The Long Shadow — The Lingering Effects of Childhood Trauma

I think this article, an interview with Bruce Perry, a highly accomplished pediatric psychiatrist (who helped the children of the Branch Davidian Cult during the Waco, Texas standoff), vindicates my journey to understand the pain and confusion that has so badly compromised my baseline experience for my entire life.  In an important way, it’s too bad that some people have seemed, at one point or another, to want to discourage me from trying to understand and heal what happened to me.  But on another hand, maybe it’s not too bad, maybe that’s just our journey together, and I hope this article will bring better understanding to at least a few of us.

The Sun Magazine | The Long Shadow

The Long Shadow

Bruce Perry On The Lingering Effects Of Childhood Trauma

by Jeanne Supin

The “fight or flight” instinct has served the human species well, helping us respond quickly to threats, but, according to child and adolescent psychiatrist and neuroscientist Bruce Perry, it can also change our brains for the worse. If the threats we encounter are extreme, persistent, or frequent, we become too sensitized, overreacting to minor challenges and sometimes experiencing symptoms of post-traumatic stress disorder, or PTSD. This is especially true for children, whose still-developing brains may be chronically altered by growing up in abusive environments that Perry calls “the equivalent of a war zone.” Perry says that instead of being offered the sort of meaningful, caring connections they need, children with these experiences are often labeled troublemakers — and later criminals. He advocates passionately for changes in parenting, teaching, policing, and public policy to help traumatized kids.

The second of four children, Perry was born in 1955 in Bismarck, North Dakota. His father was a dentist; his mother, a homemaker. Skinny and asthmatic, Perry joined the track team and says visualization techniques helped him win races and get his asthma under control. He went on to attend Stanford University in California, where he majored in human biology and participated in a seminar about the effects of early-life stress on the developing brains of rats. During his first summer home from college, Perry got married; he returned to Stanford with his wife in the fall. One night she went missing and was later found brutally murdered. After the funeral Perry didn’t return to school. He spent a lot of time alone, thinking about what had happened. When he went back to Stanford in the spring, the attention he received from other students made him uncomfortable, so he transferred to Amherst College in Massachusetts and entered the neuroscience program. In the wake of his wife’s death he stopped focusing on grades and simply pursued subjects that interested him.

Perry went on to attend Chicago’s Northwestern University, where he earned his MD and a PhD in neuroscience, satisfying his interests in both pure research and applied science. He did his medical residency at Yale University in Connecticut and joined ongoing research efforts to determine why some combat veterans developed PTSD and others didn’t. Perry recalled something he’d learned at Stanford: that rats exposed to uncontrollable stressful experiences early in life suffered lasting changes in brain chemistry. He looked at the veterans’ childhoods and found that those with a history of physical or sexual abuse were more likely to have been traumatized by the war.

In 1987, as a child-and adolescent-psychiatry fellow at the University of Chicago, Perry consulted at Saint Joseph’s Carondelet Child Center, a treatment program for boys with severe behavior disorders. He was shocked to discover that the psychiatrists who diagnosed the boys rarely took into account the children’s histories of abuse and neglect. Perry showed that, if given the structure and stability and nurturing they’d been denied earlier in life, they could improve, sometimes dramatically.

Perry has since served as chief of psychiatry at Texas Children’s Hospital and worked as a consultant and expert witness following tragedies, including such high-profile cases as the Columbine High School shootings, the Oklahoma City bombing, and the Branch Davidian standoff in Waco, Texas. He currently lives in Houston, where he is a senior fellow at the ChildTrauma Academy (childtrauma.org). He is also an adjunct professor of psychiatry and behavioral sciences at Northwestern’s Feinberg School of Medicine. In addition to having written more than two hundred scientific articles, Perry has coauthored with Maia Szalavitz two books for general audiences: The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook and Born for Love: Why Empathy Is Essential — and Endangered.

