“I NEED YOUR HELP.” THE CALLER, Stan Walker, was an attorney for the Public Guardian’s office in Cook County, Illinois. I had completed my training in child psychiatry and was now an assistant professor at the University of Chicago, still working at the clinic and running my lab. It was 1990.
“I just inherited a case scheduled to go to trial next week,” he told me, explaining that it was a homicide. A three-year-old girl named Sandy had witnessed the murder of her own mother. Now, almost a year later, the prosecution wanted her to testify about it.
“I’m concerned that this might be pretty overwhelming for her,”
Stan went on, asking if I might be able to help prepare her for court.
“Pretty overwhelming?” I thought sarcastically to myself, “You think so?”
Stan was a Guardian-ad-litem, an attorney appointed by the court to represent children in the legal system. In Cook County (where Chicago is located), the Public Guardian’s Office has a full- time staff to represent children in the Child Protective Services (CPS) system. In almost all other communities this role is played by an appointed attorney who may or may not have experience and training in child law. Cook County had created the full-time positions in the noble hope that if the attorneys worked their cases full time, they could develop experience with children, learn about maltreatment, and thus better serve those they represent.
(Unfortunately, like all other components of the child protective system, the volume of cases was overwhelming and the office was underfunded.) “Who is her therapist?” I asked, thinking that someone familiar to the child would be much better suited to help her prepare.
“She doesn’t have one,” he said. This was disturbing news.
“No therapist? Where is she living?” I asked.
“We don’t really know. She is in foster care but the prosecutor and the Department of Child and Family Services are keeping her location undisclosed because there have been threats against her life. She knew the suspect and identified him for the police. He is in a gang and there is a contract out on her.” This was sounding worse and worse.
“She gave a credible ID at age three?” I asked. I knew that eyewitness testimony is easily challenged in court because of the properties of narrative memory we noted earlier, especially its gaps and the way it tends to “fill in” the “expected.” And from a four-year- old about an event that occurred when she was three? If the prosecutors didn’t have some help, a good defense attorney would easily make Sandy’s testimony appear completely unreliable.
“Well, she knew him,” Stan explained. “She both spontaneously said he did it and later identified him from a photo array.”
I asked if there was any additional evidence, thinking that maybe the little girl’s testimony wouldn’t even be necessary. If there was enough other evidence, perhaps I could help him convince the prosecutor that testifying posed too great a risk of further traumatizing the child.
Stan explained that there was indeed other evidence. In fact, numerous types of physical evidence placed the perpetrator at the scene. Investigators had found the girl’s mother’s blood all over his clothes. Despite having fled the country after committing the crime, the man still had blood on his shoes when he was arrested.
“So why does Sandy have to testify?” I asked. I was already starting to feel pulled to help this child.
“That is part of what we are trying to figure out. We are hoping to have the case postponed until we can either get her testimony by closed-circuit TV or make sure she is ready to testify in court.”
He went on to describe the details of the murder, the girl’s hospitalization due to injuries she’d received during the crime, and her subsequent foster care placements.
As I listened, I debated whether or not to get involved. As usual I was overextended and extremely busy. Plus, I’m uncomfortable in court and I hate lawyers. But the more Stan talked, the more I couldn’t believe what I was hearing. The people who were supposed to help this girl—from the Department of Children and Family Services (DCFS) to the justice system—seemed clueless about the effects of trauma on children. I began to feel that she deserved to have at least one person in her life who might not be.
“So, let me go over this again,” I said, “A three-year-old girl witnesses her mother being raped and murdered. She has her own throat cut, twice, and is left for dead. She is alone with her dead mother’s body for eleven hours in their apartment. Then, she’s taken to the hospital and has the wounds on her neck treated. In the hospital, the physicians recommend ongoing mental health evaluation and treatment. But after she’s released, she’s placed in a foster home as a ward of the state. Her CPS caseworker doesn’t think she needs to see a mental health professional. So, despite the doctors’ recommendations, he doesn’t get her any help. For nine months, this child is moved from foster home to foster home with no counseling or psychiatric care whatsoever. And the details of the child’s experiences are never shared with the foster families because she is in hiding. Right?”
“Yeah, I guess all of that is true,” he said, hearing the unmistakable frustration in my voice and how terrible it all sounded when I described the situation so bluntly.
“And now, ten days before a murder trial is scheduled to start, you become aware of the situation?”
“Right,” he admitted, sheepish now.
“When did your office get notified about this girl?” I demanded.
“Actually we opened the case right after this happened.”
“No one in your office thought to ensure that she had some mental health support?”
“We tend to review cases when they come up for their hearings.
We have hundreds of cases apiece.” I wasn’t surprised. The public systems working with high-risk families and children are overwhelmed. Oddly enough, during my years of clinical training in child mental health I had little introduction to the child protective system or to the special education and juvenile justice systems, despite the fact that more than 30 percent of the children coming to our clinics were in one or more of these systems. The compartmentalization of services, training, and points of view was staggering. And, I was learning, very destructive for children.
“When and where can I see her?” I asked. I couldn’t help myself.
I agreed to meet Sandy in an office at the court the next day.
I was somewhat surprised that Stan had called me for help.
Earlier that year he had sent me a “cease and desist” letter. In four long paragraphs I was told that I must immediately provide justification for the use of a medication called clonidine to “control” children at a residential treatment center where I consulted. I provided the psychiatric services for the children at the center. The letter said that if I could not explain what I was up to, I must immediately stop this “experimental” treatment. It was signed by Stan Walker in his official capacity as attorney with the Public Guardian.
After receiving Stan’s letter, I contacted him to explain why I was using this medication and why I believed it would be a mistake to stop. The children at this residential center were among the state’s most difficult cases. More than one hundred boys had been placed in this program after “failing” in foster homes due to severe behavioral and psychiatric problems. Although the facility accepted boys from seven to seventeen, the average child in the facility was a ten-year-old who had lived in ten prior “homes,” meaning that for most of them no fewer than ten parent substitutes had found them unmanageable. Easy to stir up and overwhelm but very difficult to calm down, these children had been a problem for every caregiver, therapist, and teacher they had encountered. Ultimately, they’d get kicked out of foster homes, child care settings, schools, and sometimes even therapy. The final stop was this center.
