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An Introduction
Bruce D. Perry, MD, Ph.D.
This booklet is one in a series developed by the ChildTrauma Academy to assist caregivers and various professionals working with maltreated or traumatized children.
Interdisciplinary Education Series Edited by B. D. Perry Adapted from: "Maltreated Children: Experience, Brain Development and the Next Generation" by Bruce D. Perry (W.W. Norton & Company, New York, in preparation)
All Rights Reserved © 1999 Bruce D. Perry
Traumatic events in childhood increase risk for a host of social (e.g., teenage pregnancy, adolescent drug abuse, school failure, victimization, anti-social behavior), neuropsychiatric (e.g., post-traumatic stress disorder, dissociative disorders, conduct disorders) and other medical problems (e.g., heart disease, asthma). The deterioration of public education, urban violence and the alarming social disintegration seen in some of our urban and rural communities can be traced back to the escalating cycles of abuse and neglect of our children. This introductory booklet is written for an interdisciplinary audience. Caregivers, childcare providers, teachers, law enforcement, child protection workers, social workers, judges, nurses, pediatricians and mental health service providers all are will work with traumatized or maltreated children. The more we can understand these children and the impact of traumatic experiences, the more compassionate and wise we can be in our interactions and in our problem solving.
The human body and human mind have a set of very important and very predictable responses to threat. Threat may come from an internal (e.g., pain) or external (e.g., an assailant) source. One common reaction to danger or threat has been labeled the ‘fight or flight’ reaction. In the initial stages of this reaction there is a response called the alarm reaction. As the individual begins to feel threatened, the initial stages of a complex, total-body response will begin. The brain orchestrates, directs and controls this response. If the individual feels more threatened, their brain and body will be shifted further along an arousal continuum in an attempt to ensure appropriate mental and physical responses to the challenges of the threat. The cognitive, emotional and behavioral functioning of the individual will reflect this shift along the arousal continuum. During the traumatic event, all aspects of functioning of the individual change – feeling, thinking, behaving all change. Someone being assaulted doesn’t spend a lot of time thinking about the future or making an abstract plan for survival. At that moment, their thinking, behaving and feeling is being directed by more ‘primitive’ parts of the brain (see Table in Appendix). A frightened child doesn’t focus on the words; they attend to the threat related signals in their environment – the non-verbal signs of communication such as eye contact, facial expression, body posture or proximity to the threat. The internal state of the child shifts with the level of perceived threat. With increased threat a child moves along the arousal continuum from vigilance through to terror. The alarm continuum is characterized by a graded increase in sympathetic nervous system activity, in turn, causing increased heart rate, blood pressure, and respiration, a release of glucose stored in muscle and increased muscle tone. Changes in the central nervous system cause hypervigilance; the child tunes out all non-critical information. These actions prepare the child to fight with, or run away from, the potential threat. This total body mobilization, the "fight or flight" response, has been well characterized and described in great detail for adults. These responses are highly adaptive and involve many coordinated and integrated neurophysiological responses across multiple brain areas such as the locus coeruleus, the amygdala, the hypothalamus and the brainstem nuclei responsible for autonomic nervous system regulation.
For most children and adults, however, the adaptive response to an acute trauma involves a mixture of hyperarousal and dissociation. During the actual trauma, a child will feel threatened and the arousal systems will activate. With increased threat, the child moves along the arousal continuum. At some point along this continuum, the dissociative response is activated. This results in the host of protective mental (e.g., decreases in the perception of anxiety and pain) and physiological responses (decreased heart rate) that characterize the dissociative response (see Differential Response to Trauma Figure, above).