For this interview I met Perry at his small Houston office, which is decorated with photographs from summer hiking trips he has taken with his wife and adult children in the Rockies or Canadian mountain ranges. He says that to nurture healthy children and understand what they need, we first have to help them feel safe and connected and allow them time for reflection. He seemed to embody this principle himself: during the two days I interviewed him, he was relaxed, and he never appeared rushed or looked at a watch or device. Though he often spoke about childhood trauma in terms of neurons and brain development, his love for children was obvious. When the conversation turned to the kids he has worked with, I could easily imagine him sprawled out on the carpet with a five-year-old, focused only on the vulnerable human being in front of him.

Supin: What is trauma?

Perry: Despite using that word all the time, the psychiatric field still debates how to define it. Is trauma an external event? Is it the way we experience that event? Is it the long-term changes in emotional and physical functioning that follow the event?

I define trauma as an experience, or pattern of experiences, that impairs the proper functioning of the person’s stress-response system, making it more reactive or sensitive.

Supin: What is the stress-response system?

Perry: We have many stress-response systems. Essentially all the systems in our body can be recruited to respond to some form of stress, and depending upon the nature, timing, and intensity of the challenge or threat, some combination of these responses will be used to help us survive and adapt. Most people are familiar with the “fight or flight” response, which is activated when we perceive a potential threat. Our heart rate and respiration increase, glucose is released for energy, and nonessential feelings like hunger or pain will be ignored — all in preparation to flee or fight. Then, when the threat has passed, those systems return to a baseline equilibrium. These stress-response systems are a dynamic process, constantly monitoring our world and activating and deactivating to allow us to thrive.

Another important aspect of our capacity to adapt is the malleability of the brain. Neural networks tend to change according to how often they are activated, and these changes can make us either more or less functional. If the brain’s stress-response apparatus is activated for prolonged periods, such as in a domestic-violence situation, its equilibrium will change. Instead of being anxious and fearful only when confronted with a threat, a person might live in a persistent state of fear. For a child, in particular, this has many negative ramifications.

Take a school shooting: Two children in the same classroom might experience basically the same event, but they can have very different long-term responses. One might have some bad dreams and anxiety, but after three months or so those will subside, and the child returns to her baseline. She doesn’t forget the event, and even years later she will likely feel upset if she thinks about it, but the event did not fundamentally change her capacity to self-regulate, relate, and reason. She wasn’t “traumatized.”

Another child’s reaction might be much more severe and prolonged: profound anxiety, significant sleep problems, recurring nightmares, and intrusive, disruptive memories of the event itself. This child is experiencing a change in his stress response. The event shifted his baseline in unhealthy ways. He was traumatized.

When a child with a typical equilibrium is traumatized, he is aware of the change and can report his distress to others. But when a child grows up in an environment permeated with chaos or violence, that child perceives this state of hypervigilance and distractibility as the norm. If asked whether he feels anxious, he will say no. We can tell how anxious he is by the way he startles when he hears a sudden noise, by his inability to sit still, and so forth. But to him this is normal. This is his baseline.

Supin: So the difference in baselines explains why one child might recover from a school shooting and another be traumatized by it?

Perry: Many factors influence who we are and how we function. For example, previous prolonged activation of the stress-response system due to living with the unpredictability of poverty might be a factor. So could the type of support the child receives from family and community. The quality of a child’s relationships before, during, and after a horrible event influences outcomes tremendously. Children who have experienced attentive, loving parental care since birth and who live in stable, safe homes and communities will fare best.

A child will also respond to an event based on how the adults around her respond. Human emotions are contagious. If a child falls down and scrapes a knee, she will mirror the parent’s response to the accident. If the parent is calm, it strengthens the child’s stress-response system. If the parent views the situation as threatening, the child will, too. Parents’ reactions turn out to be one of the major predictors of whether a child will develop symptoms of post-traumatic stress after a tragedy. Resilient children are made, not born.

