Trauma, Brain and Relationship Helping Children Heal
From NEURONS TO NEIGHBORHOODS
Second Annual Conference
Interview with Bruce Perry, Ph.D.
DR. PERRY, SIMPLY FOR REFERNCE CAN YOU TELL ME YOUR NAME AND YOUR JOB TITLE.
My name is Bruce Perry. I'm a child psychiatrist, the senior fellow of the Child Trauma Academy in Houston, Texas.
HOW CAN YOU TELL WHEN A CHILD IS TRAUMATIZED?
Well, you can't always tell. One of the challenges that we face is that you can't always tell when a child has been traumatized. Very often, they may be going through the day interacting normally with their peers, they'll be playing games, they might be laughing, and you may not have any idea that that child the week before lost their parent in a violent event. However, if you follow that child long enough, what you'll find is that under the smallest, smallest challenge, they'll unravel and they'll unwind. And it's not always predictable. They may handle one situation very well and then completely collapse in something that seems pretty minor. It is at times very confusing to the adult world the way children respond to traumatic events, and it's very easy for adults to dismiss the profound impact that a traumatic event can have on a child, because very often they will do most things pretty well.
IS TRAUMA ALWAYS APPARENT THEREFORE IN A PATIENT?
What do you mean?
HOW DO YOU RECOGNIZE A PATIENT WITH TRAUMA IF IT IS NOT ALWAYS OBVIOUS?
Different people respond differently to traumatic events. Some people will carry it around in ways that everybody can see that they've been impacted. But most people actually will go through a traumatic experience and won't have any easily visible or obvious manifestation of that. The problems may emerge many months or sometimes even years after the original event. So it's very important for people who are trying to understand trauma to become aware of the various ways in which traumatic symptoms can manifest, the various ways in which trauma can be carried forward by children and adults, and the pervasive impact that trauma has independent of the way someone is observed to perform.
HOW DO RELATIONSHIPS AFFECT THE WAY THE BRAIN DEVELOPS?
Human beings are at our core, relational creatures. We are designed to live, work, play and grow in groups. The very nature of humanity arises from relationships. You learn language, you learn social language, you learn appropriate emotional regulation, and essentially everything that's important about life as a human being you learn in context of relationships. And the very substance of a successful individual is bathed in a whole host of relationships with people in that person's life. When there are positive relationships, there literally are physiological changes in the person's brain and in their body that make them more physically, emotionally and socially at risk.
CAN YOU CONTINE WITH THE RELATIONSHIPS AND HOW IT AFFECTS THE BRAIN.
When you look at someone, when you hear someone, when you have a conversation, when you make a joke with somebody, when you touch someone, every single one of those physical interactions are translated into patterned neuronal activity that go into the brain of both people in that interaction and result in positive changes. These physical changes influence our immune system and they influence the autonomic nervous system that controls your heart and your lungs and your gut. Literally, when people have a wealth of relationships, where relationships are present in high quantities and they're of good quality, these individuals are actually physically healthier, they're emotionally healthier, they're more cognitively enriched, and they actually reach their potential to be humane in ways that are impossible without relationships.
It's a very interesting thing that people don't really appreciate this very much, but that there's no better biological interaction that you can have than a relationship. It's much more of a biological intervention to form a relationship with someone in therapy than it is to give him or her a pill. Relationships are the absolute heart of humanity, and we are neurobiologically designed to be in relationships. We are neurobiologically designed to be able to read and respond to other people and we're neurobiologically designed to reach out and seek relationships with other people. When we have these opportunities to form healthy relationships with family, with neighbors, with coworkers, with members of the community, we're healthy. When we don't have those opportunities, we literally are physiologically at risk.
WHY IS THIS CUTTING EDGE?
Well, it's a very interesting thing that this is cutting edge in the sense that it's rediscovering something that has been part of the cumulative wisdom of many cultures for many years. Independent of what we know about how the brain works, people have known that it's healthy to have extended family around, that it's healthy to know your neighbors, that it's healthy to have an investment in community and have relationships. We've known this, and we have lots of evidence from research that's nonbiological that supports this idea. Now that we're learning about how the brain works and we have techniques to actually look at how the brain functions, we're kind of acting like this is a big revelation, this is a big surprise, that there are parts of our brain that are able to read and respond to facial cues, that there are parts of our brain that actually give us pleasure in context of human interactions.