This means, for example, that the child will now perceive the sense of fear and anxiety. This is when they will actually feel the fear associated with the trauma. The individual will begin to process and think about what happened, attempting to make sense out of what has just happened. Because the traumatic event is so far out of the normal range of experience, there will be a variety of mental attempts to process and "master" this event. The event will play itself out in the mind of the child again and again. A host of intrusive images related to the trauma may swamp the child's thinking. This set of re-living and re-experiencing phenomenon may include telling the story over and over again to friends. The child may act this event out in their play and drawings (see below) or have intrusive dreams. In essence, these children have created memories of the traumatic memory. But these memories are complex and multi-domain. Traumatic memory involves the storage and recall of traditional cognitive information (who, what, when, where), emotional information (fear, dread, sadness), motor-vestibular information (e.g., the body position during the rape) and state memory (vigilance, physiological hyperarousal). The normal and predictable mental mechanisms that are used to process all experiences will, at times, fail in the attempts to master and understand a traumatic event. Because traumatic events have features that are so outside the range of normal experience, there are very few internal experiences with which to judge or make sense out of the event. The more outside the range of the normal experience and the more life-threatening the experience, the more difficult it will be for the normal mental mechanisms to work efficiently to process and master that experience. The inability to control elements of the traumatic event or the intrusive thoughts that follow leads to a set of predictable, mental and physiological responses.
A classic set of predictable symptoms and physical changes seen in the acute post-traumatic period is related to the ability to re-evoke the emotional and physiological memories of being in the traumatic event. This means very simply that in addition to having cognitive remembrances of the facts and narrative details of their thoughts during the event, the child has the capacity for recollection and reliving of the physiological changes that were present in the alarm reaction. In effect, the child has emotional and state memories from the traumatic event. This means that the children will be hypervigilant, and may have an increased startle response, increased muscle tone, a fast heart rate (tachycardia) and blood pressure.
Persisting physiological and emotional distress is physically exhausting and emotionally painful. Because of the pain, energy and discomfort associated with the recurring intrusive thoughts and the physiological and emotional 'memories' associated with these thoughts, a variety of protective avoidance mechanisms are used to escape reminders of the original trauma. These include active avoidance of any reminders of the trauma and the mental mechanisms of numbing and dissociation.
Traumatized children, when faced with reminders of the original traumatic event, may experience so much pain and anxiety that they become overwhelmed. In these situations - when they cannot physically withdraw from those reminders - they may dissociate. Following a traumatic experience, children may act stunned or numb. Dissociating children often appear to be gazing off into nowhere. They will not readily respond to questions by adults. Their answers to questions will seem unclear, unfocused or evasive. This is understandable if we remember that while these children are present in body, their minds may be ‘off in another place’ – dissociated, trying to avoid the painful reminders of the original trauma. Avoiding direct reminders of the trauma sometimes is extremely difficult. In that case, children will withdraw in to themselves in a variety of ways. This inward focused withdrawal basically means that they will have fewer opportunities to be provoked into having more intrusive thoughts about the event, and therefore, they can thereby avoid pain.
In the first days and weeks following the traumatic event, the symptoms listed above, 1) re-experiencing phenomena, 2) attempts to avoid reminders of the original event and 3) physiological hyper-reactivity are all relatively predictable, and indeed, highly adaptive physiological and mental responses to a trauma. Unfortunately, the more prolonged the trauma and the more pronounced the symptoms during the immediate post-traumatic period, the more likely there will be long term chronic and potentially permanent changes in the emotional, behavioral, cognitive and physiological functioning of the child. It is this abnormal persistence of the originally adaptive responses that result in trauma-related neuropsychiatric disorders such as Post-traumatic Stress Disorder (PTSD).
In brief however, children who survive a traumatic event and have persistence of this low level fear state, may be behaviorally impulsive, hypervigilant, hyperactive, withdrawn or depressed, have sleep difficulties (including insomnia, restless sleep and nightmares) and anxiety. In general, these children may show some loss of previous functioning or a slow rate of acquiring new developmental tasks. Children may act in a regressed fashion. In addition, many of these children have persisting physiological hyper-reactivity with resulting fast heart rate or borderline high blood pressure.
