

A case study: Being in survival mode (fight-flight mode)

Psychologist Dag Nordanger at RVTS Vest describes the following case example of a boy with a serious trauma problem, and where the fight-flight system runs wild:

On a two-handed basis, Preben could be "the world's nicest boy". He realized that he had acted wrongly and promised dearly and sacredly to get together. But the minute after, he regained his black gaze, and began throwing chairs and tables around him as he shouted swear words and taboo expressions. The teachers experienced that he became "another", he was like two people. For a while they had been trying to calm him down by laying him on the floor. Preben became completely furious, kicked and bit, shouted for help and roared that he was raped. It was clear that the school would rather get rid of him. At the very least, they appealed for an ADHD diagnosis so that he could be brought under chemical control

He adds:

- When a child becomes "black in the eyes", it is a signal that it needs an adult who by virtue of his own calm can help him calm down.

 

The triangular brain

brain-captain

Photo: RVTS, from the movie dissociation - an introductory film

To understand more about why children who have experienced neglect can go with a more or less constant emergency preparedness, and that they may have sudden, extreme outbreaks that can be difficult to understand, it can be useful to highlight the theory of the three-part the brain.

Theorists in the field of trauma claim that we are not only equipped with one brain, but three brains. Specifically:

 

  1. The sensory brain or the survival brain

    This takes care of and handles sensory impressions, and it happens on an unconscious level for the person. It is part of the autonomic nervous system. It receives signals from all the senses, and responds, for example, to pain, visual impressions, smells, sounds, tastes, touch.

  2. The emotional brain

    This takes care of and handles emotions and has direct connections with the sensory brain. That is, the emotional brain can trigger certain emotions based on the sensory impressions (eg a visual impression), and then this can go very fast.

    Example: you are about to pull on a viper, and as soon as you discover it (through sensory impressions), the brain has "fired up" the fight-flight system - which results in you gallantly jumping over the viper - and all this on just a fraction of a second. Afterwards, you naturally feel very shaken, anxious, and "too alert". This is a consequence of the fact that the battle-flight system has put you in survival mode, and it will take some time before you calm down again.

    For children with severe trauma, it will be useful to know that the child often gets the fight-flight system activated without the child knowing why, or that the fight-escape system may be in a more or less constant state of emergency. Children who are exposed to neglect will have inadequate experience with how to regulate these feelings or seek help from adults in such a way that they can help calm or solve the problem.

  3. The thinking brain

    This takes care of conscious thoughts, planning, and managing attention, choices, and thoughts. With good development in children, the child's ability to regulate his own thoughts, feelings and behaviors is gradually increased - and the thinking brain gradually acquires a clearer managerial or steering position, which is important for good emotional and social functioning.

Such a division of the brain makes it possible to understand much of the chaotic and disorganized behavior and emotional patterns of children who have experienced severe trauma, for example in connection with having been exposed to neglect. The model also says something about the fact that it is the thinking brain that needs to be strengthened in these children.

 

Is it possible to repair the brain that has been damaged?

Fortunately, there is much that can be done to ensure that children who have been exposed to neglect can develop well, also in relation to brain development.

When the care situation becomes safe for a child, and when safe and supportive caregivers over time are able to meet the child in a way that is predictably supportive for the child, this will create new experiences in the child's brain. Over time, such positive experiences can help strengthen the child's brain connections associated with increased self-regulation, which can weaken or override the child's brain connections associated with the free flow of fight-flight response, and emotional dysregulation.

The result is that the child develops in a positive direction and learns new skills. However, there will be many factors that come into play in relation to how complete repair it will be possible to achieve in the child, and it is natural to think that the child will carry a vulnerability to react violently to certain types of stress throughout life.

The message is nevertheless this: that the brain is addictive, that the brain can change dramatically negatively as a result of neglect, but that it can correspondingly develop positively as a result of being met over time with good care - even in children who have previous experience with neglect. But then it is also in the cards that if the neglect persists, then the brain's dysregulation will also develop further.

Psychologist Dag Nordanger summarizes as follows:

- Perhaps the most important cutting-edge expertise we should promote is; to be able to give "normal care" to a child or young person who rejects you.

 

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