An innovative approach to working with children who have experienced developmental trauma: An introduction to the Building Underdeveloped Sensorimotor Systems (BUSS®) model

Abstract

BUSS® (Building Underdeveloped Sensorimotor Systems) is an innovative treatment model for children who have experienced developmental trauma. It is based on an understanding that just as a baby needs responsive, attuned and empathic relationships to grow and develop psychologically, attention needs to be given to the impact of the absence of these kinds of relationships on a child’s bodily development and regulation. The premise underpinning BUSS® is that these two processes – the need for an attuned caregiver and the progression through predictable stages of motor development – are inextricably linked; one cannot happen without the other. A case study is used to illustrate this innovation in practice, its frame of reference, methods and evaluation. Improvements were seen in physical development, parent–child relationships, cognitive functioning, self-esteem and confidence in parenting capacity. Consideration is given to how this model fits alongside therapies for children who have experienced developmental trauma and their families. This early evidence suggests that BUSS® is a clinically effective and cost-effective intervention that has positive benefits on physical and psychological development for children who have been impacted by early trauma. Further research will be required to establish both the consistency of outcomes and the mechanisms underlying its efficacy, especially in relation to psychological changes.

Plain language summary

Babies need predictable, loving care to develop physically and emotionally. They need the grown-ups in their lives to protect them from harm or stress. As newborns, babies are entirely dependent on those adult relationships for their survival – they can’t feed themselves and they don’t have control of their head or limbs. They need to be held, carried, cared for and played with to grow into their bodies, so that by the end of the first year of life, they’re able to move around and are beginning to explore their world and the people in it. Babies in frightening or stressful situations (during pregnancy and once they’re born), miss out on these crucial experiences and, as a result, the normal development of their brain and central nervous system is disrupted. This affects how children move and the sense they have of themselves and their bodies – what we call bodily regulation. Good bodily regulation is knowing where our body is without having to think about it, knowing how much pressure or force to use when we’re doing something like giving someone a hug or hanging our coat up on a peg. It’s knowing that our arms and legs will work together in a helpful way when we’re running or climbing.

We’re much more used to thinking about how early adversity affects a child’s emotional or psychological wellbeing, and we haven’t paid as much attention to how this affects bodily regulation. BUSS® is designed to bridge that gap – where there has been disruption to these earliest stages of development it’s possible to go back and fill in those touch, nurture and movement experiences that have been missed. This paper explores the BUSS® model and hears from a parent about their experience of using the model with their child.

Keywords

Sensory integration BUSS®bodily regulation developmental trauma early adversity neurosequential development fostering adoption special guardianship kinship care

Introduction

It is increasingly understood that the consequences of early adversity are complex and far reaching, stretching across behavioural, cognitive, relational and social domains (Bos et al., 2009; Hambrick et al., 2018; O’Connor and Rutter, 2000; Schaltz et al., 2008) as well as impacting on physical and mental health (Felitti et al., 1998). While there is recognition of the impact of early adversity on a child’s physical development (Towse, Cooper and John-Legare, 2019), subsequent support for foster and adoptive carers tends to focus on relational and psychological support. Much of the emphasis of post-adoption support is on the parent–child relationship, assuming that if a child can be supported to engage in a relationship with an adoptive parent or carer who is emotionally attuned and available to the child, this enables the development of new internal working models. It is hoped that that this will be the path to their recovery from earlier abuse and relational trauma (Hillman et al., 2020). While not disputing the value of this for the ongoing health and wellbeing of the child, this article seeks to highlight to the importance of an appreciation of motor development and the relational context necessary for it to grow.

The term ‘parents’ is used in this article to describe the adults who are caring for a child, be they foster carers, adoptive parents, kinship carers, special guardians or staff in residential units.

How BUSS® was developed

The Building Underdeveloped Sensorimotor Systems (BUSS®) model was developed by the author after 25 years of working as an occupational therapist and play therapist in child and adolescent mental health, across a range of health and education settings in England and Scotland. While recognising the good work being done in these contexts, the lack of consideration of the significance of the sensorimotor development of children who have experienced developmental trauma and a desire to bring this consideration alongside the psychological understanding of trauma led to the development of the model.

Babies move as they interact with their caregivers (Murray and Andrews, 2000), and those who are in frightening, abusive or neglectful situations do not move as much as those who are not (Rutter et al., 2007). Without this synthesis of relationships and movement, bodily regulation is not able to progress as it needs to, and this article argues that future physiological and psychological development can be compromised. This physical aspect of development is often overlooked and has been seen as less important than the emotional and relational consequences of developmental trauma. However, the lack of agency in one’s own body, for example not being able to gauge how much pressure or force to use in a movement, means that, for a child, standing in the line at school, sitting on the carpet to listen to the teacher, giving a hug or playing a game of tig rarely go as planned. This, coupled with the awareness of what their peers can do, can lead children to opt out of situations that facilitate peer-group relationships, engagement in sport or opportunities to learn, thus widening the gap between them and their typically developing peers.

