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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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