Unfortunately, a great majority of children who survive traumatic experiences also have a concomitant major disruption in their way of life, their sense of community, their family structure, and will be exposed to a variety of ongoing provocative reminders of the original event (e.g., ongoing legal actions, high press visibility). The frequency with which children develop post-traumatic stress disorders following comparable traumatic events is relatively high (45-60%). Children who survive traumatic events and exhibit this diverse set of symptoms and physical signs are frequently also able to meet diagnostic criteria for attention-deficit hyperactivity disorder, anxiety disorder NOS, major depressive disorder, conduct disorder, and a variety of Axis I DSM III-R diagnoses. Keeping in mind, however, that these children have been traumatized and that the symptoms of anxiety, depression and behavioral impulsivity are reflective of core changes related to the traumatic event helps one provide better diagnostic, prognostic and the therapeutic services for these children.
In a separate ChildTrauma Academy Booklet, specific recommendations regarding clinical work with traumatized children are available.
APPENDIX I
The Scope of Childhood Trauma
APPENDIX II
Key Points The Adaptive Response to Trauma
APPENDIX III The Threatened Child
How Fear Changes Thinking, Behaving and Feeling
Different children have different styles of adaptation to threat. Some children use a primary hyperarousal response some a primary dissociative response. Most use some combination of these two adaptive styles. In the fearful child, a defiant stance is often seen. This is typically interpreted as a willful and controlling child. Rather than understanding the behavior as related to fear, adults often respond to the ‘oppositional’ behavior by becoming more angry, more demanding. The child, over-reading the non-verbal cues of the frustrated and angry adult, feels more threatened and moves from alarm to fear to terror. These children may end up in a primitive "mini-psychotic" regression or in a very combative state. The behavior of the child reflects their attempts to adapt and respond to a perceived (or misperceived) threat.
There are many other places to learn more about the impact of traumatic events during childhood. A few starting places are listed below. These resources will be periodically updated and posted in a special section of the ChildTrauma Academy web site http://www.ChildTrauma.org. Visit this site for updates and for other resource materials about traumatic events and children.
Books: Stress in Children. Pfefferbaum, B. 7[1]. 1998. W.B. Saunders Company. Philadelphia, Child and Adolescent Psychiatric Clinics of North America. Lewis, M. This contributed volume summarizes the current state of clinical, research and policy related issues in the area of childhood traumatic stress. Several of the primary theoretical constructs guiding research and treatment are outlined. Excellent summaries of clinical experience and reviews of current clinical research are included. Too Scared To Cry. Terr, L. 1992 Harper Collins, New York Winner of the Blanche Ittleson Award for her research on childhood trauma, Dr. Terr is without peer in her experience and insight regarding childhood trauma. This book is a classic. She provides hope for all families and clinicians working with traumatized children. This book is highly recommended. Articles: Perry, BD and Azad, I. Post-traumatic stress disorders in children and adolescents. Current Opinions in Pediatrics 11: 4, 121-132, 1999 Perry, B. D. and Pollard, R. Homeostasis, stress, trauma, and adaptation: A neurodevelopmental view of childhood trauma. Child and Adolescent Psychiatric Clinics of North America 7[1], 33-51. 1998. Pfefferbaum, B. Posttraumatic stress disorder in children: A review of the past 10 years. J.Am.Acad.Child Adolesc.Psychiatry 36[11], 1503-1511. 1997. Terr, L. Childhood traumas: An outline and overview. Am J Psychiatry, 1991. 148: 10-20.
