The Boy Who Was Raised as a Dog (37 page)

People process, store and retrieve information and then respond to the world in a manner that depends upon their current physiological state (in other words, their response is “state-dependent”). If a child has been exposed to extreme or pervasive threat or trauma, his stress system may become sensitized and he may respond to ordinary experiences as though they are threatening. Depending on his individual response to stress, he may move primarily along the dissociative or the arousal continuum, but either change will reduce his ability to learn cognitive information, such as schoolwork.

As a result his brain may be in a very different state than that of other children around him in a classroom. As the chart illustrates, a calm child will process information very differently from one who is in an “alarmed” state, whether he tends toward a dissociative or a hyper-aroused response. Even if two children have identical IQs, the calmer child can more readily focus on the words of the teacher and, using her neocortex, engage in abstract thought and learning.

In contrast, the child who is alarmed will be less efficient at processing and storing the verbal information the teacher is providing. Subcortical and limbic areas will dominate this child's cognition. These areas focus on nonverbal information, such as the teacher's facial expressions, hand gestures and perceived mood. Further, because the brain learns in a “use-dependent” fashion, this child will already have experienced more selective development of her nonverbal cognitive capacities. The child who has been traumatized or maltreated has learned that nonverbal information is more important than verbal—for example, “When daddy smells like beer and walks funny, I know he will hurt mommy.”

As a child moves along the continuum of arousal, the part of the brain in control of his functioning shifts; the more distressed or threatened he is, the more primitive the behaviors and responses. During this state-related shift in cognition the child's sense of time is altered and the range of future planning is foreshortened. The threatened child is not thinking (nor should she think) about months from now: she is focused on the current threat.

This has profound implications for understanding the thoughts, reactions and behavior of traumatized children. For these youth immediate reward is most reinforcing; delayed gratification is almost impossible. They are quite literally unable to consider the potential consequences of their behavior because of the physical arousal state of their brains.

As a result considered reflection about behavior—including violent behavior—is impossible for the child in an alarm state. Cut adrift from the internal regulating capabilities of the cortex, the brainstem acts reflexively, impulsively and often aggressively to any perceived threat.

Due to this state-dependent processing, maltreated children may express a host of puzzling and seemingly insignificant “sensitivities.” Eye contact for too long may be perceived as a life threatening signal. A friendly touch to the shoulder may remind one child of sexual abuse by a stepfather. A well-intended, gentle tease to one may be a humiliating cut to another, similar to the endless sarcastic and degrading emotional abuse he experiences at home. A request to solve a problem on the board may terrify the girl living in a home where she can never do anything well enough. A slightly raised voice may feel like a shout to the little boy living in a violent home. To help traumatized children these responses must be taken into account and their stress response systems calmed so that they can feel safe enough to rely upon their higher brain functions and reduce the amount of time they spend higher on the arousal continuum.

Adapted from: Perry, B. D. (2006, Summer). Fear and learning: trauma-related factors in education.
New Directions for Adult and Continuing Education, 110
(21-27).

The greatest contributors to this book are those I cannot acknowledge by name: the hundreds of maltreated and traumatized children who continue to shape my evolving understanding of their condition and therapeutic needs. I am honored to have worked with each of them—and I thank them for their grace, for their courage and for their willingness to share their pain so that others might benefit. I hope their strength and spirit comes through on these pages and that we have done justice to their stories.

I would also like to thank a series of brilliant scientists and gifted clinician-researchers for the wisdom and guidance they provided throughout my professional career. These include Drs. Seymour Levine, Charles Sorenson, David U'Prichard, Jon Stolk, Earl Giller and Steve Southwick. I thank my insightful clinician-mentors, especially Drs. Jarl Dyrud and Richard Kaufman. In addition, I was fortunate to have a series of administrative mentors who provided time, lab space, resources and guidance, most notably Drs. Bennett Leventhal and Stuart Yudofsky. My primary neuroscience collaborators, Drs. Lewis Seiden, Al Heller and Bill Woolverton, also deserve mention. Further, I am deeply indebted to Drs. Lenore Terr, Robert Pynoos and Frank Putnam—and many other pioneer clinicians and researchers who inspired me. Space does not permit me to list them all.