AFTER REVIEWING THE RECORDS of some 200 boys who were then living at the center or who had been there in the past, I found that every single one of these boys—without exception—had experienced severe trauma or abuse. The vast majority had had at least six major traumatic experiences. All of these children had been born into and raised with chaos, threat, and trauma. They were incubated in terror.
All of them had been evaluated multiple times both prior to and during their stay at the center. Each had been given dozens of different DSM diagnostic labels, primarily attention deficit/hyperactivity disorder, oppositional-defiant disorder, and conduct disorder—just like Tina. But shockingly, very few of these children were viewed as “traumatized” or “stressed;” their trauma wasn’t deemed relevant to diagnosis, much like in Tina’s case.
Despite lengthy histories of domestic violence, repeatedly interrupted familial relationships often including the loss of parents to violent death or disease, physical abuse, sexual abuse, and other overwhelmingly distressing events, few had been diagnosed with post-traumatic stress disorder (PTSD). PTSD did not even make it into the “differential diagnosis,” a list included in the case report of possible alternative diagnoses with similar symptoms that each clinician considers, then rules out.
Post-traumatic stress disorder was a relatively new concept at the time, having been introduced into the DSM diagnostic system in 1980 to describe a syndrome found in Vietnam veterans who, upon returning from their tours of duty, often experienced anxiety, sleep problems, and intrusive and disturbing “flashback” memories of events that took place during the war. They were frequently jumpy and some responded aggressively to even the most minor signals of threat. Many had terrifying nightmares and reacted to loud noises as though they were gunshots and they were still back in the jungles of Southeast Asia.
During my general psychiatry training, I had worked with vets who suffered from PTSD. Many psychiatrists were, even then, beginning to recognize its prevalence in adults who’d suffered other kinds of traumatic experiences like rape and natural disasters. What struck me especially was that, although the experiences that had scarred adults with PTSD were often relatively brief (usually lasting for a few hours at most), their impact could still be seen in their behavior years—even decades—later. It reminded me of what Seymour Levine had found in those rat pups, where a few minutes of stress could change the brain for life. How much more powerful, I thought, must the impact of a genuinely traumatic experience be for a child! Later, as a general resident in psychiatry, I studied aspects of the stress response systems in vets with PTSD. I and other researchers found that these veterans’ stress response systems were overreactive, what scientists call “sensitized.” This meant that when they were exposed to minor stressors their systems reacted as though they were facing great threat. In some cases the brain systems associated with the stress response had become so active that they eventually “burnt out” and lost their ability to regulate the other functions they would normally mediate. As a result the brain’s capacity to regulate mood, social interactions, and abstract cognition was also compromised.
At the time I was working with the boys at the center, I was continuing to study the development of the stress-related neurotransmitter systems in the lab. I was looking not only at adrenaline and noradrenaline now, but exploring other related systems as well: those using serotonin, dopamine, and the endogenous opioids, which are known as enkephalins and endorphins. Serotonin is probably best known as the site of action for antidepressant medications like Prozac and Zoloft; dopamine is known as a chemical involved with pleasure and motivation involved in the “high” from drugs like cocaine and amphetamine; endogenous opioids are the brain’s natural painkillers and are affected by heroin, morphine, and similar drugs. All of these chemicals play important roles in the response to stress, with adrenaline and noradrenaline preparing the body for fight or flight, and dopamine providing a sense of competence and power to achieve one’s goals. Serotonin’s actions are less easy to characterize, but the opioids are known to soothe, relax, and reduce any pain that may be involved in responding to stress and threat.
After I’d recognized that Tina’s attention and impulsivity-related symptoms were linked to a hyperaroused stress system, I had begun to think that medications that calmed the stress system might help others like her. Clonidine, an old and generally safe medication, had long been used to treat people whose blood pressure was usually normal, but skyrocketed into hypertension when they were under stress. Clonidine helped “quiet” this reactivity down. A preliminary study using this medication had shown that it also helped decrease PTSD-related hyperarousal symptoms in adult combat veterans. Knowing that the physical symptoms many of the boys at the residential treatment center exhibited were consistent with an overactive and overly reactive stress system, I’d decided to try clonidine on them with their guardian’s permission.
And for many, it worked. Within a few weeks of beginning to take the medication, the boys’ resting heart rates had normalized and their sleep improved. Their attention became more focused and their impulsivity was reduced. Even better, the boys’ grades began to improve, as did their social interactions with each other.
To me, of course, this was no surprise. By reducing the overactivity in their stress systems, the medication enabled the boys to be less distracted by signals of threat. This helped them become more attentive to both academic material and ordinary social cues, allowing them to improve their schoolwork and interpersonal skills (see Figure 3, Appendix, for additional details).
I’d explained all of this to Stan Walker after I’d gotten his letter.
To my surprise, he withdrew his objections and asked me to send him some more information about trauma and children.
Unfortunately, as I informed him, there was not much written on the topic at the time. I sent him some of these early reports and some writing I had done myself. Until this call I had not heard back from him.
THE NEXT DAY, AS I PREPARED to meet Sandy, I tried to imagine the crime she’d witnessed from her perspective. Nine months earlier she had been found covered in blood, lying over her murdered mother’s naked body, whimpering incoherently. At the time she was not yet four. How could she go on, day after day, with those images in her mind? How could I possibly prepare her for testimony, and the confrontation of cross-examination, a threatening experience even for adults? What would she be like? I also wondered how she had survived psychologically. How could her mind protect her from these traumatic experiences? And, how could any reasonable person, let alone someone trained to deal with troubled children, not realize that she needed help after what she’d been through? Unfortunately, the prevailing view of children and trauma at the time—one that persists to a large degree to this day—is that “children are resilient.” I recall visiting the scene of a murder around this time with a colleague who had started a trauma response team to help first responders to crime and accident scenes. Police, paramedics and fire fighters often see terrible panoramas of death, mutilation and devastation, and this, of course, can take an awful toll. My colleague was justifiably proud of the services he had put into place to help these professionals.
As we walked through the house where the victim’s blood still soaked the couch and splattered the walls, I saw three young children standing like zombies in the corner.
“What about the children?” I asked, as I nodded my head toward the three blood-speckled witnesses. He glanced at them, thought for a moment, and replied, “Children are resilient. They will be fine.” Still young and respectful of my elders, I nodded my head as if to acknowledge his wisdom, but inside I was screaming.