Prevent Child Abuse, America Prevent Child Abuse (formerly the National Committee to Prevent Child Abuse) is nationally recognized as one of the most innovative leaders in child abuse prevention. It has a nationwide network of chapters and their local affiliates in hundreds of communities. Through our media campaigns, people are finding ways they can help prevent abuse. PCA seeks to equip professionals with the latest, proven prevention approaches through training and technical assistance. To find out more about your local affiliate and the national program activities contact: Prevent Child Abuse America
Child Welfare League of America CWLA is an association of more than 1,000 public and private nonprofit agencies that assist over 2.5 million abused and neglected children and their families each year with a wide range of services. There have many resources for families and professionals working with traumatized children. For more information contact: Child Welfare League of America 440 First Street, NW, Third Floor
American Professional Society on the Abuse of Children (APSAC) APSAC's mission is to ensure that everyone affected by child maltreatment receives the best possible professional response. This organization has many useful scholarly and clinical materials focused primarily at the professional audience. Caregivers working with abused or maltreated children may find this a useful resource, nonetheless. For more information contact: APSAC The National Center for PTSD The National Center for PTSD is a program of the U.S. Department of Veterans Affairs and carries out a broad range of activities in research, training, and public information. The primary focus of the Center has been combat veterans and their families. Over the last few years, however, this focus has been expanded. There are many useful programs, activities and resources for anyone interested in the effects of traumatic stressors.
The PILOTS database is an electronic index to the worldwide literature on PTSD and other mental-health sequelae of exposure to traumatic events. It is available to Internet users through the courtesy of Dartmouth College, whose computer facilities serve as host to the database. No account or password is required, and there is no charge for using the PILOTS database. The National Center for PTSD http://www.dartmouth.edu/dms/ptsd/
International Society for Traumatic Stress Study The International Society for Traumatic Stress Studies (ISTSS), founded in 1985, provides a forum for the sharing of research, clinical strategies, public policy concerns and theoretical formulations on trauma in the United States and around the world. ISTSS is dedicated to the discovery and dissemination of knowledge and to the stimulation of policy, program and service initiatives that seek to reduce traumatic stressors and their immediate and long-term consequences.
National Clearinghouse for Child Abuse and Neglect (NCCAN) The National Clearinghouse on Child Abuse and Neglect Information is a national resource for professionals seeking information on the prevention, identification, and treatment of child abuse and neglect, and related child welfare issues.
National Clearinghouse on Child Abuse and Neglect Information OTHER David Baldwin’s Trauma Information Pages Without question the best trauma-related resource that exists on the Web. Dr. Baldwin has done a remarkable job, collecting, sorting and commenting on this information. If you have access to the Web, start here. You won’t be disappointed. These Trauma Pages focus primarily on emotional trauma and traumatic stress, including PTSD (Post-traumatic Stress Disorder), whether following individual traumatic experience(s) or a large-scale disaster. New information is added to this site about once a month. The purpose of this award-winning site is to provide information for clinicians and researchers in the traumatic-stress field. Baldwin’s interests include both clinical and research aspects of trauma responses and their resolution. For example:
Supportive resources supplement the more academic or research information of interest to clinicians, researchers, and students. David Baldwin’s Trauma Information Pages
Dissociation: The mental process of disengaging from the stimuli in the external environment and attending to inner stimuli. This is a graded mental process that ranges from normative daydreaming to pathological disturbances that may include exclusive focus on an inner fantasy world, loss of identity, disorientation, perceptual disturbances or even disruptions in identity. Hyperarousal: Mental and physical changes caused by alterations in central and peripheral nervous system activation related to perceived or actual threat. This graded response includes increased sensory and perceptual focus on the threat, activation of physiological systems required for survival and corresponding changes in emotional and behavioral functioning. Post-traumatic Stress Disorder (PTSD): A neuropsychiatric disorder that may develop following a traumatic event that includes changes in emotional, behavioral and physiological functioning. Trauma: A psychologically distressing event that is outside the range of usual human experience, often involving a sense of intense fear, terror and helplessness.
Bruce Duncan Perry, M.D., Ph.D. Dr. Perry is the Medical Director, Provincial Programs in Children's Mental Health for the Alberta Mental Health Board. In addition he continues to lead the ChildTrauma Academy, a training and research institute founded in 1990. From 1992 to 2001, Dr. Perry served as the Thomas S. Trammell Research Professor of Child Psychiatry at Baylor College of Medicine and Chief of Psychiatry at Texas Children's Hospital in Houston, Texas.
