The therapy under evaluation, known as Neuro-Physiological Psychotherapy (NPP), was developed for maltreated children placed in adoptive and foster families. It is deliberately multi-modal: rather than relying on a single technique, it integrates somatosensory work that addresses the body’s sensory and motor systems, creative and play-based interventions, dyadic therapies that treat the child and caregiver as a unit, and structured support for therapeutic parenting. The theoretical scaffolding draws heavily on Stephen Porges’ Polyvagal Theory, which proposes that the autonomic nervous system continuously evaluates safety and threat through a process called neuroception, and that states of calm social engagement can only emerge once the body’s defensive arousal systems have been downregulated. In practical terms, NPP attempts to help a hypervigilant child’s nervous system learn, through repeated safe relational experiences, that the world is no longer dangerous.

Earlier work by the same team had shown significant differences between children receiving NPP and a non-equivalent control group, but questions remained about whether those gains would persist in a larger cohort and, crucially, whether they would extend to children with prenatal alcohol exposure (PAE)—a group often assumed to be harder to treat because alcohol acts directly on the foetal brain. The new evaluation addressed both questions. Adopted children and young people who received NPP were compared with a control group using two widely validated instruments: the Behaviour Rating of Executive Functioning (BRIEF), completed by parents and teachers, and the Child Behaviour Checklist (CBCL), completed by parents to capture a broad range of emotional and behavioural difficulties.

The results were striking in their consistency. On the BRIEF, the treatment group showed significantly better global executive functioning than controls, with the analysis reporting F(1,74) = 7.53, p = .008, and a partial eta squared of .09, indicating a moderate effect size. Behavioural regulation showed an even stronger separation, F(1,74) = 10.62, p = .0002, with a partial eta squared of .22—a large effect by conventional standards. Emotional control, the capacity to modulate emotional responses rather than being overwhelmed by them, also differed significantly between groups, F(1,74) = 10.38, p = .002. Importantly, these were not merely the optimistic reports of parents invested in their child’s therapy: teacher-reported indices, gathered by professionals who had no stake in the treatment programme, showed similar patterns of advantage for the intervention group.

The CBCL data told a complementary story. Parents of children who had received NPP reported significantly fewer total behavioural difficulties than control-group parents, F(1,74) = 5.63, p = .003, and significantly fewer externalising problems—the aggressive, defiant, and rule-breaking behaviours that most often drive family breakdown and placement disruption, F(1,74) = 8.36, p = .005. For adoptive families, externalising behaviour is frequently the symptom that precipitates crisis; a therapy that measurably reduces it addresses one of the most clinically urgent outcomes in the field.

The most novel contribution of the study, however, lies in its treatment of prenatal alcohol exposure. Using Linear Mixed-effects Modelling on the Behavioural Regulation Index score, the researchers tested whether the presence of PAE changed how children responded to NPP. It did not. The model indicated that NPP was as effective for children with PAE as for those without, with a coefficient of -12.82 (SE = 5.12, t = -2.51, p = .015) reflecting the significant improvement associated with the therapy. This finding challenges a quiet therapeutic nihilism that sometimes surrounds foetal alcohol spectrum disorder, the condition that may arise when alcohol exposure in the womb disrupts brain formation. A recent systematic review of interventions for executive function difficulties in FASD had found the evidence base thin; this study contributes controlled, quantified support for a treatment approach that works at the level of the nervous system rather than trying to teach skills to a brain not yet ready to learn them.

The neuroscience rationale is worth unpacking. Prenatal alcohol exposure alters brain structure in measurable ways, including differences in cortical and subcortical regions that support attention, memory, and self-regulation, and neuroimaging studies have documented maturational differences in the amygdala and prefrontal cortex of exposed children. Early maltreatment compounds these changes through stress biology: chronic activation of the hypothalamic-pituitary-adrenal axis during critical developmental windows recalibrates threat responses, and research on childhood adversity consistently links such dysregulation to later psychiatric illness. Polyvagal Theory adds a third layer, describing how the vagus—the tenth cranial nerve—mediates the shift between defensive states and social engagement. NPP’s designers reasoned that if trauma and alcohol exposure disrupt the body’s regulatory circuitry, then therapy must engage that circuitry directly, through sensory input, rhythmic dyadic interaction, and caregiver relationships that repeatedly signal safety. The significant improvements in behavioural regulation and emotional control observed in the study are precisely the outcomes this framework would predict.