Consideration of both the emotional and physiological aspects of development are critical to really understanding the implications of abuse and neglect. While other therapies do consider the impact of trauma on the body, such as Ogden and Fisher (2015), their emphasis is on the disconnect between body and mind caused by traumatic incidents, and the therapy seeks to work with the body and the defensive responses emanating from the trauma. Similarly, sensory integration therapy, as practised by occupational therapists, uses a model of sensory processing disorder to address difficulties children and adults may have in movement or regulation but may not involve parents.

BUSS® seeks to understand the interplay between the relational context and the stepped progression of the foundation sensorimotor systems and appreciate the effect that any disruption to development has on the child’s bodily regulation, which underpins the development of emotional regulation, relationships and learning. The model harnesses the potential, once children are in safe and nurturing environments, to make sense of what’s been missed and go back and fill in the gaps in their experiences, thus supporting a child to develop good bodily regulation. It assumes that where there has been disruption to development, there will be disruption to the foundation sensorimotor systems.

BUSS® is a bottom-up approach that fits well alongside a Neurosequential Model of Therapeutics (Perry and Dobson, 2013), which describes the development of the child through the lens of brain development, beginning with the brainstem (responsible for heart rate, respiration, blood pressure) and moving up through the diencephalon (arousal, sleep, appetite, movement) and through the limbic system (reward, memory, bonding, emotions) to the cerebral cortex (creativity, conscious thought, language, values, time, hope) (Perry and Winfrey, 2021). This, in turn, complements the work of Developmental Dyadic Psychotherapy (DDP) and Theraplay, which are focused on the parent and child relationship (Hughes, Golding and Hudson, 2019; Norris, 2020).

The BUSS® model offers parents concrete, tangible strategies and activities that are effective in building foundation sensorimotor systems in their children, the development of which has been disrupted by early adversity.

Key tenets underpinning the model

Three key tenets underpin the BUSS® model. The first is the assertion that if a child has experienced developmental trauma, there will inevitably have been some disruption to their development (Toth and Cicchetti, 2013). It is the contention of this article that this will include the development of their foundation sensorimotor systems (vestibular, proprioceptive and tactile), which will be explained below.

The second tenet is the notion of disruption rather than disorder. It is a cornerstone of this model that the foundation sensorimotor systems of children cannot adequately develop without consistent, attuned care. The model offers hope that what has been missed can be relearned and re-experienced.

The third tenet of BUSS® is that parents are the most effective agents of change in this work. For typically developing children, these foundation sensorimotor systems grow within the context of attuned caregiving, and BUSS® uses this blueprint where there has been disruption to that process. In keeping with this, the BUSS® intervention includes support for parents by other parents who have used the model with their children, through monthly parent-mentor groups.

Early child development

It is helpful to begin with some consideration of the development of bodily regulation, without which children can face challenges with movement, balance, coordination, knowing how much pressure or force to use in a movement, as well as knowing whether they are hungry or not, whether they feel hot or cold or when they need to go to the toilet. Typically developing children progress through expected stages of development, from the newborn infant acquiring head control, through the stages of creeping and crawling towards walking (Sharma and Cockerill, 2014). In line with the early work of Franklin (1889) and Sherrington (1906), Ayres (2005) maintained that it is the successful maturation of these systems in the early years of life that allows us to feel at ease in our bodies, giving reliable information about the world around us, as well as our internal physiological state. As the child develops mastery of each stage, less conscious brain activity is needed to perform each action, thus freeing up capacity for more complex movement as well as the development of cognitive, social and emotional regulation capacities. On a motor level, walking opens the door to running, dancing, skipping, jumping, while interoception allows us to use our bodies as a reliable way of making sense of incoming sensory input (touch, taste, smell, pressure), for example, being able to ignore the sound of the washing machine while at the same time listening to music. This simplistic description belies numerous complexities. As readers may be less familiar with the foundation sensorimotor systems – vestibular, proprioceptive and tactile – they will be described with a consideration of their relevance to this way of working.

Foundation sensorimotor systems: Vestibular, proprioceptive and tactile

The development of the foundation sensorimotor systems begins at conception. In utero development is negatively affected by stress, while postpartum development is dependent on nurture, touch and movement (Ayres, 2005; Bundy, Lane and Murray, 2002).

The vestibular system

The five senses of touch, taste, smell, hearing and vision have been long understood and were perhaps first described by Aristotle around 335 BCE in De Anima (On the Soul) (1987). Franklin’s work, published in 1889, suggested that part of the inner ear was involved in balance rather than hearing, and with this came the discovery of the vestibular sense. Often described as the foundation of all systems, the vestibular system forms a platform for the development of the other systems.

The two main functions of the vestibular system are to provide the body with a stable base for movement (good head, neck, shoulder girdle and trunk control) and to give a sense of wellbeing when moving (gravitational security) (Bear, Conners and Paradiso, 2007). The vestibular system is also involved with the rhythms of the body: the cycle of wake and sleep, being alert and relaxed (Young, 2021). Receptors for the vestibular system are in the ears (otoliths and semi-circular canals) and are stimulated by movement of the head.

The development of core strength and stability can be observed in typically developing babies. Within a nurturing environment, by four months of age the baby is usually comfortable spending time on their tummy. They are able to hold their head up so that their forehead is no longer on the floor and from this vantage point the infant can begin to build a different sense of the world. With attuned care and stimulation, babies spend increasing amounts of time in this position, gradually supporting their bodies on their arms as their head, neck, shoulder girdle and trunk strength increases. From here, babies typically progress to creeping and crawling, with each stage of development building on the preceding one.