However, none of that should be surprising, because all of the history of our ancestors and all of the other successful living models that we have seen, both in our current era and throughout history, have depended upon relationships. And I think that it's perceived as something new and cutting edge, because we folded in some of the biology and some of the neuroscience. But in fact, we're only saying things that have been said for many, many generations.
DOESN'T THAT CRYSTALLIZE THESE IDEAS IN ANOTHER ASPECT?
What has been unique about the work that our group has done has been the combination of basic neuroscience and developmental neuroscience with clinical mental health work. Previously there were very few people who did a lot of clinical work that knew a lot about brain development, and the people that did really excellent work in brain development really didn't know much about these clinical issues. In the last, I'd say, decade, there have been more and more people like myself who have been trained in both the neurosciences and in clinical areas, and we've seen that these are complementing and interfacing areas. There are certain insights about the human condition that you can gather by understanding how the brain works and how the brain develops and how the brain changes. It helps us understand better how to educate children, how to raise children in healthy environments, how to understand mental health problems, how to minimize distress and trauma during development and what positive changes can come from that. So to some degree, it's not as if it's really new information, but it's a new perspective. We're looking at a lot of the same issues and using some of the same information we've always known, but we're putting it together in a somewhat different perspective.
Well, one of the most important things about human beings is that we literally invent things about the way we live. So the nuclear family, for example, is an invention. We are for 99.9 percent of the time we've been on this planet we've lived in these large extended family models, hunter/gatherer groups. It's only been in the last few thousand years that we've lived in these smaller and smaller and smaller family groups in larger and larger urban areas. And, ironically enough, the more people we get into an urban area, the more isolated the individual becomes. Our family sizes become smaller.
We've compartmentalized our culture so that we've taken the elderly and we've thrown them out of the lives of our families. We keep children with children. We have done a whole number of things to act in ways that we think are efficient but turn out to be tremendously biologically disrespectful. And the consequence is that we're raising our children in a world where there's poverty of relationships. Children are having at least one-fourth as many opportunities when they grow up to interact with people as they were two decades ago. We're taking 30 percent of the day and we're filling it with electronic interactions with television that don't involve human interaction. We are creating artificial human interactions in our schools where we have ratios of one adult to 30 children.
We are in our homes having our own bedrooms and we're not having family meals, we're not spending time with neighbors, we're not spending time with extended families. So we've tremendously compartmentalized our world and decreased opportunities to have relationships, which as we've discussed, are the absolute heart of a humane person. And we're seeing the manifestation of this in all of our high-risk populations.
The problems in schools that we're seeing now, disrespect, impulsiveness, aggression, are much worse than they were two decades ago. The number of children who meet criterion for special education has been skyrocketing. The number of children that have severe mental health problems has been increasing. The number of children who are in the child protective system has been increasing.
Every single one of our high-risk groups is getting bigger, and the resources we have to address their problems are getting smaller. And I believe that a big part of this is because the entire curve is shifting, that what were once considered normal behaviors are considered exceptional. What were once considered inappropriate and abnormal behaviors are the norm. And so that what we used to be dealing with this little 5 percent of the curve over here, this small group of kids that had high-risk problems, well now that's a much bigger group. The problems that used to be considered worthy of the attention of the system, the mental health system, the special education system, we can't even address those, because we have all these really severely disturbed kids.
WHY IS IT PERTINENT TO FOCUS ON THE EARLY YEARS IN ORDER TO PREVENT OR TREAT TRAUMA? WHERE IS THE GENERAL PUBLIC FOCUS, AT THE MOMENT, WITH TREATING TRAUMA?
I mean one of the great things about this recent early childhood focus and the public awareness campaigns, trying to help people understand more about the importance of early childhood and high quality childcare and how the brain develops is that more and more people are becoming aware of the fact that if we provide excellent, high quality early life experiences, we have a tremendous head start on creating a healthy human being. Because the brain develops so rapidly early in life, it means that 85 percent of the foundational neurobiological systems that we use for our whole life are created and organized in the first five years of life. So, if we invest time in the lives of children when they're young, and we are respectful and we are present and we make sure that they have a wealth of relationships, so they get cognitive enrichment and social enrichment and emotional enrichment, that means that we'll have a tremendous head start on solving a lot of these problems.