Many people believe that children are more resilient than adults, yet the opposite is true. The developing brain is sensitive to experiences both good and bad. The same neurological principles that allow young children to rapidly learn motor skills and language are also at play when it comes to processing stress or trauma. An infant who receives predictable, consistent care develops a neural framework that helps that child think and learn later in life. An infant who is neglected or abused develops a different neural framework.

Supin: Can you explain a little more about how our stress-response systems work?

Perry: All input — feelings of hunger or thirst, loud noises, the sound of someone’s voice, some information we learn — first enters the lower, more primitive part of our brains, which determines if this input is familiar or unfamiliar. If the input is familiar, it then travels to a higher, more evolved part of our brain, where we decide based on memory whether it’s good, bad, or neutral. If the input is unfamiliar, the brain’s default conclusion is This can’t be good. Any novelty — even desirable novelty, like learning something new — activates our stress-response system.

Some stress is actually good for us — for example, the stress related to meeting a new person or traveling to a new place. Predictable, controllable, and moderate activation of the stress-response system has been shown to build our capacity to manage challenges. When a child has the opportunity to challenge herself in the presence of supportive adults, it builds resilience. It’s the dose, the pattern, and the controllability that determine whether the stress is adaptive or harmful.

Let’s say you’re a six-year-old boy, and up until now your life has been OK. Mom and Dad split up, and there was some conflict around the divorce, but nothing too horrible. Then all of a sudden Mom has a new boyfriend in the house. That’s novel, so it generates moderate stress. At dinner he raises his voice at you; that’s unpredictable. He soon starts barking orders at you more frequently. He yells at your mom. He hits you, or he hits your mom. Your stress-response system doesn’t have time to return to baseline before another source of stress arrives. You start having anticipatory anxiety about what will happen next. Your baseline level of stress increases; things that would not have bothered you much before now bother you a lot. A harsh tone of voice that may have been mildly upsetting is now overwhelming. If the boyfriend’s behavior continues, your stress-response system may start to register any angry tone of voice as threatening. You’ve become what we call “sensitized.”

Supin: Conventional wisdom might suggest that the boy would get used to the angry, violent behavior and be less affected by it over time, but you’re saying the opposite is true.

Perry: Exactly. The more our stress-response system is activated in uncontrollable ways, the less able we are to handle even small amounts of stress.

When you are overstressed, you no longer have efficient access to your higher brain functions. By the time you’re in a state of alarm, significant parts of your cortex — the highest-functioning part of your brain — have shut down entirely. This is adaptive if you’re confronted by a predator, because you don’t want to waste time thinking about how to respond: you want to fight or run away. But to do your best reasoning, you need access to that sophisticated part of your brain. To learn and plan, you need to be in a relatively calm state.

Supin: Let’s go back to the six-year-old boy in your example. What happens to him at school?

Perry: The brain is good at generalizing from one kind of experience to another. Most of the time this ability is a gift, but this boy may generalize that all male authority figures who raise their voices are terrifying. This starts a vicious cycle: The boy arrives at school already on heightened alert due to his home situation, and he can’t pay attention. The teacher gets frustrated and raises his voice. The child is now even more on red alert. It’s impossible for him to concentrate. The rational parts of his brain shut down. Instead he has access only to the parts that process information valuable in threatening situations. He’s attuned to the teacher’s tone of voice, to whom the teacher is smiling at. He’s learning to read nonverbal cues. The calm child will learn the state capitals; the sensitized child will learn who is the teacher’s pet.

Supin: Can he recover from that?

Perry: Yes, opportunities for controlled, moderate doses of stress can shift these systems back toward well-regulated functioning. The key is that a moderate challenge for a typical child may be a huge challenge for a sensitized child.

The achievement gap in schools has a lot to do with the child’s home and community life. If the family is concerned about not having money for food or rent or a doctor’s visit, that creates a pervasive sense of anxiety and unpredictability. The longer the child is in that environment, the worse the vicious cycle at school becomes. Eventually the kid says to himself, “There’s something wrong with me. I’m stupid.” And he drops out as soon as he can.