In parallel to this, being held, rocked and carried support the development of gravitational security. Considering a tiny baby being carried and comforted, the front of the baby is against the parent’s body, and the parent’s hands are holding the baby’s head and back. In this way, they absorb not only the love and care emanating from the adult as they talk or sing to the baby, but as the adult sways and moves with the baby, so the baby develops a sense of wellbeing in relation to movement. It is really critical to think of both parts of this, that is, what the baby is experiencing on an emotional and physical level during these early interactions. Without the emotional care, the baby will not move as much as they need to, and without movement the baby cannot progress through the stages of development.

The proprioceptive system

In 1906, Sherrington described proprioception as ‘the perception of joint and body movement as well as position of the body … in space’ (cited in Ribeiro and Oliveira, 2007: 71). Core strength and gravitational security provide a platform for the development of this system, which is concerned with quality of movement. Good movement is smooth and well-coordinated, with the body working as an integrated unit (Bear, Conners and Paradiso, 2007). It involves a constant exchange of information between the brain/central nervous system and the muscles and joints, which feeds the brain with the information it needs about body position and how much pressure or force to use in a movement. It can be helpful when working with families to think of movement building a body map (Lloyd, 2020). In the same way that a detailed map enables a holiday maker potential for greater exploration of a new place, the greater the quantity and richer the variety of movement the baby experiences, the greater the potential for increasingly complex patterns of movement as the child grows.

Babies in adverse or frightening situations do not move as much as typically developing children (Perry, 2009; Rutter et al., 2007), and it is this combination of the absence of good enough nurture and attuned care, along with the resultant lack of movement, that is important.

The tactile system

Consideration of this system, which develops from a state of high arousal/defensive functioning in the newborn to a system that allows for exploration and staying in the moment of an experience, is critical when working with children who have experienced developmental trauma. On a physiological level, the tactile receptors in the newborn are primed for defensive functioning. Repeated experiences of their needs being met on a physiological and emotional level allow the defensive receptors to recede, enabling discriminatory receptors to develop (Bundy, Lane and Murray, 2002). This is particularly pertinent to children whose experiences have meant that they have stayed in this state of high alert both physiologically and psychologically for extended periods. The BUSS® model works on a physiological level to address this hyperarousal in both spheres.

Understanding the significance of the interplay between the innate potential of babies to develop sensory integration/bodily regulation and the environment in which they are developing is critical. Without this, it is easy to misunderstand the presentation of a child and assume that their lack of balance or awareness of their body is indicative of a sensory processing disorder. This, it can be argued, is premature. BUSS® was developed to offer a framework not only to understand the complexity of that interplay but also a methodology to support parents to go back and fill in the gaps in movement and nurture experiences, thus building sensory integration. Once this is complete, it may be appropriate to consider whether a child’s presentation can be understood as being part of a sensory processing disorder.

Having provided the context in which the BUSS® model sits, this article will now describe the methodology of the model, the intervention employed in the following case study and the associated outcomes.

The BUSS® methodology

BUSS® is a way of working with children and young people across the age range. Holding in mind the premise of BUSS® – that where there has been developmental trauma systems are underdeveloped rather than damaged – alongside research around the potential for growth and change, particularly in the motor cortex (Eagleman, 2020), there is no time limit on when progress can be made. An understanding of the conditions required for a child’s sensory processing to develop optimally means that it follows that nearly all children who have experienced early adversity could benefit from an intervention like BUSS®, but adequate training of professionals alongside careful assessment of both the child and the family situation are required to ensure the intervention is as efficacious as possible.

The BUSS® clinical intervention

BUSS® is a brief intervention that typically comprises 10 sessions (including liaison with the professional network around the child) over a four- to six-month period.

Children are typically referred to the team by their social workers, often after initial enquiries have been made by parents. Work in England is generally funded by the Adoption Support Fund (ASF).

The assessment comprises four stages, outlined below. In the examples of children given, all names have been changed.

Stage one – Gathering information

As the BUSS® model requires collaborative working between parents, practitioners and the child, the first stage is to ensure parents have a working knowledge of the model. This is done through the use of the website (www.bussmodel.org), recorded webinars or prescribed reading (Lloyd, 2016; 2020). Subsequently, parents are asked to complete a screening tool. This is written to be accessible and understandable to parents without any specialist knowledge. They are asked to notice how their child performs everyday tasks, such as walking up and down stairs, running or drawing a picture.

Parents then meet with their practitioner to think together about the child, focusing particularly on early experiences and current functioning, as well as gaining insight into family functioning and answering any questions parents may have.

The key components of BUSS® are movement, relationship and playfulness. Parents are the main agents of change, and the BUSS® practitioner walks alongside the family as the work is done. This is an intensive experience for parents and initial assessment must consider parental capacity. BUSS® involves parents playing games and doing activities designed to take children back through the stages of movement that have been missed, and it has to be fun. Preparatory work to build parental capacity (e.g., DDP) may be indicated.