If anything, children are more vulnerable to trauma than adults; I knew this from Seymour Levine’s work and the work of dozens of others by then. Resilient children are made, not born. The developing brain is most malleable and most sensitive to experience—both good and bad—early in life. (This is why we so easily and rapidly learn language, social nuance, motor skills, and dozens of other things in childhood, and why we speak of “formative” experiences.) Children become resilient as a result of the patterns of stress and of nurturing that they experience early on in life, as we shall see in greater detail later in this book.
Consequently, we are also rapidly and easily transformed by trauma when we are young. Though its effects may not always be visible to the untrained eye, when you know what trauma can do to children, sadly, you begin to see its aftermath everywhere.
At that time my laboratory was studying neurobiological mechanisms, which I knew were related to resilience and vulnerability to stress. We were examining a curious but very important effect of drugs that stimulate the systems I’d been studying in the brain. These effects are called sensitization and tolerance, and they have profound implications for understanding the human mind and its reaction to trauma.
In sensitization, a pattern of stimulus leads to increased sensitivity to future similar stimulus. This is what is seen in the Vietnam veterans and the rats that were genetically oversensitive to stress or became that way because of early exposure to it.
When the brain becomes sensitized, even small stressors can provoke large responses. Tolerance, on the contrary, mutes one’s response to an experience over time. Both factors are important for the functioning of memory: if we didn’t get tolerant to familiar experiences, they would always appear new and potentially overwhelming. The brain would probably run out of storage capacity, like an old computer. Similarly, if we didn’t become increasingly sensitive to certain things, we would not be able to improve how we respond to them.
Curiously, both effects can be achieved with the same amount of the same drug, but you get completely opposite results if the pattern of drug use is different. For example, if a rat, or a human, is given small, frequent doses of drugs like cocaine or heroin that act on the dopamine and opioid systems, the drugs lose their “strength.” This is part of what happens during addiction: the addict becomes tolerant, and so more of the drug is needed to achieve the same “high.” In contrast, if you give an animal the exact same daily quantity of drug, but in large, infrequent doses, the drug actually “gains” strength. In two weeks a dose that caused a mild reaction on day one can actually cause a profound and prolonged overreaction on day fourteen. Sensitization to a drug, in some cases, can lead to seizures and even death, a phenomenon that may be responsible for some otherwise inexplicable drug overdoses. Sadly for people with addiction, their drug craving tends to produce patterns of use that cause tolerance, not sensitization to the “high” that they desire, while simultaneously producing sensitization to certain undesirable effects, like the paranoia associated with cocaine use.
More importantly, for our purposes, resilience or vulnerability to stress depend upon a person’s neural system’s tolerance or sensitization following earlier experience. These effects can also help further explain the difference between stress and trauma, which is important to understand as we consider children like Tina and Sandy. For example, “use it or lose it” is something we hear at the gym with good reason. Inactive muscle gets weak, while active muscle gets stronger. This principle is referred to as “use- dependence.” Similarly, the more a system in the brain is activated, the more that system will build—or maintain—synaptic connections.
The changes—memory of sorts—in muscle occur because patterned, repetitive activity sends a signal to muscle cells that “you will be working at this level” so they make the molecular changes required to do that work easily. In order to change the muscle, however, the repetitions must be patterned. Curling twenty-five pounds thirty times in three closely timed sets of ten curls leads to stronger muscle. If you curl twenty-five pounds thirty times at random intervals during the day, however, the signal to the muscle is inconsistent, chaotic and insufficient to cause the muscle cells to become stronger. Without the pattern the very same repetitions and very same total weight will produce a far less effective result. To create an effective “memory” and increase strength, experience has to be patterned and repetitive.
And so it is with the neurons, neural systems and the brain.
Patterns of experience matter. On a cell-by-cell basis, no other tissue is more suited to change in response to patterned repetitive signals. Indeed, neurons are designed to do just that. It is this molecular gift that allows memory. It produces the synaptic connections that allow us to eat, type, make love, play basketball and do everything else a human being is capable of doing. It is these intricate webs of interconnection that make the brain work.
By forcing either your muscles or your brain to work, however, you do “stress” them. Biological systems exist in balance. In order to function they have to stay within a certain limited range appropriate to their current activity, and it is the brain that is charged with maintaining this essential equilibrium. The actual experience is a stressor; the impact on the system is stress. And so, if you get dehydrated during exercise, for example, that stress will make you thirsty because your brain is trying to drive you to replace the needed fluids. Similarly, when a child learns a new vocabulary word, there is a tiny stress applied to the cortex, which requires repetitive stimulation to create accurate recall. Without the stress, the system wouldn’t know there is something new to attend to. In other words, stress is not always bad.
Indeed, if moderate, predictable and patterned, it is stress that makes a system stronger and more functionally capable. Hence, the stronger muscle in the present is the one that has endured moderate stress in the past. And the same is true for the brain’s stress response systems. Through moderate, predictable challenges our stress response systems are activated moderately.
This makes for a resilient, flexible stress response capacity. The stronger stress response system in the present is the one that has had moderate, patterned stress in the past.
However, that is not the whole story. If you try to bench press 200 pounds on your first trip to the gym, if you do manage to lift the weight at all, you’re not likely to build muscle, but tear it and hurt yourself. The pattern and intensity of experience matter. If a system is overloaded—worked beyond capacity—the result can be profound deterioration, disorganization, and dysfunction whether you are overworking your back muscles at the gym or your brain’s stress networks when confronted with traumatic stress.
This also means that as a result of the strengthening effect of previous moderate and patterned experience, what may be traumatically stressful for one person may be trivial for another.
Just as a body builder can carry weights that untrained people cannot even move, so too can some brains deal with traumatic events that would cripple others. The context, timing and response of others matters profoundly. The death of a parent is far more traumatic for the two-year-old child of a single mother than it is for a fifty-year-old married man with children of his own. In Tina’s case and that of the boys at the center, their experience of stress was far beyond their young systems’ capacities to carry it. Rather than moderate, predictable and strengthening activation of their stress systems, they had suffered unpredictable, prolonged and extreme experiences that had marked their young lives profoundly. I couldn’t see any way that this would not be true for Sandy as well.