I also wish to acknowledge here the work and ongoing inspiration of author and attorney Andrew Vachss. Over the years, he has been
generous with his wisdom and guidance in shaping my work. He has helped me ask the right questions. He is true north in a murky world.

In addition, I am grateful to the current and former Fellows and staff of The ChildTrauma Academy. The compassion these clinicians show for troubled children has always been inspiring, and the intellectual stimulation they provide is priceless. First among equals is Dr. Robin Fan-court, a remarkable and selfless pediatrician who has transformed an entire country by her efforts. Special thanks are due to the present ChildTrauma Academy leadership, Jana Rosenfelt, Dr. Chris Dobson and Stephanie Schick, and to my current primary clinical research collaborators in the CTA, Drs. Rick Gaskill and Gizane Indart.

Our work over the years has been supported by many generous and compassionate individuals. I especially wish to thank here Irving Harris, Jeffery Jacobs, Maconda Brown O'Connor and Richard and Meg Weekley.

Further gratitude is due to Jo Ann Miller, editorial director of Basic Books, for her editorial sculpting and support and to Andrew Stuart, our agent, for his hard work and encouragement during this project.

My greatest thanks, however, must go to my family. My father, Duncan, and mother, Donna, have many gifts: curiosity, humor, compassion, industry. My own gifts reflect the world they gave me as a child. For that and so much more, I am profoundly grateful. But of all my family, my utmost gratitude must be reserved for my wife, Barbara. She has tolerated moves, time away from home, too much time working at home and me, in general. Our children are my greatest joy and my greatest teachers. My family continues to provide the love, strength, support and inspiration that sustains me.

Finally, this book exists because of Maia Szalavitz. I am extremely grateful that we have started this collaboration. She is a hard-working and superb writer with a remarkable capacity to digest scientific concepts across many disciplines and translate these concepts for general readers. Most importantly, she has a big heart. I hope you have enjoyed reading this book as much as we have enjoyed writing it.

It has been a real honor to work with one of my scientific heroes, Bruce D. Perry, and I couldn't have asked for a better collaborator. I thank him first and foremost for his kindness, wisdom, generosity, support and inspiration and for allowing me to help this book come into being. As a science writer, my idea of heaven is being paid to ask important questions of great minds—and this project involved just that. Kudos are due as well from me to our agent Andrew Stuart for his guidance and help in shaping this book from proposal onwards and to Jo Ann Miller for elegant editing and support. Special thanks to Lisa Rae Coleman for her fine transcription, friendship and sharp wit and to Trevor Butter-worth and
stats.org
for their ongoing support. My mom, Nora Staffanell, and my Dad, Miklos Szalavitz, my siblings Kira Smith (and her children, Aaron, Celeste and Eliana), Sarah and Ari Szalavitz also deserve credit. As ever, my gratitude also goes to Peter McDermott for making both my work and my life better.

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affect at least 7 percent of all Americans:
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005, June). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.
Archives of General Psychiatry
,
62(6)
, 593-602. See also: Kessler, R. C., et al. (1995, December). Posttraumatic Stress Disorder in the National Comorbidity Survey.
Archives of General Psychiatry
,
52(12)
, 1048-1060.

2
about 40 percent of American children:
Franey, K., Geffner, R., & Falconer, R. (Eds.). (2001).
The Cost of Maltreatment: Who Pays? We All Do
(pp. 15-37). San Diego, CA: Family Violence and Sexual Assault Institute. See also: Anda, R. F., Felitti, V. J., Bremner J. D., Walker, J. D., Whitfield, C. H., Perry, B. D., Dube, S. R., & Giles, W. H. (2006, April). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology.
European Archives of Psychiatry and Clinical Neuroscience
,
256(3)
, 174-186. Epub 2005, November 29.