Stage two – Direct assessment of the child

The BUSS® assessment comprises a series of activities, carried out with parents and children together, to build a picture of the stage of development of the child’s vestibular, proprioceptive and tactile systems respectively. It can be a face-to-face session or parents can make videos of their child performing specific activities, based on the initial consultation and guided by the practitioner. Families are sent recordings demonstrating the required activity. A detailed report is then written.

Alongside clinical observation and parental observation, the child’s perspective is invaluable – they truly are the experts! Children are often able to describe exactly what is happening on a bodily level; whether they feel their body works well and does what they want it to do. For example, in previous assessments Ryan, an eight-year-old boy, knew that his legs and arms both worked well, but he also knew that they didn’t work very well together. When he ran, he concentrated on his legs to make sure he wasn’t going to fall, but this meant that he couldn’t concentrate on his arms, which he described as flapping around like an octopus in a really unhelpful way. Adam, who was also eight, described his body as feeling as if he had some kind of blockage – his brain knew what he wanted his hand to do (in his case, cursive writing) but there must be some kind of blockage because it just didn’t work.

A 14-year-old girl, who was wriggling and squirming in the initial consultation, was asked by her foster carer to sit still and listen. Astutely, she replied that she could either sit like this and listen or she could sit still but then wouldn’t be able to listen because she’d be concentrating on sitting still.

At other times, children describe the consequences of feeling unable to play the games that their peers can. Peter, a nine-year-old boy, talked of his increasing social isolation at playtimes at school because he wasn’t physically able to join in the games of the other children – when he tried to, he kept falling over, crashing and banging around the football pitch in a way that was annoying to the other players and made him feel inept and self-conscious. Lexi, a seven-year-old girl, described how she put stones in her shoes when she went to school so that she could feel where her feet were and wouldn’t fall over so much at playtime. Naomi, also seven, hooked her top over the back of a chair when she was standing, providing the extra stability that she wasn’t getting from her body.

Stage three – The intervention

Following assessment, families are given a bespoke programme of activities and games to play with their child to begin to build the child’s foundation sensorimotor systems and further the development of the parent–child relationship. The BUSS® practitioner then meets with the family as frequently as is practicable for the family and the work to progress – ideally every two weeks. The purpose of the meetings is to review the work that families have been doing, making sure that the activities and level of challenge are correct to ensure the child is successful but not so easy that they are unlikely to progress, as well as confirming that parents are able to facilitate these playtimes often enough for it to be effective.

Parents are also invited to attend monthly parent-mentor-led support groups. Parent mentors have been through the BUSS® intervention and bring their lived experience to support and help other parents going through it. BUSS® parent mentors follow the same programme of training as professionals and are supervised and paid for the work that they do.

Parent mentors add value to BUSS® in many ways, from their role in training to their support of families. End of intervention evaluations invariably mention the warmth, support, understanding and encouragement that these groups offer and the importance of this in holding onto hope, especially in the early stages of the intervention.

Stage four – Reassessment and forward planning

This is either a face-to-face or virtual meeting to review progress and address any outstanding issues. It is always hard to predict the rate of progress of the child at the beginning of an intervention. Where parents have the capacity to carry out the programme of work, it is usual to see observable differences in functioning within the first two months. Existing diagnoses, for example fetal alcohol spectrum disorders (FASD) or a neurodevelopmental diagnosis, do not seem to be helpful predictors of outcome. There are times when a child with a diagnosis of FASD can develop far beyond the level that might be expected (one such child was signed up by a Premier League football team for their youth development squad). At other times it’s clear that ongoing work will be needed by the family to maintain the slower rate of progress that has been achieved.

For some children and families, a BUSS® intervention will be as much as they need at the time. The progression that they have been able to make in building foundation sensorimotor systems has opened up the world of play, learning and friendships for them in a way that offers potential for ongoing development. For other children and families, it is timely to consider psychological therapies. Occasionally it can be helpful to contribute to neurodevelopmental assessments, when it seems useful to have disentangled some of the impact of early adversity on the child’s presentation.

Case study

The following case study was written in collaboration with the child’s parents, with informed consent and explicitly for the purpose of this article. Names have been changed. The case study is broadly illustrative of the process and outcomes of the clinical intervention.

Michael is a four-year-old boy who was adopted at 14 months from an orphanage in Africa. He had been in orphanages from birth. Care in the orphanage in which he spent his first five months was very poor. Babies shared cots and feeding was once a day. When he moved to a different orphanage, he was already severely malnourished. The routine here was better, feeding was more regular and, while extended periods were spent in cots, they were taken out of them for an hour a day, sitting in a moulded chair and given a toy to play with.

Michael’s parents live in the UK and met him in the orphanage when he was nine months old. They spent as much of the next five months as they could in the country, coming back to the UK as a family when Michael was 14 months old. Michael’s parents had extensive experience of young children and were aware that he was behind age-expected developmental milestones. They were advised that what he needed was love and nurture to ‘catch up’ with his peers. Mum stayed at home to be with Michael, and both were nurturing, attuned and playful parents. The gap between Michael and his peers became more noticeable when he started nursery at age three.

Nursery staff commented on Michael’s lack of facial expression and communication, and how much he dribbled (he needed to have his bib and top changed at least once a morning). He frequently bumped, tripped and crashed into things and other children. He couldn’t discern how much pressure or force to use in a movement and when he hugged another child it usually ended with both children on the floor. He didn’t join in with nursery activities and was described as being like a whirlwind. After a year, it was suggested to his parents that he would not manage mainstream education and advice was given to embark on assessments of autism (ASD) and attention-deficit/hyperactivity disorder (ADHD).