Until we remedy the mismatch between opportunity and investment, between the time when the brain is most easily changed and where we're spending all of our public dollars, we're never going to solve this problem. We're spending literally 95 percent of our public dollars to change the brain, because that's what mental health is, that's what public education is, that's what juvenile justice intervention is, all of these are trying to change the brain. We're spending 95 percent of our dollars on children at a time when their brain is much harder to modify. We're spending almost nothing in the first five years of life when the brain is easiest to modify and it takes the least amount of professional input, the least amount of insight. It takes just high quality caregiving during the early years of life.
WHY IS IT IMPORTANT TO UNDERSTAND A CHILD'S DEVELOPMENTAL HISTORY FOR PROFESIONALS WHO ARE WORKING ON TREATING TRAUMA?
If you really want to understand how a child is functioning in the present, you need to understand their personal history because the brain more than anything is an historical organ. It stores experiences. If you understand the personal experiences of the child, you will understand a lot about how different systems in the brain are organized. So it's very important to take a high quality developmental history of that child. One of the most important factors in a good developmental history is getting some understanding and some insights about the childrearing beliefs and practices of their caregiver, which you can usually get by asking them about their family and the way they were raised.
CAN YOU TELL ME HOW PRENATAL DEVELOPMENT, SPECIFICALLY PRENATAL BRAIN DEVELOPMENT, INFLUENCES THE RATE OF DEVELOPMENT OF SOCIAL AND EMOTIONAL LEARNING?
The brain is a relatively complex organ, but it has a very sensible and simple organization. From the bottom to the top, it goes from simple to complex. The bottom part of the brain, the brainstem, is important for regulating heart rate, blood pressure, body temperature regulation, and it is the one part of the brain that has to be developed by the time you're born- because obviously you have to regulate your respirations and your heart rate and body temperature. So, in utero, the intrauterine environment and things that happen in utero are going to shape and influence how well regulated the brainstem is.
Now it turns out that the brainstem plays a major role in organizing these higher parts of the brain. So if the brainstem is well organized, and it's smoothly regulated, it means that after birth the child is going to be easier to soothe. They're going to engage in social affiliation behaviors with their caregivers in an easier way, it will make even a young and inexperienced caregiver feel competent, and it will facilitate that maternal/infant interaction, which is the basis for all kinds of social emotional learning that will take place over the first year of life.
On the other hand, if the brainstem, for whatever reason, it has some insult during development-it could be alcohol exposure in utero, cigarette smoking, prenatal exposure to drug or significant distress in the caregiver-for whatever reason, if the brainstem is poorly organized and over reactive and dissynchronous, the baby's born and very often they will have what we call a state regulation problem. They are hard to soothe, you can't quiet them down very well, it's hard to engage them, and it makes the caregivers feel overwhelmed. That leads to kind of a fractured maternal infant interaction, which can then have this whole cascade of negative effects. The caregiver doesn't feel very competent, they can't calm the child down very well, and the child stays all stirred up. Instead of having this smooth, synchronous interaction, you have kind of this bad fit. It leads to problems with normal social emotional development.
WHAT KIND OF RESEARCH SUPPORTS YOUR THEORY ON TRAUMA AND BRAIN DEVELOPMENT, OR WHAT EVIDENCE DO YOU HAVE?
When we first came out and started to talk about the probability that a traumatic experience literally changed the physical organization of the brain, there were a lot of people that were somewhat skeptical. But in the last ten years or so, there have been more and more studies where we've been able to look at not just brain-related factors like heart rate and cortisal release and other external physiological things, we've literally been able to look at the brain. What we've seen is that children who have been exposed to traumatic experiences have a host of abnormalities in the way key parts of their brain are organized and the way they function. So the whole idea that trauma changes the brain is now commonly accepted.
The next step, of course, is can therapy and therapeutic experiences that you provide change the brain in ways that would link to recovery of function or repair following trauma. That research is ongoing, and it is less evolved than this other research, but I'm convinced that the biological principles are the same. The brain changes with activity. We know that all parts of the brain throughout almost all ages of life can change, given the right opportunities and the right experiences.
I'm convinced that over time people will begin to see that you have a child who has had a traumatic experience and they'll see one sort of abnormality in the brain. Then as a function of certain kinds of therapeutic interventions, you'll start to see changes in those parts of the brain and recovery of function. On one hand it's absolutely logical. You cannot get changes in function unless the brain changes. Right? I mean it's not your pancreas. So if you see functional improvement in the child following therapeutic intervention, it's got to be the brain. Now we just have to sort of prove it. There's no other explanation. The next step is to investigate and know exactly which systems in the brain are going to be changed.