The study’s authors, led by Elaine McCullough and colleagues at Family Futures and collaborating clinicians including Raja Mukherjee of Surrey and Borders Partnership NHS Foundation Trust, are careful about what the data can and cannot show. The control group was non-equivalent, meaning participants were not randomly assigned, so causality cannot be established with the certainty of a randomised trial. The measures are parent and teacher reports rather than direct neuropsychological testing, and the cohort, though larger than in previous evaluations, remains modest in size. Nevertheless, the convergence of findings across informants, instruments, and analytic methods—and the demonstration that treatment effects hold for children with prenatal alcohol exposure—represents a substantial advance over the team’s earlier work. The authors frame the results as support for interventions that recognise the complex, multi-system effects of neurodevelopmental trauma and that are explicitly informed by neuroscience, rather than for any single technique in isolation.

The wider implications reach beyond the clinic. Children with FASD frequently carry co-occurring diagnoses—ADHD, attachment difficulties, mood disorders—and their families often navigate services that are fragmented and poorly informed about the condition. Public health data suggest that alcohol consumption during pregnancy remains common, and UK prevalence studies have estimated that fetal alcohol spectrum disorders affect a meaningful share of the birth population, most of whom are never diagnosed. For adopted children, in whom PAE and post-natal maltreatment frequently co-occur, the clinical picture is among the most complex in child mental health. A therapy that integrates somatosensory, creative, and dyadic work with parenting support—and that demonstrably improves executive functioning and reduces externalising behaviour in this population—offers a template for what neurodevelopmentally informed care could look like if embedded in mainstream services. The authors’ conclusion is measured but pointed: when treatment speaks the language of the nervous system, some of society’s most vulnerable children can be helped not simply to cope, but to regulate, relate, and recover.

Subject of Research: Effectiveness of Neuro-Physiological Psychotherapy for adopted children with neurodevelopmental trauma and prenatal alcohol exposure

Article Title: An Evaluation of Neuro-Physiological Psychotherapy for Adopted Children and Young People with Neurodevelopmental Trauma and Prenatal Alcohol Exposure Who May Meet Criteria for Foetal Alcohol Syndrome Disorder

Article References: An Evaluation of Neuro-Physiological Psychotherapy for Adopted Children and Young People with Neurodevelopmental Trauma and Prenatal Alcohol Exposure Who May Meet Criteria for Foetal Alcohol Syndrome Disorder. (n.d.). https://doi.org/10.1007/s40653-026-00956-6

Image Credits: AI Generated

DOI: 10.1007/s40653-026-00956-6

Keywords: Neuro-Physiological Psychotherapy, neurodevelopmental trauma, prenatal alcohol exposure, foetal alcohol spectrum disorder, adopted children, executive functioning, Polyvagal Theory, behavioural regulation, emotional control, therapeutic parenting, BRIEF, Child Behaviour Checklist

The study, conducted at Chrysalis Associates, a specialist developmental trauma and attachment service in the north of England, evaluated a 30-hour neuro-collaborative Theraplay-informed intervention delivered between April 2020 and April 2024. The therapeutic package comprised three equal components: ten hours of Theraplay-informed family therapy involving parents and children, ten hours of therapeutic parenting sessions guided by the principles of dyadic developmental parenting, and ten hours of sensory regulation work delivered directly to children or psycho-educationally to parents. This integrative design deliberately expands on Perry’s neurosequential model, which proposes treating trauma by targeting the brainstem first, then the limbic system, and finally the cortex. Instead of moving sequentially, the neuro-collaborative approach addresses multiple brain systems concurrently, pairing body-based regulation with attachment-focused play and reflective parenting support.

The researchers compared 35 autistic care-experienced children with 172 non-autistic children who received the same intervention. The autistic group had an average age of just over nine years, ranged from four to seventeen, and attended on average more than 96 percent of their scheduled sessions. Outcomes were measured before and after therapy using four well-validated caregiver-report instruments: the Trauma Symptom Checklist for Young Children, the Child Behaviour Checklist, the Behaviour Rating Inventory of Executive Function, and the Assessment Checklist for Children. Paired t-tests and analyses of covariance controlling for age and gender were used to assess change within and between the groups.

The results told a nuanced story. Across the full cohort, every outcome measure improved significantly, and after applying a Bonferroni correction for multiple comparisons, total post-traumatic stress, post-traumatic stress arousal, total behavioural problems, and oppositional defiant problems remained significantly reduced, with effect sizes ranging from small to approaching medium. The larger non-autistic group alone also showed statistically significant improvements on most measures. The smaller autistic group did not reach statistical significance, but scores moved consistently in the direction of improvement with encouraging effect sizes, including a moderate effect for reduced rule-breaking behaviour. Crucially, the analyses of covariance found no significant difference in treatment response between autistic and non-autistic children once pre-treatment scores, age, and gender were accounted for.

