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Sandy was four years old when I met her. Nine months
earlier, she was found covered in blood, lying over her
murdered mother’s naked body, whimpering incoherently.
But now, her eyes studied my face, my hands, and my slow
movements - only partly attentive to the few words I spoke.
She was justifiably suspicious as I joined her on the
floor in coloring. For many minutes we colored together
in silence. Sandy broke the rhythm by silently directing
me to use a specific color. I complied.
But soon I had to ask her about what had happened. She
knew that was why I was there; I knew she knew that was
why I was there. All of the adults in her ‘new’
life had sooner or later returned her to that night.
"What happened to your neck?" I asked, pointing
to the two scars running from behind her ear to the front
of her throat. She acted as if she did not hear me. She
did not change her expression. She did not change the
pace of her coloring.
I repeated the question. She took her crayon and scribbled
over her well-formed, disciplined picture but gave no
verbal response.
Again I asked.
Sandy stood up, grabbed a stuffed animal, held it by
a tuft of hair and slashed at the neck of the animal with
the crayon. As she slashed she repeated "It’s
for your own good, dude." Over and over - a stuck
recording.
She threw the animal to the floor, ran to the radiator,
climbed up and jumped off - again and again. She did not
respond to my verbal warnings about being careful. Finally,
I rose and caught her on one of her jumps. She melted
into my arms. We just sat together for more minutes. I
felt her frenzied breathing slow and then almost stop.
And then, in a slow, robotic monotone, she told me about
that night.
An acquaintance of her mother came to their apartment.
"Mama was yelling, the bad guy was hurting her; I
should have killed him." "I came out of my room
and mama was asleep - then he cut me - he said "It’s
for your own good, dude."
The assailant cut her throat - twice. Sandy immediately
collapsed. Later she regained consciousness and attempted
to ‘wake up’ her mother. She took milk from
the refrigerator and gagged when she tried to drink some.
She gave some to her mother -- ‘she was not thirsty’.
A three-year-old, throat-cut child, weeping, whimpering,
comforting and seeking comfort from her naked mother’s
hog-tied, bloody, cold body. The mother’s multiple
stab wounds oozed at first - then there was nothing but
drying, ‘sticky’ blood. Sandy wandered that
apartment for eleven hours before anyone came.
Sandy was alone - her world forever changed. Her entire
being was altered - the way she thinks, the way she behaves,
the way she feels, the way she grows. Her brain is etched
with the memories of terror. She carries elements of this
trauma with her everyday. She carries elements of her
terror into every relationship and every classroom. In
so many ways, she was robbed of her future, robbed of
her true potential.
Traumatized Children
Sadly, Sandy is not alone. In the United States alone
from 1996 to 1998 there were more than 5 million children
exposed to some form of severe traumatic event such as
physical abuse, domestic and community violence, motor
vehicle accidents, chronic painful medical procedures
and natural disasters. These experiences can have a devastating
impact on children. Beginning with Lenore Terr’s
landmark work, investigators over the last twenty years
have determined that more than thirty percent of children
exposed to these kinds of traumatic events will develop
serious and chronic neuropsychiatric problems. The most
common are Post-traumatic Stress Disorders (PTSD). PTSD
has been studied primarily in adult combat veterans. Indeed,
the United States has spent billions of dollars on research
and clinical services for the 1 million veterans from
the Vietnam era suffering from PTSD. In contrast, the
twenty million (or more) children with PTSD are among
the least understood, under-studied and inconsistently
served groups in the United States.
Trauma and the Developing Brain
To help Sandy and millions of other traumatized children,
we need to understand how the brain responds to threat,
how it stores traumatic memories and how it is altered
by the traumatic experience. Yes, altered. All experience
changes the brain – good experiences like piano
lessons and bad experiences like living through a tornado
as it destroys your home. This is so because the brain
is designed to change in response to patterned, repetitive
stimulation. And the stimulation associated with fear
and trauma changes the brain.
Over the last twenty years, neuroscientists studying
the brain have learned how fear and trauma influence the
mature brain, and more recently, the developing brain.
It is increasingly clear that experience in childhood
has relatively more impact on the developing child than
experiences later in life. This is due to the simple principles
of neurodevelopment.
The functional capabilities of the mature brain develop
throughout life, but the vast majority of critical structural
and functional organization takes place in childhood.