ARE YOU SAYING, FOR MY CLARITY, THE ACTUAL CHANGES IN THE BRAIN HAVE NOT BEEN YET DOCUMENTED?
They've been documented for traumatic experiences. We know that traumatic events change the brain. There are a whole lot of important questions about that. A traumatic event at age one is going to cause different changes than a traumatic event at age four, because the brain is different at one and four. A different kind of traumatic event at age one is going to cause a different kind of change than another kind of traumatic event. There literally are many, many things that we need to look at before we have complete clarity about the relationship between traumatic experiences in development and how the brain changes. But I'm convinced that we will find these changes, we will fill in all of the squares in this matrix. In ten years we'll have the techniques that will allow us to not only track the impact of bad events, but the impact of good events, and see how positive therapeutic, nurturing events actually result in changes in the brain that have positive functional consequences.
WHAT WOULD YOU SAY TO THE PROFESSIONAL IN TERMS OF WHAT TO LOOK FOR IN A TRAUMATIZED CHILD OR TEENAGER AND HOW TO RESPOND? WHAT WOULD YOU SAY TO OTHER GROUPS, PARENTS, TEACHERS, PEDIATRICIANS, HEALTH WORKERS AND JUDGES, WHO ARE ALSO WORKING WITH TRAUMATZED INDIVIDUALS.
Well, I think a lot of the answers are the same for some of these groups. If you're an adult and there are children in your life, whether you're in law enforcement, a teacher, a parent, foster parent, whatever you are, and you know that a child has been exposed to something that's potentially traumatic, the first thing that you should be aware of is that not all traumatic events lead to disastrous mental health outcomes. In fact, the vast majority of children that are traumatized actually do pretty well. But they do need your attention, they do need your kind support, and they do need your awareness about what are warning signs that would tell you to actually take the next step and try to get some professional help.
If you know that somebody in your sphere of concern has been traumatized, take the time to learn a little bit about how trauma manifests in children and adolescents. There are lots of sources for that. Educate yourself about what the normal responses are following a trauma. It is normal after you lose a parent to be sad. It is normal to have recurring intrusive ideations after you witness a violent act. That doesn't mean that you need mental healthcare right away, but you should be aware of the length of those symptoms, you should be aware of how disruptive they are for the child, and you should reach out to the child and say, "Listen, I know this stuff happened, I'm happy that I'm here, you can come and talk about it whenever you want. I don't want to push it on you, but you just should know that I'm okay talking about it if you just ever want to, you know, pass something by, let me know." Make yourself available, make yourself aware, and make yourself attuned to the child, and that will help them tremendously.
WHAT IS "IDEATION"?
A thought. If you find yourself, I don't know, just thinking about something again and again, you can't get it out of your head, that's an ideation.
WHY DO YOU LOVE THIS WORK?
I think I love this work because I meet the most remarkable children. I'm a curious person. I'm fascinated by the way people work and the way systems work. I meet these amazing people, these kids that have gone through unbelievable things and they'll still play a practical joke on me. You know, they'll come up and they'll give me a high five in the hallway when they're walking through out clinic. You think you know these kids, literally some of these kids have been kept as animals for the first years of their life, and now they're walking down the hall they're wearing a Michael Jordan jersey and they high five me because the Rockets won today. You know, it's the kind of thing that you think geez there's this little human being, and despite all these horrible things that have happened, they've got this wonderful little shred of humanity that they're clinging to, and going to make a difference. So it's meeting these kids and meeting the people that work with them, and it's just interesting and inspiring. It just makes me feel good about the work that we do, because I think we're making a difference.
HOW DID YOU GET INVOLVED IN THIS WORK?
There have been a couple of accidents in my life where I stumbled into this, and the first one was a very fortunate accident when I was an undergraduate at Stanford. They have an undergraduate advisor's program where they take in the freshman class and once a week you are in a seminar with the senior faculty member. I was put into a group with a gentleman named Seymour Levine, who was very, very famous and pioneer in the area of neuroendocrinology. He had done some fascinating studies that included one that particularly sort of caught my interest. They had found that if you took a little rat pup, pretty much a newborn rat pup, and a human being held it for a very brief period of time, which was stressful to the rat, and put the rat pup back in the litter with the mother and let the rat grow up, and then looked at its brain, it was different than animals that hadn't been handled. So the idea that a very, very brief experience early in life could lead to a lifelong change in the physiology of the brain was just amazing to me. So I think that that was one of the reasons that I sort of ended up being fascinated about the brain.