Supin: What about the character-building benefits of facing down adversity, of “rising to the challenge”? Is that ever applicable in these situations?

Perry: If you start from a healthy place, adversity can be character building. But if you grow up amid constant adversity, you are less likely to have the flexible and capable stress-response systems you need to face down adversity. Certainly many children do grow up with remarkable gifts and strengths despite their challenges, but when this happens, it’s often because there were people in the child’s environment who helped create a safe, predictable space for the child at least part of the time.

Supin: Are there instances in which well-intentioned parents protect their children from stress too much?

Perry: Yes, I’ve seen upper-middle-class children develop anxiety disorders because they had never been given the opportunity to explore the world. They’d been told only, “Don’t do this, don’t do that, don’t get dirty.” By the time these children went to preschool, they hadn’t learned to tolerate even slight discomforts. They became overwhelmed by the novelty of preschool and had meltdowns.

Resilience comes from stress. It’s important that parents, teachers, and coaches not be afraid of it. Exploring, getting dirty, and falling down help you build resilience and tolerate novelty and discomfort.

Supin: How might we apply this to whole communities?

Perry: First we have to understand that feeling connected to other people is one of our most fundamental needs. We feel safer when we are with kind and familiar people. Tension can arise from being part of a marginalized minority, whether you define that minority status by economics, race, ethnicity, religion, gender identity, sexual preference, or whatever. The marginalized group has a much higher level of baseline stress. It’s not a specific traumatic event; it’s a continuous sense of disconnection.

Our brain is constantly monitoring our environment to gauge whether or not we belong someplace. If we frequently get feedback that we don’t belong — or, worse, overt threats — then our body’s systems stay in a constant state of arousal. This increases the risk for diabetes and hypertension and makes learning, reflection, planning, and creative problem-solving harder. Over time it will actually change the physiology of your brain.

For example, for someone who already feels marginalized and is hypervigilant, even a relatively benign interaction, such as a police officer asking for your license, can trigger a volatile reaction. This is true for both the person being stopped and for the cop who’s doing the stopping. They both can be sensitized. People in law enforcement should know the principles of stress and trauma. It’s the key to understanding why some of their policies and behaviors have a destructive effect.

Supin: Are you aware of any programs to train law-enforcement personnel in these principles?

Perry: I did some work with the FBI after the Branch Davidian standoff in Waco, Texas. [In 1993 the Federal Bureau of Alcohol, Tobacco, and Firearms; the FBI; and the Texas National Guard held the Branch Davidian religious group under siege for fifty-one days, culminating in an explosive clash and eighty-six deaths. —Ed.]

Supin: What were you doing, and what did you learn?

Perry: The events at Waco were astoundingly tragic. We brought in a team of people to help with the Branch Davidian children both during and after the standoff.

The Branch Davidians were a highly insular fundamentalist religious group who had sworn absolute allegiance to their charismatic and controlling leader, David Koresh. The group certainly conformed to all academic definitions of a cult. In the first three days of the standoff, twenty-one children were released into the care of the FBI and the Texas Child Protective Services. I got involved because I lived nearby, and someone in the Texas government asked for my assistance. I went to Waco figuring I’d make some recommendations and be back home in a few days. I ended up assembling a team and staying for months.

When I first arrived, I was greeted by an imposing Texas Ranger who was feeling understandably protective of these children and none too keen about a psychiatrist messing with their heads. In trauma work we routinely track heart rates, because even when traumatized children express no outward stress response, their heart rates are often elevated. I offered the ranger a deal: he could take the pulse of a girl sleeping soundly nearby, and if it was below a hundred, I’d leave. The normal resting heart rate for a child her age is about eighty beats per minute. Her pulse was 160. I stayed, and the ranger and I became close collaborators in helping these kids.

Others wanted the kids to get therapy, but I said no. First let’s bring them consistency and predictability. Let’s minimize the number of new adults in their lives. Let’s settle them into a routine and allow them to build some familiarity with us.