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To date, few of the systems designed to care for, protect, educate, evaluate or heal our children have solved the multiple problems posed by the maltreated or traumatized children. A first step in solving these problems is learning about the roots of trauma-related problems: the adaptive responses to threat present during the traumatic experiences.
The most well characterized response to threat is the fight or flight response. However, it is increasingly clear that individual responses to threat can vary tremendously. Another of the major adaptations to threat involves a different set of physiological and mental changes. Sometimes, when fighting or fleeing is not possible, the child will use avoidant and psychological fleeing mechanisms that are dissociative. Dissociation is basically a mental mechanism by which one withdraws attention from the outside world and focuses on the inner world. Dissociation may involve a distorted sense of time, a detached feeling that you are "observing" something happen to you as if it is unreal, the sense that you may be watching a movie of your life. In extreme cases, children may withdraw into an elaborate fantasy world where they may assume special powers or strengths. Like the alarm response, this "defeat" or dissociative response is graded. The intensity of the dissociation varies with the intensity and duration of the traumatic event. Even when we are not threatened, we use dissociative mental mechanisms all of the time. Daydreaming is an example of a dissociative event. The period between wakefulness and sleep is another example of dissociating from the present to your inner thoughts, ideas, fears, fantasies and, then, ultimately moving into the state of sleep. All children and most adults use some degree of dissociation during a traumatic event. Some individuals will use, and some kinds of trauma induce, dissociation as a primary adaptive response. 
As the traumatic event ends, the mind and body slowly move back down the arousal or dissociative continuum. The child moves from the brink of terror, through fear, alarm and, with time and support, back to calm (see The Acute Response to Trauma figure above). Heart rate, blood pressure and other physiological adaptations normalize. If a child can move back down the arousal continuum, their brain will resume baseline (pre-trauma) styles of thinking, feeling and behaving. Hypervigilance decreases and the mental mechanisms related to attention begin to normalize as well. The child that has dissociated will begin to pay attention to external stimuli. While the child that has been completely focused on external cues related to threat will actually pay attention to internal stimuli (e.g., feelings, thoughts, sensing their pounding heart or noticing the cut on their leg from diving under a desk during the shooting). 
Unfortunately, as this event plays itself out again and again in the mind of the child, not only will the thoughts of the event be recalled, the emotions and feelings (fear, anxiety, pain) of being out of control and threatened will be re-experienced as well. Each intrusive thought, nightmare and re-enactment in play also re-evokes the emotional or affective memory of being in the midst of the threatening event.
Indeed, even at rest in the weeks following a traumatic event, children and adolescents often exhibit signs of physiological hyperarousal - including tachycardia or a fast heart rate. Despite normal behaviors in most situations, children exposed to trauma are internally agitated. They have not truly been able to move back down the arousal continuum to the state of calm. This has profound implications for the child's long term functioning (see Post-traumatic Stress Disorders below).
Children and adults surviving traumatic events very frequently will have persistence of the acute post-traumatic stress response beyond six months. When this occurs, the child or adult is then considered to be suffering from post-traumatic stress disorder (PTSD). Post-traumatic stress disorder is a diagnostic label that has been traditionally associated with combat veterans. More recently however, it has been very well described in children who have been survivors of physical abuse, sexual abuse, exposure to community or domestic violence, natural disasters, motor vehicle accidents and a host of other traumatic events. The three major clusters of symptoms as described above are observed in a variety of forms of post-traumatic stress disorder. 
Whether or not someone develops post-traumatic disorder following a traumatic event is related to a variety of factors. The more life-threatening the event, the more likely someone is to develop PTSD. The more the event disrupts their normal family or social experience the more likely someone is to develop PTSD. Having an intact, supportive and nurturing family appears to be a relative protective factor. 