BEFORE I MET HER I TRIED TO GET as much background and history on Sandy as I could. I talked with her current foster family, her new caseworker and, ultimately, with members of her extended family. I learned that she had profound sleep problems and was pervasively anxious. I was told that she had an increased startle response. Just like the traumatized Vietnam vets I’d worked with, she would jump at the slightest unexpected noise. She also had episodic periods of daydreaming, during which it was extremely difficult to get her to “snap out of it.” A doctor who saw her without knowing her history might have diagnosed her with the “absence” or “petit mal” form of epilepsy: she was that hard to reach during these episodes.
I also learned that Sandy sometimes had aggressive, tantrum- like outbursts. Her foster family couldn’t find any pattern to these behaviors, couldn’t pinpoint what set them off. But they did report another set of “odd” behaviors: Sandy didn’t want to use silverware. Unsurprisingly, she was especially afraid of knives; but she also refused to drink milk, or even look at milk bottles. When the doorbell rang, she would hide like a skittish cat, sometimes so effectively that it took twenty minutes for her foster parents to find her. She could also be found, on occasion, hiding underneath a bed, behind a couch, in a cabinet under the kitchen sink, rockingand crying.
So much for resilience. Sandy’s startle reaction alone told me that her stress response systems had become sensitized.
Testifying would immerse her in painful reminders of that terrible night. I had to get some sense of whether or not she could tolerate it. Though I didn’t want to, at some point in my initial visit I was going to have to probe her memory a little to see how she would react. But I comforted myself with the knowledge that a little pain now could help protect her from a lot of pain later, and might even help her begin the healing process.
I FIRST MET SANDY IN A SMALL room housed in a typical, sterile government building. It had been set up to be “child-friendly” with some child-size furniture, toys, crayons, coloring books, and paper.
A few cartoon figures had been painted on the walls, but “system” still screamed out from the tile floors and cinder-block construction.
When I walked in, Sandy was sitting on the floor with some dolls around her. She was coloring. What first struck me, as it had when I first met Tina, was how small she was. I guessed she stood a bit less than four feet tall. She had huge, liquid brown eyes and long, thick, curly brown hair. On her neck were visible scars on both sides, from her ears to the middle of her throat. But they were much less noticeable than I had imagined they might be; the plastic surgeons had done a good job. As I walked in with Stan she stopped everything and stared at me, frozen.
Stan introduced me. “Sandy, this is the doctor I told you about.
He is going to talk with you, OK?” he asked anxiously. She didn’t move, not one millimeter. There was no change in her wary expression. In response Stan looked at me and back at her, gave a big smile and said in his best cheerful, kindergarten-teacher voice,
“OK. Good. Well, I will leave you two together.” As he walked out I looked at him like he was nuts, surprised by how he’d dismissed Sandy’s lack of response to his question. When I looked back at Sandy her face wore the same expression that mine did. I shook my head, shrugged my shoulders, and gave a little smile. As if in a mirror, Sandy did the same.
Aha! A connection! This was a good start, I thought. Don’t let it slip away. I knew if I walked toward this tiny girl—I’m pretty big— her sensitized alarm response would go crazy. Her surroundings were already unfamiliar enough—new adults, new place, new situation—I needed her to stay as calm as possible.
“I want to color some too.” I said without looking at her. I wanted to be as predictable as possible and let her know what I was going to do step by step. No sudden moves. Make yourself smaller, I thought, get on the floor. Don’t look at her, don’t face her, use slow deliberate movements as you color. I sat down on the floor, a few feet away. I tried to make my voice as soothing and calm as possible.
“I really like red. This should be a red car,” I said, pointing at a picture in my coloring book.
Sandy studied my face, my hands, and my slow movements.
She was only partly attentive to my words. This little girl was justifiably suspicious. For a long time I colored alone, chattering about my choices of colors, being as casual and friendly as possible without being overly “bright” as Stan had been when he tried to mask his anxiety. Eventually, Sandy broke the rhythm by moving a bit closer toward me and silently directing me to use a specific color. I complied. Once she came over to me, I stopped talking. For many minutes more we colored together in silence.
I had yet to ask her about what had happened, but I could sense that she knew that was why I was there—and that she knew that I knew she knew. All of the adults in her “new” life had sooner or later, in some way, returned her to that night.
“What happened to your neck?” I asked, pointing to her two scars. 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. Now, she froze. Coloring stopped. Her eyes stared off into space, unblinking. I asked again. She took her crayon and scribbled over her well-formed, disciplined picture but gave no response.
Again, I asked. I hated this. I knew I was pushing her toward her painful memories.
Sandy stood up, grabbed a stuffed rabbit, held it by the ears 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, and climbed up and jumped off again and again. She did not respond to my warnings to be careful. Worried that she would hurt herself, I rose and caught her on one of her jumps. She melted into my arms. We sat together for a few more minutes. Her frenzied breathing slowed and then almost stopped.
And then, in a slow, robotic monotone she told me about that night.
An acquaintance of her mother had come to their apartment. He had rung the doorbell and her mother had let him in. “Mama was yelling, the bad guy was hurting her,” she said. “I should have killed him.”
“When I came out of my room and Mama was asleep, then he cut me,” she continued, “He said, ‘It’s for your own good, dude.’”
The assailant had 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. It oozed through the slit in her throat. She tried to give some to her mother, but “she was not thirsty,” Sandy told me. Sandy wandered that apartment for eleven hours before anyone came. A relative, worried that Sandy’s mother had not answered the phone, had dropped by and discovered the horrifying crime scene.
BY THE END OF THAT INTERVIEW I was certain that testifying would be devastating for Sandy. She needed help and, if she did have to testify, more time to prepare. Stan would work successfully, as it turned out, to postpone the trial. “Could you do the therapy?” he asked me. Of course. I couldn’t say no.
THE IMAGES OF SANDY BURNED into my mind during that interview were staggering: a three-year-old child, her throat cut, weeping, trying to comfort and also seeking comfort from her naked mother’s hog-tied, bloody, and ultimately cold body. How helpless, confused, and terrified she must have felt! Her symptoms —her “absences,” her avoidant responses to my questions, her hiding, her specific fears—were defenses constructed by her brain to keep the trauma at bay. Understanding those defenses would be critical to helping her and other children like her. Even in utero and after birth, for every moment of every day, our brain is processing the nonstop set of incoming signals from our senses. Sight, sound, touch, smell, taste—all of the raw sensory data that will result in these sensations enter the lower parts of the brain and begin a multistage process of being categorized, compared to previously stored patterns, and ultimately, if necessary, acted upon.