His parents had already sought advice from healthcare professionals. A paediatric occupational therapist suggested that Michael had a sensory processing disorder, a paediatric consultant thought pursuing a neurodevelopmental assessment was appropriate, whilst the health visitor suggested that Michael just needed more time. Michael’s parents were frustrated that none of these options adequately considered his early experiences and continued to look for more appropriate alternatives, which was when they heard the Adoption UK webinar on the BUSS® model.

All work was carried out remotely due to both the Covid-19 pandemic and geographical distance, with the family sending recordings of Michael, followed by Zoom conversations and the therapist sending the family recordings of suggested activities. The BUSS® intervention began with developing the parents’ understanding of the model, foundation sensorimotor systems and the impact of Michael’s early experiences on their development. This included watching videos together of Michael at home, walking, running, playing, crawling, going up and down stairs, drawing and trying to ride his scooter to build up a picture of his foundation sensorimotor systems.

There were significant gaps in all of Michael’s systems. His head, neck, shoulder girdle and trunk were very weak and not nearly as strong as his legs. Lying on his tummy, he was unable to hold his head up or use his arms to move his body forward, which was indicative of poor core strength and stability (the vestibular system). In terms of gravitational security, he was fearful and uncertain when his feet were off the ground and walked upstairs sideways, both hands on the banister, two feet on each step. He came down on his bottom and avoided any activities that involved jumping. He was desperate to be able to ride his scooter to nursery like the other children but unable to manage this.

Considering tactile functioning, while Michael presented as a fussy eater, on closer examination it was clear that his mouth and tongue weren’t strong enough to manage chewing. He struggled to blow and suck. His speech was hard for people outside of his family to understand, and he was dribbling a lot. He was over-responsive to some stimuli (e.g., noise) and under-responsive to others (e.g., pain).

Initial work focused on building core strength, gravitational security and oral motor strength. With guidance, Michael’s parents found engaging things for them to be doing when they were lying on the floor on their tummies (a simple but effective way to start to build core strength). Once he was able to hold his head up in this position (within a few weeks), they were able to add in some movement, inventing games to encourage him to ‘commando crawl’.

To build gravitational security, Michael needed experiences where he was connected to his parents and moving, in a very gentle way, mimicking the swaying motion parents use to soothe a young child. He was too big to be carried and didn’t like being in a rocking chair but did like to be wrapped in a blanket and rocked, a parent holding each end of the blanket while they gently rocked and sang to him.

Building Michael’s tactile system involved blowing and sucking games to build oral strength, alongside games to encourage the development of touch and discrimination. All of the activities were based around improving physiological functioning, but all needed that attuned, nurturing relationship to support Michael – his parents ‘commando crawled’, blew and sucked alongside him as they worked together to build these systems.

This work started in May 2020 during the first UK lockdown, and after six weeks of working together Michael went back to nursery. Nursery staff met mum at the end of that first session, unable to make sense of the difference they saw in Michael. For the first time, he’d been able to sit down on the carpet and take part in the discussion, taking turns and sharing things. He’d played with other children rather than hanging around on the periphery, had enjoyed snack time and hadn’t needed them to change his clothes that would previously have been wet through with his dribbling. They were even more amazed to see his delight at being able to ride his scooter away with the other children at the end of nursery.

Over the next few months, as the BUSS® work continued to build his vestibular and tactile systems, Michael made leaps forward in terms of development. He became a boy who loved to jump and splash in puddles, to run around and explore. Nursery started sending home photos of Michael painting with the other children, sitting and taking part in circle time and playing with other children – things he hadn’t managed previously. They now described him as animated and expressive, interacting with his peers and adults, curious and interested in them and the world around him. Nursery continued to notice improvement, and by early 2021 his concentration and ability to stay on task were at age-expected levels. Nursery staff were no longer of the opinion that he would need specialist education provision or assessments for ADHD or ASD.

Michael and his family worked remotely with the author over six months initially, meeting virtually approximately once a month. The poverty of his early experiences and the catastrophic impact this had on his foundation sensorimotor systems meant that a further piece of work was started after another six months. The focus of this work was building strength and stamina. This is a usual way of working with families where there is significant complexity or comorbidity.

Michael’s parents describe how much the intervention has helped their relationship with their son. Their sense of agency and joy at being able to be what he needed is immense. As Michael’s bodily regulation has developed, he has become more able to reflect on himself and his experiences in a way that has surprised his parents. He has started to talk about things he remembers from his first year of life, like how noisy it always was in that big home and how much he didn’t like that. He is increasingly able to problem-solve in situations that would previously been too stressful for him – on a recent visit to a medical practice he was startled by the very loud buzzer at the front door. As they came out, he suggested to his mum that next time they came, he could stand back a bit while mum rang the buzzer.

