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
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.
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
Trauma and the Developing
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.
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
*This is a special Academy
version of an article originally published in
The JOURNAL of the California Alliance for
the Mentally Ill
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