About seven weeks passed from the time the twenty-one children were released until the bloody conclusion of the standoff. I interviewed each child multiple times during that period but was also just with them day in and day out. So I got to know them.

Each evening, after the kids had gone to bed, the adults would sit together and talk about what we’d seen during the day. We found that each child had about three hours of therapeutic interaction a day, even though none of them received formal therapy. Throughout the day kids would seek out small doses of support. One child might go up to the best adult hugger and get a hug; later that same child might find the funniest adult and get a laugh. The key here is that the children controlled the nature and duration of the interaction. Their heart rates began to go down.

We had a diverse-enough group that the children could find exactly what they needed at any particular moment. It reminded me of traditional multigenerational clans, where maybe Mom is good at fixing a hurt, and Grandpa is good at storytelling, and someone else can start a fire, and so on. The community offers a rich array of people to learn and receive support from.

Living with those twenty-one Branch Davidian children changed how I thought about therapeutic work. We offered structure, familiarity, caring — and no therapy. A fifty-minute therapy session might be a part of treating trauma, but ideally it’s simply one thread in a much larger web of therapeutic encounters.

My confidence in our approach grew when the Davidians’ attorneys insisted that the children be allowed to visit with their parents. During those visits the parents repeated Koresh’s apocalyptic message, warning that we were going to kill them all. And, sure enough, after the visits the kids’ heart rates shot back up. As soon as the visits stopped, the children returned to baseline.

Over the years my colleagues and I have honed our ability to identify and educate the adults in a child’s family, community, and school who might help provide therapeutic experiences. We teach them about the impact that trauma and adversity have had on a child’s functioning. We give them realistic expectations. The most at-risk children are often disconnected from family, school, and community. Reestablishing those connections appears to buffer the effects of trauma. Distributing caregiving duties among a set of healthy and loving adults is one of the best ways to help isolated, overwhelmed, and incompetent parents. Grandparents, partners, and friends can all shoulder some of the burden.

Supin: What can communities do to support and encourage healthy development?

Perry: A number of years ago Chicago’s Cabrini-Green public housing added some green space among the high-rise apartment buildings. They put in a better playground. They put in benches where people could sit. No other changes were made or new services offered, but over the next couple of years violent crime in that housing project dropped by 30 percent.

If your living environment increases the probability that you will interact with your neighbor, it makes both of you physically healthier, socially healthier, and less likely to suffer the mental-health issues associated with being isolated and marginalized.

Another set of studies were done of indigenous populations in British Columbia that had suffered the long-term consequences of cultural genocide — authorities suppressing languages, religious practices, economic systems, all the things that create a cohesive community. Throughout British Columbia dozens of these indigenous communities have recovered their languages, traditional practices, and so forth, and those same communities have experienced decreases in violent crime, alcoholism, and suicide. In some the suicide rates dropped to the same as the general population, which is astounding for an indigenous population.

Supin: How do you know if something traumatic happened with a child? Will he or she express it behaviorally?

Perry: Frequently yes, but it’s amazing how many times kids will also make an initial disclosure. They’ll say, “I don’t like to go to Grandpa’s house.” If that gets no response, they might come back later and say, “Grandpa likes to play games. . . .” But if, when a kid makes that comment, the adult says, “Grandpa loves you. Don’t talk bad about Grandpa,” the kid won’t bring it up again. The child was testing the waters, to see how open you are to hearing something negative about Grandpa. The moment the child senses that you’re not open, he or she backs away.

Supin: When you’re getting children to talk about what happened to them, how do you approach them?

Perry: People who have experienced trauma, especially children, need to be able to control how and when they tell their story. When we demand that someone tell us what happened, even with good intentions, we often reactivate the traumatic memory and the accompanying stress, which makes matters worse. Only the child knows what the proper time and method of revisiting the trauma is.