3
around 872,000 of these cases were confirmed:
http://www.acf.hhs.gov/programs/cb/pubs/cm04/index.htm

3
one in eight children under the age of seventeen
: Finkelhor, D., Ormrod, R., Turner, H., & Hamby, S. L. (2005, February). The victimization of children and youth: a comprehensive, national survey.
Child Maltreatment
, 10(1), 5-25.

3
about 27 percent of women and 16 percent of men
: Finkelhor, D., Hotaling, G., Lewis, I. A., & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors.
Child Abuse & Neglect, 14
, 19-28.

3
6 percent of mothers and 3 percent of fathers: A statistical portrait of fathers and mothers in America
. (2002). (p. 24). Washington, D.C.: ChildTrends. Survey results from 1995 Gallup Survey on Disciplining Children in America.

3
up to ten million American children
: Strauss, M. A. (1991).
Children as witnesses to marital violence: A risk factor for lifelong problems among a nationally representative sample
of American men and women
. [Paper presented at the Ross Roundtable on “Children and Violence.”] Washington, D.C.

3
4 percent of American children under the age of fifteen
: Strauss, M. A. (1991). Ibid.

3
some 800,000 children will spend time in foster care
: Child Welfare League of America. (2005, June 5). Statement of the Child Welfare League of America for House Subcommittee on Human Resources of the Committee on Ways and Means for the hearing on federal foster care financing.
http://www.cwla.org/advocacy/fostercare050609.htm

3
more than eight million American children suffer from serious, diagnosable, trauma-related psychiatric problems
: Perry, B. D. & Pollard, R. (1998, January). Homeostasis, Stress, Trauma and Adaptation.
Child and Adolescent Psychiatric Clinics of North America, (7)1
, 33-51.

3
one third of children who are abused
: Perry, B. D. & Azad, I. (1999, Aug). Posttraumatic stress disorders in children and adolescents.
Current Opinion in Pediatrics
,
11(4)
, 310-316.

24
respond properly to stress for a lifetime
: Perry, B. D., Stolk, J. M., Vantini, G., Guchhait, R. B., & U'Prichard, D. C. (1983). Strain differences in rat brain epinephrine synthesis and alpha-adrenergic receptor number: Apparent in vivo regulation of brain alpha-adrenergic receptors by epinephrine.
Science, 221
, 1297-1299.

24
change a rat's stress response forever
: Reviewed in Levine, S. (2005, November). Developmental determinants of sensitivity and resistance to stress
. Psychoneuroendocrinology
, 30(10), 939-946. See also generally: Terr, L. (1990).
Too scared to cry: how trauma affects children and ultimately, us all
. New York: Basic Books.

36
stress-response systems in vets with PTSD
: Perry, B. D., Giller, E. L., & Southwick, S. (1987). Altered platelet alpha2-adrenergic binding sites in post-traumatic stress disorder.
American Journal of Psychiatry
,
144(11)
, 1511-1512; Perry, B. D., Southwick, S. W., Yehuda, R., & Giller, E. L. (1990). Adrenergic receptor regulation in post-traumatic stress disorder. In E. L. Giller, (Ed.),
Advances in psychiatry: biological assessment and treatment of post traumatic stress disorder
(pp. 87-115). Washington, D.C.: American Psychiatric Press; Giller, E. L., Perry, B. D., Southwick, S. M., Yehuda, R., Wahby, V., Kosten, T. R., & Mason, J. W. (1990). Psychoendocrinology of posttraumatic stress disorder. In M. E. Wolf & A. D. Mosnaim (Eds.),
PTSD: biological mechanisms and clinical aspects
(pp. 158-170). Washington, DC: American Psychiatric Press.

37
improve their schoolwork and interpersonal skills
: Perry, B. D. (1994). Neurobiological sequelae of childhood trauma: Post traumatic stress disorders in children. In M. Murburg (Ed.),
Catecholamine function in post traumatic stress disorder: emerging concepts
(pp. 253-276). Washington, D.C.: American Psychiatric Press.