The Boy Who Was Raised as a Dog Page 5
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 sky-rocketed 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 hyper-arousal 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 addicts, 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.
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, rocking and 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.