IN TERMS OF HEALING TRAUMA, IS THERE ONE ASPECT THAT YOU'D LIKE TO ADDRESS?
The one thing I think is really important to know about recovery from trauma is that no matter what your theoretical perspective, no matter what your therapeutic training, no matter what your approach, in the end what makes people better is what happens in a relationship. A lot of times it's the relationships that are not therapeutic, not a therapy relationship. In fact, most therapeutic things happen out of therapy. Many things that happen in therapy aren't therapeutic.
What makes children get better following a trauma is connection to other human beings: human beings who are present, who are patient, who are kind, and who are sensitive. They don't need to be necessarily psychologically insightful. They need not to know anything about trauma. All they need to know is that they're right there with this child, they're trying to be comforting, they're trying to be supportive, they're trying to encourage. Those kinds of interactions end up being much more therapeutic and healing than many of the other things that we try to do with kids.
FABULOUS. THANK YOU, SIR.
Over the last 15 years, the work that we've done at the Child Trauma Academy has been slowly creeping towards awareness and understanding of how important relationships are for healthy development. One of the major teachers that we've had in this process has been the wisdom and the experience of the Native American peoples. In the last several years, I've had an opportunity to spend time with the Cree, Lakota, Navaho, and Apache. In each of these environments I've learned from the elders about their views on raising children, their views on health, their views on growth and education. What we've learned from them is the importance of a continuous dynamic interaction between all members of the community.
We in the west compartmentalize education and mental health and child protection and juvenile justice. This compartmentalization has been tremendously destructive. We're struggling now in the west to figure out ways to recapture the health that comes from community, the health that comes from an extended family model. Because, for 99.9 percent of the time we've been on this planet, we've lived in these dynamic, interactive living groups where there's continuous interaction between the elderly and the young, between neighbors and between all members of this community in such a way that there may have been economic poverty, but there was wealth of relationships. And in the end, what we're finding is that it's this wealth of relationships that makes the difference for the person's physical, emotional and social health.
As we'll talk about in more detail in this video, the brain develops over your lifetime. It changes from the moment of conception to the moment of death. However, 95 percent of the major changes in the brain and 95 percent of the organizational activities that take place go on during childhood. Because the brain changes in response to experience, because the brain shapes itself following patterned repetitive experiences, what we're finding out is the experiences of childhood, the emotional experiences, the social experiences, the cognitive experiences literally shape how the brain organizes and how it functions. Which means that a child growing up in an environment where there are loving caregivers that are playing a role in the way that child grows up, is going to have tremendous, tremendous advantages in comparison to a child who grows up where there's poverty of relationships.
Now in the west, we have compartmentalized our world so that our children are not benefiting from their grandparents. They're not benefiting from their neighbors. They're not benefiting from older children, because they spend most of their day with children that are all the same ages they are. So that as we struggle to come up with new models, to recapture healthy environments for child rearing, we turn to the Native American. They have for generations known that babies have to be part of the entire community. That all members of the living group play a role in providing support, protection, nurturing and education for this developing child. It's something that we have to recapture in the west. So even though this video is meant to try and teach a little bit about how the brain develops and about how important early childhood is, we want to actively acknowledge that so many of the points that we will make and so much of the positive impact that we're learning about early childhood, is something that has already been present and has been practiced actively in healthy Native American clans.
We also know, sadly, that several generations ago the intact belief systems, the language, the values and the economies of the Native Americans were destroyed. That a product of that was increases in violence, increases in suicide, increases in mental health problems, and increases in physical health problems. As Native American communities reweave the social fabric and recapture the old ways, they're getting healthier. So that it's absolutely essential for a young Native American child, as they grow up, to learn about their past, to learn their language, to learn their religious views and values of the elders, to become part of that community because only through that process of reweaving social fabric and recapturing their past that they're going to have some idea of where their future should go.
THAT WAS GREAT DR. PERRY. IT'S VERY CLEAR.
(END OF INTERVIEW)
Stan Tatkin, Psy.D. - Psychotherapist
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