In many cases the pattern of incoming signals is so repetitive, so familiar, so safe, and the memory template that this pattern matches is so deeply engrained, that your brain essentially ignores them. This is a form of tolerance called habituation.
We ignore familiar patterns in ordinary contexts, so much so that we forget large portions of our days, which are spent doing routine things like brushing our teeth or getting dressed.
We’ll remember if a familiar pattern occurs out of context, however. For example, you might be on a camping trip, brushing your teeth as the sun comes up. The beauty of the moment is so powerful that you will remember this one time as unique. Emotions are powerful markers of context. The pleasure and joy of the sunrise in this instance is unusual in the “brushing teeth” memory template, so it makes it more vivid and memorable.
Similarly, if you happen to be brushing your teeth when an earthquake destroys your home, those events may become forever connected in your mind and recalled together. Negative emotions often make things even more memorable than positive ones because recalling things that are threatening—and avoiding those situations in the future if possible—is often critical to survival. A mouse that didn’t learn to avoid the scent of cats after one bad experience, for example, would not be a mouse likely to produce many offspring. As a result, however, such associations can become the source of trauma-related symptoms. For an earthquake survivor who was brushing her teeth when the house collapsed around her, simply seeing a toothbrush might be enough to provoke a full-fledged fear response.
In Sandy’s case, milk, once associated with nurturing and nutrition, now became the stuff that spilled from her throat, that her mother “refused” as she lay dead. Silverware was now no longer something used to eat your food, but rather something that killed and maimed and horrified. And doorbells—well, that was what had started the whole thing: the ringing of the doorbell had announced the arrival of the killer.
For her these mundane and ordinary things had become evocative cues that kept her in a state of continual fear. This, of course, confused her foster parents and her teachers, who didn’t know the details of what had happened to her and therefore often couldn’t recognize what might be prompting her strange behavior.
They couldn’t understand why she would be so sweet one moment and then impulsive, defiant, and aggressive the next. The outbursts seemed disconnected from any event or interaction that the adults could identify. But both the seeming unpredictability and the nature of her behaviors made complete sense. Her brain was trying to protect her based upon what it had previously learned about the world.
The brain is always comparing current incoming patterns with previously stored templates and associations. This matching process takes place initially in the lowest, simplest parts of the brain, where, as you may recall, the neural systems involved in responding to threat originate. As the information moves upward from this first stage of processing, the brain has opportunities to take a second look at the data for more complex consideration and integration. But at first all it wants to know is: Does this incoming data potentially suggest danger? If the experience is familiar and known as safe, the brain’s stress system will not be activated. However, if the incoming information is initially unfamiliar, new, or strange, the brain instantly begins a stress response. How extensively these stress systems are activated is related to how threatening the situation appears.
It’s important to understand that our default is set at suspicion, not acceptance. At a minimum, when faced with a new and unknown pattern of activity, we become more alert. The brain’s goal at this point is to get more information, to examine the situation and determine just how dangerous it might be. Since humans have always been the deadliest animal encountered by other humans, we closely monitor nonverbal signals of human menace, such as tone of voice, facial expression, and body language.
Upon further evaluation, our brain may recognize that the new pattern of activation has been caused by something familiar, but out of context. For example, if you are in the library reading and someone drops a heavy book on a table, the loud noise will immediately make you stop reading. You will activate your arousal response, focus on the source of the noise, categorize it as a safe, familiar accident—perhaps annoying, but nothing to worry about. If, on the other hand, you hear a loud noise in the library, turn and discover that other people around you seem alarmed, then look up and see a man with a gun, your brain would move from arousal to alarm and probably then into full-blown fear. If in a few minutes, you learn that this was a bad student prank, your brain would slowly move back down this arousal continuum toward a state of calm.
The fear response is graded, calibrated by the brain’s perceived level of threat (see Figure 3, Appendix). As you become increasingly frightened, the threat systems in your brain continue to integrate incoming information and orchestrate a total body response aimed at keeping you alive. To that end an impressive set of interacting neural and hormonal systems work together to make sure your brain and the rest of your body do the right things.
First, your brain makes you stop thinking about irrelevant things by shutting down the chatter of the frontal cortex. Then, it focuses on cues from others around you to help you determine who might protect or threaten you, by letting the limbic system’s “social cue reading” systems take over. Your heart rate increases to get blood to your muscles in case you need to fight or flee. Your muscle tone also increases and sensations like hunger are put aside. In thousands of different ways your brain prepares to protect you.
When we are calm it is easy to live in our cortex, using the highest capacities of our brains to contemplate abstractions, make plans, dream of the future, read. But if something attracts our attention and intrudes on our thoughts, we become more vigilant and concrete, shifting the balance of our brain activity to subcortical areas to heighten our senses in order to detect threats.
As we move up the arousal continuum toward fear, then, we necessarily rely on lower and faster brain regions. In complete panic, for example, our responses are reflexive and under virtually no conscious control. Fear quite literally makes us dumber, a property that allows faster reactions in short periods of time and helps immediate survival. But fear can become maladaptive if it is sustained; the threat system becomes sensitized to keep us in this state constantly. This “hyperarousal” response accounted for many of Sandy’s symptoms.
But not all of them. The brain doesn’t have just one set of adaptations for threat. In the situation Sandy faced she was so small and so powerless and the threat she experienced so overwhelming, that she was unable to fight or flee. If her brain had responded by raising her heart rate and preparing her muscles for action, that would only have made her more likely to bleed to death when she was injured. Amazingly, our brains have a set of adaptations for these kinds of situations as well, which accounts for another important set of trauma-related symptoms, known as “dissociative” responses.
Dissociation is a very primitive reaction: the earliest life forms (and the youngest members of higher species) can rarely escape dire situations under their own steam. Their only possible response to being attacked or hurt, then, is essentially to curl up, to make themselves as small as possible, to cry for help and hope for a miracle. This response appears to be driven by the most primitive brain systems, located in the brainstem and immediately surrounding it. For infants and young children, incapable of or ineffective at fighting or fleeing, a dissociative response to extreme stressors is common. It is also more common in females than males and, if prolonged, dissociation is connected with increased odds for post-traumatic stress symptoms.