In keeping with the fundamental principle of parents as the main agents of change in BUSS®, the following description is written by Michael’s mum:

When Michael was three-and-a-half years old, it felt as though we were standing at a crossroads, with a variety of diagnostic routes ahead of us, but we had a gut feeling that none of them were the right way to go. It was a difficult time as we knew he needed support but everything being suggested raised far more questions than answers. Then we found BUSS® and suddenly everything made sense – the gaps that we were so conscious of from his early life were being taken seriously, not as an end point or a description of symptoms, but as understandable and, most importantly, something that we could [use to] support and help our son in ways that we hadn’t previously imagined or known.

One day in the park he was climbing when he turned to me and said, ‘Mummy, I feel safe in my body now’. That was an emotional moment – not least in realising how precarious he’d felt, but in knowing that this was just the beginning of him being able to do all of the things that he’d seen other children doing and not been able to do successfully. We call him King of Puddles now – our boy, who hated it when his feet were off the ground, now loves nothing more than jumping over waves in the sea or running and jumping in puddles. It’s so easy to forget the joy that movement should be and so wonderful to have it in our lives now.

We no longer need to explore the suggested diagnostic routes or any additional support for Michael because he’s no longer having those difficulties. We don’t know what the future holds, but we do know that BUSS® has given Michael the solid foundation to be able to make use of any further support [that may be] needed one day.

BUSS® has been life-changing for us all, and we couldn’t be more grateful to have found it when we did.

Evaluation

Early development of the model was shaped by parental feedback. Recently, a more systematic approach to evaluation has been used. This involves pre- and post-intervention measures using a combination of standardised measures (the Strengths and Difficulties Questionnaire, Goodman, Meltzer and Bailey, 1998; the KIDSCREEN-10 index¹), as well as the BUSS® screening tool, Goal Based Outcomes,² Evaluation of Service Questionnaires³ (child and parent version) and human figure drawing tasks. In addition, there have been five small-scale qualitative studies on the model (in preparation for publication), including one doctoral thesis⁴ which reported cognitive changes and language development that had been observed by parents of children who had completed a BUSS® intervention. This early work supports the notion that BUSS® improves parental confidence, children’s bodily regulation, emotional regulation and cognitive functioning.

Training in BUSS®

There is something very tangible about BUSS® that can make it seem a simple intervention. However, developmental trauma is invariably complex, with far reaching consequences for the child and those around them (Hindle and Shulman, 2008; Perry, 2009). BUSS® practitioners need to understand the legacy of developmental trauma and the way in which the interplay of emotional, psychological, physical and cognitive factors affect the life of the child and those caring for them. Clinical or social work training as well as experience of working therapeutically with children and families are prerequisites for training in the model.

Discussion

Most clinical work and research in this area has focused on the emotional and relational sequalae of developmental trauma. While the impact on bodily regulation is recognised, the potential of understanding and working with this in a pragmatic way that seeks to redress the missed opportunities has perhaps been overlooked. Eminent clinicians and researchers such as van der Kolk (2015) and Porges (2011) have sought to reconnect brain, body and mind, and therapies like Dance Movement Therapy (Gray, 2018) restate the importance of rhythm and movement in the healing process.

BUSS® seeks to add to these an appreciation of the relational conditions required for the development of foundation sensorimotor systems, which constitute the building blocks of bodily regulation. By understanding this process as having been disrupted as a consequence of developmental trauma, the BUSS® framework supports parents to fill in gaps in these systems. This builds a foundation of bodily regulation, allowing children to re-join the developmental trajectory towards relating to and learning alongside their typically developing peers.

The case study of Michael above illustrates the efficacy of addressing bodily dysregulation caused by early adversity. His presentation and progression through the intervention are typical of the children seen by BUSS®. In terms of presentation, there is a common thread that runs among the children and young people that their development has progressed in some respects, regardless of the foundation being built upon. Thus, it often appears that these children follow an upside-down kind of development; they learn to walk without a foundation of good core stability, often without good enough gravitational security. Their development happens from the feet up rather than the head down. Without those foundational experiences, children describe the effects of a lack of agency over their own bodies and the impact this has on learning and relating to others.

Two unexpected but welcome outcomes of BUSS®, and ones that merit further research, are the speed at which improved bodily regulation is possible and its impact on other areas of functioning. Children often describe feeling more relaxed, calmer and happier, while parents report their children being more interested in symbolic play, a developing sense of humour, as well as shifts in understanding, reasoning, retention of information and impulse control. Current research on BUSS® has focused on the efficacy of the model and has not begun to explore underlying mechanisms.

It is perhaps easier to understand the physical changes – working with a child like Michael and playing games to improve oral motor strength led quickly to a reduction in dribbling. Speculating on the social, psychological and emotional consequences, it is useful to consider not only the neurosequential process of development (Perry and Dobson, 2013) but also Sroufe’s work (2009) on the role of development in developmental psychopathology. It could be argued that reasserting the importance of the physical development of the child and the relational context necessary for its development are in line with one of the aims of developmental psychopathology, namely, ‘identifying premorbid patterns of maladaptation that allow targeted early intervention and prevention’ (Sroufe, 2009: 178). While acknowledging that the sensorimotor development of the child is only one aspect of their development, placing more emphasis on this than there has been previously may be efficacious.