I once worked with a girl who at the age of three had witnessed her mother’s brutal rape and murder. The attacker then slashed the girl’s throat and left her for dead. She was alone with her deceased mother’s body for eleven hours before someone found her. I’d been brought in by the girl’s attorney to prepare her for possibly testifying in court. The first time we met, she was sitting on the floor in a room with dolls, toys, and books. I sat down on the floor nearby, to make myself less imposing, and began drawing in a coloring book, chatting with her about what I was coloring and the colors I chose. Eventually she moved closer and directed me to use specific crayons. We colored together in silence for several more minutes before I asked, “What happened to your neck?” She ignored the question. I quietly asked again. She became agitated and reenacted the events by pretending to slash the throat of her stuffed animal. She then started jumping off the furniture. Afraid she’d hurt herself, I caught her, and she collapsed in my arms and in a slow monotone told me what had happened.

From then on I let her determine what we did at each therapy session. For many months she would motion for me to lie silently on the floor as she revisited her trauma in small, controllable doses in order to make sense of it. She would have me lie down, and she would demonstrate how she had tried to revive her dead mother. She always insisted that I wake up, which, of course, I did. She wanted a different outcome. We did this again and again, and little by little she made the violent memory into something she could live with and not have it crush her.

Her emotional state evolved, too. Over the months her behavior softened, and she grew more deliberate. Finally one day, instead of instructing me to lie on the floor, she led me to a rocking chair, chose a book from the bookshelf, crawled into my lap, and asked me to read her a story.

Supin: What advice do you give to people who work with traumatized kids?

Perry: It’s critically important to meet the child exactly where he or she is developmentally. Imagine a twelve-year-old living in poverty, with hurtful and unpredictable parenting and miserable experiences at school. That child will be much less mature than a typical twelve-year-old. In fact, he’s probably more like a four-year-old socially, and maybe a seven-year-old cognitively.

I teach people to change their expectations at first, because otherwise he won’t progress. I’ll tell his teachers that even though he’s in sixth grade, his ability to learn is closer to a first-grader’s, and he has the attention span of a preschooler. You wouldn’t expect a preschooler to sit still for more than a few minutes, would you? So they adjust their expectations and allow the child to move around or shift to a new task more frequently. The child’s behavior soon improves, and that once-disruptive boy can learn and even excel at an appropriate age level.

Supin: Is it really so easy?

Perry: The great thing about our brains is that they can adapt and improve quickly as soon as we’re given the support we need. I’ve seen many instances in which children with extreme trauma histories and seemingly insurmountable deficits catch up to their chronological age remarkably fast.

Justin, who inspired the title of my book The Boy Who Was Raised as a Dog, was six when I first met him in a hospital pediatric intensive-care unit. He was nonverbal and always either rocking and moaning or screaming and throwing food and feces at staff. He’d been diagnosed with “static encephalopathy” — severe brain damage of an unknown origin, unlikely to improve. The doctors had assumed he would be unresponsive to treatment, so they’d offered none.

Tragically no one had asked about Justin’s living conditions prior to his hospitalization. His story was heartbreaking. When Justin was two months old, his fifteen-year-old mother had left him with his grandmother, who’d died nine months later. The infant ended up with the grandmother’s boyfriend, who did not have the emotional or intellectual skills to raise a baby. He called Child Protective Services, but since he didn’t seem to pose a threat to the boy, CPS didn’t act. The man was a dog breeder by profession. So he raised this child in a kennel as if he were a puppy. Justin was fed and changed, but otherwise lived in a cage for five years with only dogs for companions.

His severe developmental delays were the direct result of the conditions he’d endured. We immediately conducted new assessments, operating from the premise that Justin did, in fact, have the capacity for developmental growth. Our treatment gave him the opportunities he had missed earlier in life. Speech therapists introduced him to language and words as they would a toddler, and physical therapists helped with toilet training and the motor skills typically acquired by preschoolers. His progress was astounding. He leaped over developmental milestones in mere weeks instead of years.

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