During dissociation, the brain prepares the body for injury. Blood is shunted away from the limbs and the heart rate slows to reduce blood loss from wounds. A flood of endogenous opioids—the brain’s natural heroin-like substances—is released, killing pain, producing calm and a sense of psychological distance from what is happening.
Like the hyperarousal response, the dissociative response is graded and occurs on a continuum. Ordinary states like daydreaming and transitions between sleep and wakefulness are mild forms of dissociation. Hypnotic trance is another example. In extreme dissociative experiences, however, the person becomes completely focused inward and disconnected from reality. Brain regions that dominate thinking shift from planning action to concerning themselves with brute survival. There is a sense that time has slowed and what’s happening isn’t “real.” Breathing slows.
Pain and even fear shut down. People often report feeling emotionless and numb, as though they are watching what’s happening to them affect a character in a movie.
In most traumatic experiences, however, not one but a combination of these two major responses occurs. Indeed, in many cases a moderate dissociation during a traumatic event can modulate the intensity and duration of the hyperarousal response.
The capacity to become “numb” and partially robotic during combat, for example, allows the soldier to continue to function effectively without panic. But in some cases one pattern or the other predominates. And if these patterns are activated repeatedly long enough, due to the intensity, duration, or pattern of the trauma, there will be “use-dependent” changes in the neural systems that mediate these responses. The result is that these systems can become overactive and sensitized, leading to a host of emotional, behavioral, and cognitive problems long after the traumatic event is over.We have come to understand that many post-traumatic psychiatric symptoms, in fact, are related to either dissociative or hyperarousal responses to memories of the trauma. These responses can help people survive immediate trauma, but if they persist, they can cause serious problems in other areas of life down the road.
There are few better examples of trauma-related problems than what I saw in those boys at the residential center. The impact of trauma—and the frequent misinterpretation of its symptoms— revealed itself in the fact that nearly every one of them had some kind of diagnosis related to attention and conduct problems. In a classroom setting, unfortunately, both dissociation and hyperarousal responses look remarkably like attention deficit disorder, hyperactivity, or oppositional-defiant disorder. Dissociated children quite obviously are not paying attention: they seem to be daydreaming or “spacing out,” rather than focusing on schoolwork, and indeed, they have tuned out the world around them.
Hyperaroused youth can look hyperactive or inattentive because what they are attending to is the teacher’s tone of voice or the other children’s body language, not the content of their lessons.
The aggression and impulsivity that the fight or flight response provokes can also appear as defiance or opposition, when in fact it is the remnants of a response to some prior traumatic situation that the child has somehow been prompted to recall. The “freezing” response that the body makes when stressed—sudden immobility, like a deer caught in the headlights—is also often misinterpreted as defiant refusal by teachers because, when it occurs, the child literally cannot respond to commands. While not all ADD, hyperactivity, and oppositional-defiant disorder are trauma-related,it is likely that the symptoms that lead to these diagnoses are trauma-related more often than anyone has begun to suspect.
THE FIRST TIME I MET SANDY FOR therapy it was in the foyer of a church. Still in a form of witness protection, she had to be protected from the killer’s fellow gang members, who could not be arrested because they hadn’t directly taken part in the crime. So we met in unusual places at atypical times. Often, this turned out to be Sundays at a church. She was there with her foster parents. I greeted them. Sandy recognized me, but did not smile.
I brought her foster mother into the room where we were to hold the session, a preschool classroom. Then, I took some crayons and paper and lay down on the carpet to color. In a minute or two Sandy came over and joined me on the floor. I looked over to the foster mother and said, “Sandy, Mrs. Sally* is going to go to church while we play. Is that OK?”
She didn’t look up, but said, “OK.”
We sat on the floor and colored in silence. For ten minutes our play was just like the initial visit in the court. Then, it changed.
Sandy stopped coloring. She took the crayon from my hand, pulled at my arm and tugged at my shoulder to make me lay face down on the floor.
“What game is this?” I asked playfully.
“No. Don’t talk,” she said. She was deadly serious and forceful.
She had me bend my knees and put my arms behind my back, as if I was hog-tied. And then, the reenactment took place. For the next forty minutes, she wandered the classroom, muttering things, only some of which I heard.“This is good. You can eat this,” she said, coming over to me with plastic vegetables and opening my mouth to try to feed me.
Then, she brought a blanket over to cover me. During that initial therapy session she would approach me, lay on me, shake me, open my mouth and my eyes, and then leave again to find something in the room, almost always returning with a toy or another object. She did not reenact her own assault, and for the rest of the time I worked with her she never did fully reenact it, but she frequently said, “For your own good, dude,” as she walked around.
While she did this, I had to do exactly what she wanted: don’t talk, don’t move, don’t interfere, don’t stop. She needed to have total control while she performed this reenactment. And that control, I began to recognize, would be critical to helping her heal.
AFTER ALL, ONE OF THE DEFINING elements of a traumatic experience—particularly one that is so traumatic that one dissociates because there is no other way to escape from it—is a complete loss of control and a sense of utter powerlessness. As a result, regaining control is an important aspect of coping with traumatic stress. This can be seen vividly in the classic research on a phenomenon that has come to be known as “learned helplessness.” Martin Seligman and his colleagues at the University of Pennsylvania created this experimental paradigm in which two animals (in this case, rats) are housed in separate but adjacent cages. In one of these cages, each time the rat presses a lever to obtain food, it is first given an electric shock. This is, of course, stressful for the rat, but over time, recognizing that it will receive food after the shock, it adjusts and becomes tolerant. The rat knows that the only time it will be shocked is when it presses the lever, so it has some level of control over the situation. As we’ve discussed, over time, a predictable and controllable stressor actually causes less “stress” on the system while tolerance increases.
But in the second cage, while the rat can press the bar to receive food just like the rat in the first cage does, this one gets shocked when the other rat presses the lever. In other words, the second rat has no idea when it will be shocked and no control over the situation. This rat becomes sensitized to the stress, not habituated to it. In both rats major changes can be seen in the stress systems of their brains: healthy changes in the case of the rats with control over the stress, and deterioration and dysregulation in the others. The animals that don’t have control over the shock often develop ulcers, lose weight, and have compromised immune systems that actually make them more susceptible to disease. Sadly, even when the situation is changed so that they can control the shock, animals that have been placed in a situation without control for long enough become too frightened to explore the cage to figure out how to help themselves. The same kind of demoralization and resignation can often be seen in humans who become depressed, and research increasingly links the risk of depression to the number of uncontrollable stressful events people experience during their childhood. Unsurprisingly, PTSD is frequently accompanied by depression.