Another possibility that it would be useful to explore is the effect of this intervention on parental confidence and capacity. In trying to understand this, it is possible that the design of the model is useful in a number of ways. It may aid parental attunement by highlighting their child’s developmental rather than chronological age, thus allowing parents to adapt their expectations of their child and increase the likelihood of utilising strategies that may be more successful. It may be that by keeping the emphasis of the intervention on the observable, physical attributes of the child, rather than emotional or behavioural aspects, parents shift their focus onto what can be done rather than what they might be struggling to make sense of or know how to manage. BUSS® is, especially in the early stages, a highly scripted intervention, requiring parents to play in a particular way with their child, which is designed to ensure success within their developmental capacity. This can be of particular help to new adoptive parents who may not feel themselves to have extensive experience of norms of child development or psychological development.

Strengths, limitations and future development

This model has a number of strengths. The first is efficacy, both in terms of outcomes and economics. It is a brief intervention, and it is effective in building bodily regulation. This typically impacts in a positive way on emotional regulation, parent–child relationships and cognitive functioning. Alongside this, working in a collaborative way strengthens parental belief in themselves as agents of healing and change, boosting their effectiveness and confidence. It is hoped that this will increase their ability to manage future challenges.

BUSS® is a cost-effective intervention. While financial investment is required for the training of practitioners, the impact of the intervention on parents, children and learning and the speed of change observed seem to be promising enough to warrant further research.

A second strength is inclusivity: BUSS® is a therapy that can sit compatibly alongside practitioners’ existing skills and expertise. BUSS® training has been designed to meet the needs of practitioners whose core training does not have the necessary depth of child development training required to work in this way. BUSS® welcomes practitioners from health, social care and education backgrounds to train, understanding the importance of the knowledge held by the people who are most likely to come into professional contact with children who have experienced developmental trauma during their lives.

A third is accessibility: BUSS® seems to work as effectively remotely as when children and families are seen face to face. This flexibility means that it can be responsive to the individual needs of children and families.

A fourth strength is clarity of purpose. BUSS® clearly sets out to improve a child’s bodily regulation, empowering parents to become the main agents of change in the process. It does not claim to deal with other consequences of early trauma but rather, by filling in gaps in foundation sensorimotor systems, offers children a platform to be able to do other work that may be required.

When considering limitations to this way of working, as the author of this paper and the person who developed the BUSS® model, the potential for bias must be acknowledged. However, the quantitative research referred to in this paper has been carried out independently, and the growing number of statutory and voluntary fostering and adoption agencies commissioning both the therapy and training for staff teams might go some way towards ameliorating that potential risk.

In terms of the limitations of the model itself, the necessity for parents to be the main agents of change can be challenging for the work with individual families. There are times when parents feel the expertise required is beyond them, and they would like to pass their child to someone else to ‘sort out’. Preparatory work to support parents and the help offered by the parent-mentor group are generally sufficient to enable them to work in this way. The BUSS® in Early Years Groupwork programme, which is delivered for newly adopted children and their parents or for children in foster care and their carers, is proving to be helpful not only for developing children’s regulation and relationships but also for the supportive bonds that develop between parents and carers, outcomes that are significant because they last beyond the life of the group.

The case study illustrates the process of the intervention and while BUSS® is reliant, at this stage, on anecdotal evidence and small-scale studies, there is a growing body of evidence to suggest that this model has a positive impact on a child’s bodily and emotional regulation, parent–child relationships and learning. But further scrutiny is required. Ongoing evaluation and research are necessary to establish a strong evidence base.

Future work may include other populations with similar features, such as children who have been hospitalised for long periods as infants. In the sphere of education, work that the author is doing with foster carers and preschool children, in partnership with the virtual school, is showing promising results. Ongoing research and development within this area will be important in contributing to the body of work around inequalities in educational outcomes of previously looked after children and their peers (Brown, Waters and Shelton, 2017).

Conclusion

While there are many excellent ways of working with children who have experienced developmental trauma (Douglas, 2007; Golding and Hughes, 2012; Norris, 2020; Perry and Dobson, 2013), relatively little attention is paid to bodily regulation. BUSS® integrates the disruption that early trauma has on the development of foundation sensorimotor systems. It is the reconnecting of the bodily and emotional development of the child that is critical. BUSS® offers a relational-based intervention that addresses the physical legacy of missed early experiences. Gaps in foundation sensorimotor systems can be identified and rebuilt, facilitating good regulation. Alongside this, developments in parent–child relationships, emotional regulation and learning are typically seen.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research/authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Sarah Lloyd is a consultant occupational therapist and the Director of BUSS® Model Ltd.

References

Aristotle (1987) De Anima (On the Soul). Translated by Lawson-Tancred H. London: Penguin Classics.

Ayres

(2005) Sensory Integration and the Child: Understanding Hidden Sensory Challenges, 25th Anniversary Edition. Los Angeles, CA: Western Psychological Services.

Bear

Connors

Paradiso

(2007) Neuroscience: Exploring the Brain. Philadelphia, PA: Lippincott, Williams and Wilkins.

Brown

Waters

Shelton

(2017) A systematic review of the school performance and behavioural and emotional adjustments of children adopted from care. Adoption & Fostering 41(4): 346–368.

Bos

Fox

Zeanach

Nelson

(2009) Effects of early psychosocial deprivation on the development of memory and executive function. Frontiers in Behavioural Neuroscience 3(16): 1–7.