Indeed, by the age of three the brain has reached 90 %
of adult size, while the body is still only about 18 %
of adult size. By shaping the developing brain, experiences
of childhood define the adult. Neurodevelopment is characterized
by (1) sequential development and ‘sensitivity’
(the brain "grows" from brainstem to the cortex)
and (2) ‘use-dependent’ organization ("use
it or lose it"). The mature organization and functional
capabilities of brain reflect aspects of the quantity,
quality and pattern of the somato-sensory experiences
of the first years of life. The sequential and use-dependent
properties of brain development result in an amazing adaptive
malleability, ensuring that, within its specific genetic
potential, an individual’s brain develops capabilities
suited for the ‘type’ of environment he or
she is raised in. Simply stated, children reflect the
world in which they are raised. If that world is characterized
by threat, chaos, unpredictability, fear and trauma, the
brain will reflect that by altering the development of
the neural systems involved in the stress and fear response.
The Neurobiological Responses to Threat
When a child is threatened, various neurophysiological
and neuroendocrine responses are initiated. If they persist,
there will be ‘use-dependent’ alterations
in the key neural systems involved in the stress response.
These include the hypothalamic-pituitary-adrenal (HPA)
axis. In animal models, chronic activation of the HPA
system in response to stress has negative consequences.
Chronic activation may "wear out" parts of the
body including the hippocampus, a key area involved in
memory, cognition and arousal. This may be occurring in
traumatized children as well. Dr. Martin Teicher and colleagues
have demonstrated hippocampal/limbic abnormalities in
a sample of abused children.
Another set of neural systems that become sensitized
by repetitive stressful experiences are the catecholamine
systems including the dopaminergic and noradrenergic systems.
These key neurochemical systems become altered following
traumatic stress. The result is a cascade of associated
changes in attention, impulse control, sleep, fine motor
control and other functions mediated by the catecholamines.
As these catecholamines and their target regions (e.g.,
amygdaloid nuclei) also mediate a variety of other emotional,
cognitive and motor functions, sensitization of these
systems by repetitive re-experiencing of the trauma leads
to dysregulation in many functions. A traumatized child
may, therefore, exhibit motor hyperactivity, anxiety,
behavioral impulsivity, sleep problems, tachycardia and
hypertension. In preliminary studies by our group, we
have seen altered cardiovascular regulation (e.g., increased
resting heartrate) suggesting altered autonomic regulation
at the level of the brainstem. In other studies, clonidine,
an alpha2 adrenergic receptor partial agonist has been
demonstrated to be an effective pharmacotherapeutic agent,
presumably by altering the sensitivity of the noradrenergic
systems. Studies by Dr. Michael DeBellis and colleagues
have demonstrated other catecholamine and neuroendocrine
alterations in a sample of sexually abused girls. These
indirect studies all support the hypotheses of a use-dependent
alteration in the brainstem catecholamine systems following
childhood trauma.
Implications of Trauma-related Alterations in
Brain Development
All experiences change the brain – yet not all
experiences have equal ‘impact’ on the brain.
Because the brain is organizing at such an explosive rate
in the first years of life, experiences during this period
have more potential to influence the brain – in
positive and negative ways. Traumatic experiences and
therapeutic experiences impact the same brain and are
limited by the same principles of neurophysiology. Traumatic
events impact the multiple areas of the brain that respond
to the threat. Use-dependent changes in these areas create
altered neural systems that influence future functioning.
In order to heal (i.e., alter or modify trauma), therapeutic
interventions must activate those portions of the brain
that have been altered by the trauma. Understanding the
persistence of fear-related emotional, behavioral, cognitive
and physiological patterns can lead to focused therapeutic
experiences that modify those parts of the brain impacted
by trauma.
Our evolving understanding of neurodevelopment suggests
directions for assessment, intervention and policy. Primary
among these is a clear rationale for early identification
and aggressive, pro-active interventions that will improve
our ability to help traumatized and neglected children.
The earlier we intervene, the more likely we will be to
preserve and express a child’s potential.
The ChildTrauma Academy
www.ChildTrauma.org
*This is a special Academy version of an article originally
published in The JOURNAL of the California Alliance
for the Mentally Ill
Official citation: Perry, B.D. Traumatized
children: How childhood trauma influences brain development.
In: The Journal of the California Alliance for the
Mentally Ill 11:1, 48-51, 2000
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