As a result of the link between control and habituation, and between lack of control and sensitization, recovery from trauma requires that the victim return to a situation that is predictable and safe. Our brains are naturally pulled to make sense of trauma in away that allows us to become tolerant to it, to mentally shift the traumatic experience from one in which we are completely helpless to one in which we have some mastery.
That’s what Sandy was doing in her reenactment behavior. She controlled our interactions in a way that allowed her to “titrate” the degree of stress during the sessions. Like a doctor balancing desired effects and side effects of a drug by choosing the right dose, Sandy regulated her exposure to the stress of her reenactment play. Her brain was pulling her to create a more tolerable pattern of stress, a more predictable experience that she could put in its place and leave behind. Her brain was trying, through reenactment, to make the trauma into something predictable, and, hopefully, ultimately boring. Pattern and repetition are the key to this. Patterned, repetitive stimuli lead to tolerance, while chaotic, infrequent signals produce sensitization.
To restore its equilibrium, the brain tries to quiet our sensitized, trauma-related memories by pushing us to have repetitive, small “doses” of recall. It seeks to make a sensitized system develop tolerance. And, in many cases, this works. In the immediate aftermath of a distressing or traumatic event we have intrusive thoughts: we keep thinking about what happened, we dream about it, we find ourselves thinking about it when we don’t want to, we often tell and retell the event to trusted friends or loved ones.
Children will reenact the events in play, drawings, and their daily interactions. The more intense and overwhelming the experience, however, the harder it becomes to “desensitize” all of the trauma- related memories.
In her reenactments with me, Sandy was attempting to develop tolerance to her terrible traumatic memories. She had control of these reenactments; this control let her modulate her own level of distress. If it became too intense she could redirect our play, and that’s what she often did. I did not try to interfere with the process or push her to recall anything after that first time, when I had to do it for the evaluation.
In the first months of our work together each session would start the same way: silently. She would reach up for my hand and lead me to the middle of the room, pull me down and gesture. I would lay down and curl myself into the hog-tied position. She would explore the room, coming back and forth to me. Finally she would come and lay on my back. She would start to hum quietly and rock.
I knew better by then not to talk or change position. I let her have the total control she needed. It was heartbreaking.
The responses of traumatized children are often misinterpreted.
This even happened to Sandy at some points in foster care.
Because new situations are inherently stressful, and because youth who have been through trauma often come from homes in which chaos and unpredictability appear “normal” to them, they may respond with fear to what is actually a calm and safe situation.
Attempting to take control of what they believe is the inevitable return of chaos, they appear to “provoke” it in order to make things feel more comfortable and predictable. Thus, the “honeymoon” period in foster care will end as the child behaves defiantly and destructively in order to prompt familiar screaming and harsh discipline. Like everyone else, they feel more comfortable with what is “familiar.” As one family therapist famously put it, we tend to prefer the “certainty of misery to the misery of uncertainty.” This response to trauma can often cause serious problems for children when it is misunderstood by their caretakers.Fortunately, in this case I was able to educate those who worked with Sandy about what to expect and how to respond to it.
But still, outside of therapy, at first her sleep, anxiety, and behavioral problems persisted. Her resting heart rate was over 120, extremely high for a girl her age. Despite occasional profound dissociative behaviors, she was likely to appear “tuned up” and hypervigilant—similar, in some ways, to the boys I was seeing in the residential center. I discussed the potential positive effects of clonidine with her foster family, her caseworker, and with Stan.
They agreed that we should try it and, indeed, her sleep soon improved and the frequency, intensity, and duration of her meltdowns decreased. She started to be easier to live with and to teach, at home as well as in her preschool classroom.
Our therapy continued as well. After about a dozen sessions she started to change the position in which she wanted me to lie.
No more being hog-tied; now I would lie on my side. The same ritual took place. She explored the room, always coming back to my body lying in the middle of the floor and bringing me the things she collected. She would still hold my head to try to feed me. And then she’d lie down on me, rocking, humming fragments of tunes, sometimes stopping as if frozen. Sometimes, she would cry.
Throughout this part of the session, usually about forty minutes, I would remain silent.
But over time, little by little, she transformed her reenactment.
She did less muttering and exploring and spent more time rocking and humming. Finally, after many months of having me lie on the floor, as I started to walk to the middle of the room to lay down, she took my hand and led me to a rocking chair instead. She had me sit. She walked over to the bookcase, pulled down a book, and crawled into my lap. “Read me a story,” she said. And as I started she said, “Rock.” Thereafter, Sandy sat in my lap and we rocked and read books.
It was not a cure, but it was a good start. And even though she had to go through an awful custody battle as her biological father, her maternal grandmother, and her foster family fought for custody of her, I’m pleased to say that ultimately, Sandy did all right. Her progress was slow but steady, especially after the custody case was resolved in favor of the foster family, with whom she spent the rest of her childhood. Sometimes, she struggled, but mostly she did amazingly well. She made friends, got good grades, and was notably kind and nurturing in her interactions with others. Often, years would go by and I wouldn’t hear anything about her. But frequently, I thought about Sandy and what she had taught me in our work together. As I write this I am pleased to say that only months ago I received an update. She is doing well. Because of the circumstances of her case I cannot reveal any further details.
Suffice it to say, she’s having the kind of satisfying and productive life we had all wanted for her. Nothing could make me happier.
Commentary
Today, no one would argue that a three-year-old who witnessed the death of her mother, was slashed and left for dead, then placed in foster care is not at risk for suffering lasting psychological damage. While, thankfully, most children have the capacity to recover, the data suggesting that severe early life stress can have a lifelong impact has only continued to accumulate since this book was first published.
So too has our understanding of the role of sensitization and tolerance in trauma and healing. These are two key processes that alter critical stress response networks in the brain. Sensitization amps up the baseline activity and reactivity of these systems, while tolerance dampens down stress response reactivity. (See Figure 6 at the end of this commentary.) Importantly, there are certain patterns of activation that lead to sensitization and can cause problems, while other patterns lead to tolerance and can build resilience.