The theoretical rationale for the intervention rests on how early relationships shape developing regulatory systems. Drawing on Schore’s account of right-hemisphere development and Porges’ polyvagal theory, the authors argue that attachment experiences sculpt the autonomic and nonverbal systems underlying emotional attunement, bodily awareness, and social engagement. Theraplay, a structured, playful, and largely preverbal approach organised around the domains of structure, engagement, nurture, and challenge, is designed to intervene precisely at this nonverbal, embodied level. Because autistic children often process sensory input and social cues differently, the therapy was adapted flexibly, honouring the child’s developmental stage and sensory profile rather than demanding eye contact or touch that could prove dysregulating.

The authors also invoke monotropism theory, which describes the intensely focused attentional tunnel characteristic of autism, to explain how trauma and autistic hypersensitivity can interact. A child whose nervous system is hypervigilant for danger after trauma, and whose attention is already narrowly channelled by autistic monotropism, may become overwhelmed by stimuli inside that channel while missing cues outside it. The intervention’s sensory regulation component, drawing on the Just Right State program and the Alert Program, helps parents create predictability and reduce overload, while Theraplay-informed sessions teach carers to synchronise with the child’s attention rather than fight against it, building experiences of being seen, understood, and co-regulated.

Not every measure responded identically across groups. On the Assessment Checklist for Children, which probes attachment-related relational behaviours, the non-autistic group improved significantly while the autistic group’s scores on indiscriminate and non-reciprocal scales remained stable or rose slightly. The researchers argue this divergence is expected and even reassuring: non-reciprocal and indiscriminate friendliness in trauma-exposed children typically reflects damaged internal working models, which attachment-rich therapy can repair, whereas analogous presentations in autistic children stem from innate neurobiological differences in social reciprocity. Attempting to modify those differences therapeutically would be neither appropriate nor neurodiversity-affirming, and the authors caution that the checklist itself may simply be insufficiently sensitive to capture relational change in autistic children.

The study’s significance lies partly in dismantling a persistent clinical misconception. Some practitioners have assumed that Theraplay’s emphasis on touch and eye contact makes it unsuitable, or even harmful, for autistic children. This evaluation found no evidence of deterioration in functioning and instead suggests the model can be adapted in a neurodiversity-affirming way to achieve trauma-related outcomes comparable to those of non-autistic peers. Prior scoping reviews had already found that interventions relying less on verbal skills and emphasising caregiver involvement, both hallmarks of Theraplay, suit neurodivergent children who have experienced interpersonal trauma. The present study extends that literature to the specific and understudied intersection of autism, developmental trauma, and attachment disruption in care-experienced children.

Nevertheless, the authors are candid about the limitations inherent in practice-based evidence. The evaluation was retrospective rather than randomised, the autistic subgroup was small, the integrative design makes it impossible to isolate which component drove change, and all outcome data relied on caregiver report vulnerable to expectancy effects. Formal treatment fidelity checks were not routinely conducted, dropout information was not collected, and the generic psychometric measures were not adapted to autistic symptomatology. Changes in executive function and attachment-related outcomes, while directionally positive and at times showing moderate effect sizes, did not reach significance, likely reflecting insufficient statistical power.

The research team concludes that the 30-hour neuro-collaborative Theraplay-informed intervention is effective for children with developmental trauma and attachment disruption, and may also benefit autistic children, though larger, adequately powered trials are needed to confirm this. They call for qualitative research capturing the lived experiences of autistic children, their carers, and their therapists, alongside the development of autism-sensitive assessment tools. For now, the message for services supporting care-experienced autistic children is cautiously optimistic: attachment-based, sensory-informed, neurodiversity-affirming therapy deserves a place in the treatment conversation, and services are encouraged to evaluate and publish their own anonymised data to build the collective evidence base.

Subject of Research: Evaluation of a neurocollaborative Theraplay-informed psychotherapeutic intervention for developmental trauma and attachment difficulties in autistic looked after children

Article Title: The Impact of a Neurocollaborative Theraplay®-Informed Intervention on the Presentations of Developmental Trauma and Attachment Difficulties in a Sub-Group of Autistic Looked after Children: a Retrospective Service Evaluation

Article References: Purrington, J., Hartley, G., Price, A., Bass, E., Godfrey, C., Lynch, J., & Mukherjee, R. (2026). The Impact of a Neurocollaborative Theraplay®-Informed Intervention on the Presentations of Developmental Trauma and Attachment Difficulties in a Sub-Group of Autistic Looked after Children: a Retrospective Service Evaluation. Journal of Child & Adolescent Trauma. https://doi.org/10.1007/s40653-026-00964-6

Image Credits: AI Generated

DOI: 10.1007/s40653-026-00964-6

Keywords: autism, developmental trauma, attachment disruption, Theraplay, looked after children, sensory regulation, therapeutic parenting, neurodiversity, psychotherapy outcomes, service evaluation, child and adolescent trauma, care system