Bundy

Lane

Murray

(2002) Sensory Integration: Theory and Practise. Philadelphia, PA: FA Davis.

Douglas

(2007) Containment and Reciprocity: Integrating Psychoanalytic Theory and Child Development Research for Work with Children. London: Routledge.

Eagleman

(2020) Livewired: The Inside Story of the Ever-Changing Brain. London: Canongate Books.

Felitti

Anda

Nordenberg

Spitz

Edwards

Marks

(1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventative Medicine 14(4): 245–258.

10.

Franklin

(1889) An unknown organ of sense. Science 14(345): 183–185.

11.

Golding

Hughes

(2012) Creating Loving Attachments: Parenting with PACE to Nurture Confidence and Security in the Troubled Child. London: Jessica Kingsley Publishers.

12.

Goodman

Meltzer

Bailey

(1998) The Strengths and Difficulties Questionnaire: A pilot study on the validity of the self-report version. European Child and Adolescent Psychiatry 7: 125–130.

13.

Gray

(2018) Roots, rhythm and reciprocity: Polyvagal-informed dance movement therapy for survivors of trauma. In: Porges

Dana

(eds) Clinical Applications of The Polyvagal Theory: The Emergence of Polyvagal Informed Therapies. New York, NY: WW Norton, pp. 207–226.

14.

Hambrick

Brawner

Perry

Brandt

Hofmeister

O’Collins

(2018) Beyond the ACE Score: Examining relationships between timing of early adversity, relational health and developmental outcomes in children. Archive of Psychiatric Nursing 33(3): 238–247.

15.

Hillman

Hodges

Steele

Cirasola

Asquith

Kanuik

(2020) Assessing changes in the internal worlds of early- and late-adopted children using the Story Stem Assessment Profile (SSAP). Adoption & Fostering ( 44)4: 377–396.

16.

Hindle

Shulman

(eds) (2008) The Emotional Experience of Adoption. London: Routledge.

17.

Hughes

Golding

Hudson

(2019) Dyadic Developmental Psychotherapy with Children and Families. New York, NY: WW Norton.

18.

Lloyd

(2016) Improving Sensory Processing in Traumatised Children. London: Jessica Kingsley Publishers.

19.

Lloyd

(2020) Building Sensorimotor Systems in Children with Developmental Trauma: A Model for Practice. London: Jessica Kingsley Publishers.

20.

Murray

Andrews

(2000) The Social Baby: Understanding Babies’ Communication from Birth. London: The Children’s Project.

21.

Norris

(2020) Theraplay: The Practitioners Guide. London: Jessica Kingsley Publishers.

22.

O’Connor

Rutter

(2000) Attachment disorder behaviour following early severe deprivation: Extension and longitudinal follow–up. English, and Romanian Adoptees Study Team. Journal of the American Academy of Child and Adolescent Psychiatry 39(6): 703–712.

23.

Ogden

Fisher

(2015) Sensorimotor Psychotherapy: Interventions for Trauma and Attachment. New York, NY: WW Norton.

24.

Perry

(2009) Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma 14(4): 240–255.

25.

Perry

Dobson

(2013) The neurosequential model of therapeutics in young children. In: Ford

Courtois

(eds) Treating Complex Traumatic Stress Disorders in Children and Adolescents: Scientific Foundations and Therapeutic Models. New York, NY: Guilford Press, pp. 249–260.

26.

Perry

Winfrey

(2021) What Happened to You? Conversations on Trauma, Resilience and Healing. New York: Flatiron Books.

27.

Porges

(2011) The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, Self-Regulation. New York, NY: Norton.

28.

Ribeiro

Oliveira

(2007) Aging effects on joint proprioception: The role of physical activity in proprioception preservation. European Review of Aging and Physical Activity 4: 71–76.

29.

Rutter

Beckett

Castle

Colvert

(2007) Effects of profound early institutional deprivation: An overview of findings from a UK longitudinal study of Romanian adoptees. European Journal of Developmental Psychology 4(3): 332–350.

30.

Schaltz

Smith

Borkowski

Whitman

Keogh

(2008) Maltreatment, risk, self-regulation and maladjustment in at-risk children. Child Abuse & Neglect 32(10): 972–982.

31.

Sharma

Cockerill

(2014) Mary Sheridan’s from Birth to Five Years: Children’s Developmental Progress. London: Routledge.

32.

Sherrington

(1906) The Integrative Action of the Nervous System. New Haven, CT: Yale University Press.

33.

Sroufe

(2009) The concept of development in developmental psychopathology. Child Development Perspectives 3(3): 178–183.

34.

Toth

Cicchetti

(2013) A developmental psychopathology perspective on child maltreatment. Child Maltreatment 18(3): 135–139.

35.

Towse

Cooper

John-Legare

(2019) The high incidence of developmental difficulties and evolving needs of children and young people after adoption: A review of 40 children adopted from Southward. Adoption & Fostering 43(1): 101–105.

36.

van der Kolk

(2015) The Body Keeps the Score: Mind, Brain and Body in the Transformation of Trauma. London: Penguin Books.

37.

Young

(2021) Super Senses. The Science of Your 32 Senses and How to Use Them. London: John Murray.