Neuroscientists have been studying these phenomena for over 50 years. Their relevance to experiences like drug use, addiction, and pain management have long been obvious, but ten years ago, their importance in understanding the effects of childhood trauma was only beginning to be recognized.
Today, the neurobiology of sensitization and tolerance has taught us a great deal about the crucial roles of pattern and predictability in the development and regulation of our stress response systems. Early life experience sets the template for later life responses—this is true of our stress responses, not just our memories. Changing the average level of activity in stress systems and their responsiveness or reactivity during development can have profound and lingering effects.
The key point here is that some patterns of experience make these systems become more easily activated and more prone to reacting even to small changes—while other patterns help allow these systems to respond more smoothly and with less likelihood of over-reaction. Thus, the decades of neuroscience research that suggest how these mechanisms work can account not only for how and why symptoms can result from potentially traumatic experiences but can also give us essential clues to the healing process.
One of the major advances in the clinical arena over the last ten years is the understanding that some forms of developmental experience—for instance, food and housing insecurity, racial or cultural marginalization, and other stresses often associated with poverty—can result in physiological, emotional, social, and cognitive symptoms similar to those seen following extreme traumatic events, including physical or sexual abuse or exposure to domestic violence.
This has led some in the field to refer to big “T” trauma versus little “t” trauma; we don’t use that language but appreciate the point being made. We prefer to think of both capital “T” and small “t” as examples of “sensitizing” patterns of stress response activation that would result in predictable changes throughout the brain and body.In neuroscience studies, you can create a sensitized stress response by simply creating uncontrollable, unpredictable exposure to small stressors, which, if experienced only once or twice or if their timing was known in advance, would not be likely to be traumatic for typical people. Many of us have had real-life experience with this, for example, in a workplace where a supervisor is unpredictably shaming, then supportive, then angry.
Over time, in this situation, many employees become will become sensitized to the boss’s moods and experience anxiety, intrusive thoughts and worries, particularly a desire to avoid dealing with the person. These are all classic PTSD symptoms, though a bad boss rarely will be awful enough to cause a full-fledged case in an adult with no history of developmental adversity.
This same sensitization—often described as “walking on eggshells”—can happen with foster or adoptive parents when the behaviors of the child are, to the carers, completely unpredictable.
Obviously, a child’s tantrum is not considered a “traumatic” event on the scale of witnessing a shooting, yet over time the physiological and psychological effects of many small, uncontrollable stresses can be very similar to those we associate with more extreme experiences.
The pattern and context of stress system activation—i.e., whether it is controllable or not, whether it occurs predictably or not —is as important as the intensity of the activation, and can sometimes be more so. In the real world, this means that a child of color living in poverty with no exposure to abuse, domestic violence, or other overt “trauma” can develop “trauma-related” problems that look just like those seen in a child who witnessed a shooting or lived through a natural disaster. And, if children like this also have exposure to overt major trauma such as community violence, their problems will be compounded.
To explore this further, let’s briefly review the features of the patterns of stress activation that can lead to a less sensitive, less reactive stress response capacity. As we’ve seen, the majority of physical, emotional, behavioral, social, and cognitive problems related to developmental trauma can be linked to changes in the pervasive, widely-distributed neural networks involved in responding to stressors. We’ve seen as well that neural networks are “plastic”—capable of changing. So what does research in the area of neuroplasticity tell us about how to change these systems? The first and primary principle of neuroplasticity is that in order to intentionally modify—in any way—a specific neural network, we must first “activate” (or, in some cases “deactivate”) that specific neural network. This of course seems obvious; in order to learn how to play the piano, one must sit at the piano and play. Reading a book or watching a YouTube video about playing piano won’t change the specific neural networks responsible for piano playing.
Your time at the piano may benefit from what you can learn in a book or video, but you will not create or modify the widely- distributed neural network that allows “piano playing” unless you activate it fully by actually tickling the ivories.
The same is true for traumatic memory and the sensitized stress response networks that are yoked to the complex, widely- distributed trauma reaction that follows the traumatic event. For Sandy, her set of trauma memories were reinforced and strengthened each time an evocative cue activated this chain: for example, when she did something as simple as drink milk. The vast majority of these activations for the first years following her mother’s murder were unpredictable to her because she didn’t know when to expect them. As a result, her stress response systems became more and more sensitized, and she often experienced an extreme and prolonged response. And as a result of that, she got worse.
A major challenge of doing therapy when trauma and sensitized stress responses are involved is that the principle of specificity has to be applied in order to change the sensitized stress response systems; healing involves the process of “revisiting” and “reactivating” very painful experiences in some way. The key to effective healing and therapeutic work is paying attention to the three essential elements of the resilience-building and healing pattern of stress activation. These are predictability, controllability, and moderation.
What we’ve learned about these factors since we first wrote this book relates back to the concept of “dosing.” What is a moderate dose of revisiting a trauma and reactivating a chain of traumatic memory? Who determines what is moderate? Should it be the clinician who asks the child to recount the traumatic event—or the child? When we ask a child to come to our office once a week for a 50- minute dose of revisiting, doesn’t that, in itself, take control away from him or her? Can we create safe and regulated settings for children to control the dose, space, and pattern of their healing journeys? In Sandy’s case, during our therapy, she could go back to these dark times, spend some moments living with the pain of the reactivated trauma memory—but she also could control her own disengagement, so she could regulate herself before revisiting the experience.She controlled what parts of that experience she would reactivate and reenact—this provided controllability. She also decided for herself how long she would stay there—this controlled the dosage. She determined how much time would pass before she would revisit those experiences, which controlled the spacing of the experience. In our sessions, she allowed herself to activate some component of her pervasive trauma memory, and then created controllable, predictable, and moderate activation of her sensitized stress response systems. Over time, this led to a less reactive system, a shift in symptoms, and some degree of healing.
We cannot emphasize enough how important it is for traumatized children to be given the most possible control, predictability, and ability to moderate the timing, duration, and intensity of their experiences. They need these elements to be maximized, not just in therapy—but in the rest of their lives, particularly places where they spend a lot of time, like school. To become resilient, children need environments where they feel safe and comfortable, and know what to expect so that their sensitized, overreactive stress systems can gradually become calmer, and more “smoothly” regulated.
(The chart below illustrates the key principles here).
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