The Boy Who Was Raised As a Dog: And Other Stories from a Child Psychiatrist's Notebook

by Bruce D. Perry

By conservative estimates, about 40 percent of American children will have at least one potentially traumatizing experience by age eighteen:

Fire can warm or consume, water can quench or drown, wind can caress or cut. And so it is with human relationships: we can both create and destroy, nurture and terrorize, traumatize and heal each other.

the main problem with the DSM—to this day—is that it is a catalog of disorders based on lists of symptoms.

a person with an overactive stress system would pay close attention to the faces of people like teachers and classmates, where threat might lurk, but not to benign things like classroom lessons.

Memory is the capacity to carry forward in time some element of an experience.

memory makes us who we are

This powerful property of association is a universal feature of the brain. It is through association that we weave all of our incoming sensory signals together—sound, sight, touch, scent—to create the whole person, place, thing and action.

early experiences will necessarily have a far greater impact than later ones.

Neural systems have evolved to be especially sensitive to novelty, since new experiences usually signal either danger or opportunity.

One of the most important characteristics of both memory, neural tissue and of development, then, is that they all change with patterned, repetitive activity.

prevailing view of children and trauma at the time—one that persists to a large degree to this day—is that “children are resilient.”

If anything, children are more vulnerable to trauma than adults;

The developing brain is most malleable and most sensitive to experience—both good and bad—early in life.

resilience or vulnerability to stress depend upon a person’s neural system’s tolerance or sensitization following earlier experience.

Without the stress, the system wouldn’t know there is something new to attend to. In other words, stress is not always bad.

the stronger muscle in the present is the one that has endured moderate stress in the past.

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.

If a system is overloaded—worked beyond capacity—the result can be profound deterioration, disorganization and dysfunction

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.

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.

important to understand that our default is set at suspicion, not acceptance.

First, your brain makes you stop thinking about irrelevant things by shutting down the chatter of the frontal cortex.

In thousands of different ways your brain prepares to protect you.

Fear quite literally makes us dumber, a property that allows faster reactions in short periods of time and helps immediate survival.

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.

In a classroom setting, unfortunately, both dissociation and hyper-arousal responses look remarkably like attention deficit disorder, hyperactivity or oppositional-defiant disorder.

The aggression and impulsivity that the fight or flight response provokes can also appear as defiance or opposition,

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.

we tend to prefer the “certainty of misery to the misery of uncertainty.”

One of the few things I knew for sure by then about traumatized children was that they need predictability, routine, a sense of control and stable relationships with supportive people.

The fact that the brain develops sequentially—and also so rapidly in the first years of life—explains why extremely young children are at such great risk of suffering lasting effects of trauma: their brains are still developing.

when people are faced with a frightening situation their brains begin to shut down their highest cortical regions first.

Exposing a person to chronic fear and stress is like weakening the braking power of a car while adding a more powerful engine: you’re altering the safety mechanisms that keep the “machine” from going dangerously out of control.

To develop a self one must exercise choice and learn from the consequences of those choices; if the only thing you are taught is to comply, you have little way of knowing what you like and want.

the most effective interventions involve educating and supporting the existing social support network, particularly the family, about the known and predictable effects of acute trauma and offering access to more therapeutic support if—and only if—the family sees extreme or prolonged post-traumatic symptoms.

Because the post-traumatic response can keep a child in a persistently aroused, fearful state, we knew that fear might prompt them to act impulsively or aggressively and that they might not immediately be able to control these reactions. We didn’t want to punish them for these natural responses.

post-traumatic stress disorder is not signaled by a constellation of new symptoms that develop long after a stressful event but is, in many regards, the maladaptive persistence of the once adaptive responses that began as coping mechanisms in response to the event itself.

the research on the most effective treatments to help child trauma victims might be accurately summed up this way: what works best is anything that increases the quality and number of relationships in the child’s life.

Relationships matter: the currency for systemic change was trust, and trust comes through forming healthy working relationships. People, not programs, change people.

we know that an infant’s early attachment to a small number of consistent caregivers is critical to emotional health and even to physical development.

the most powerful rewards we can receive are the attention, approval and affection of people we love and respect. Similarly, the most powerful pain we experience is the loss of that attention, approval and affection

Children who don’t get consistent, physical affection or the chance to build loving bonds simply don’t receive the patterned, repetitive stimulation necessary to properly build the systems in the brain that connect reward, pleasure and human-to-human interactions.

It is through the thousands of times we respond to our crying infant that we help create her healthy capacity to get pleasure from future human connection.

if a baby’s smiles are ignored, if she’s left repeatedly to cry alone, if she’s not fed, or fed roughly without tenderness or without being held, the positive associations between human contact and safety, predictability and pleasure may not develop.

many young victims of abuse and neglect need physical stimulation, like being rocked and gently held, comfort seemingly appropriate to far younger children.

you don’t interact with these children based on their age, but based on what they need, what they may have missed during “sensitive periods” of development.

Research has repeatedly found that surrounding a child with other troubled peers only tends to escalate bad behavior.

these children need patterned, repetitive experiences appropriate to their developmental needs, needs that reflect the age at which they’d missed important stimuli or had been traumatized, not their current chronological age.

Many of the traumatized children I’ve worked with who have made progress report having had contact with at least one supportive adult: a teacher who took a special interest in them, a neighbor, an aunt, even a school bus driver.

Because trauma—including that caused by neglect, whether deliberate or inadvertent—causes an overload of the stress response systems, which is marked by a loss of control, treatment for traumatized children must start by creating an atmosphere of safety. This is done most easily and effectively in the context of a predictable, respectful relationship. From this nurturing “home base,” maltreated children can begin to create a sense of competence and mastery. To recover they must feel safe and in control. Consequently, the last thing you want to do is force treatment on these children or use any kind of coercive tactics.