Working with local medical and social agencies, the researchers recruited first-time (Caucasian) mothers who were poor enough to qualify for public assistance but who had different backgrounds and different kinds and levels of support available for parenting. The study began three months before the children were born and followed the children for thirty years into adulthood, assessing and, where relevant, measuring all the major aspects of their functioning and all the significant circumstances of their lives. It considered several fundamental questions: How do children learn to pay attention while regulating their arousal (i.e., avoiding extreme highs or lows) and keeping their impulses under control? What kinds of supports do they need, and when are these needed?
After extensive interviews and testing of the prospective parents, the study really got off the ground in the newborn nursery, where researchers observed the newborns and interviewed the nurses caring for them. They then made home visits seven and ten days after birth. Before the children entered first grade, they and their parents were carefully assessed a total of fifteen times. After that, the children were interviewed and tested at regular intervals until age twenty-eight, with continuing input from mothers and teachers.
Sroufe and his colleagues found that quality of care and biological factors were closely interwoven. It is fascinating to see how the Minnesota results echo—though with far greater complexity—what Stephen Suomi found in his primate laboratory. Nothing was written in stone. Neither the mother’s personality, nor the infant’s neurological anomalies at birth, nor its IQ, nor its temperament—including its activity level and reactivity to stress—predicted whether a child would develop serious behavioral problems in adolescence.20 The key issue, rather, was the nature of the parent-child relationship: how parents felt about and interacted with their kids. As with Suomi’s monkeys, the combination of vulnerable infants and inflexible caregivers made for clingy, uptight kids. Insensitive, pushy, and intrusive behavior on the part of the parents at six months predicted hyperactivity and attention problems in kindergarten and beyond.21
Focusing on many facets of development, particularly relationships with caregivers, teachers, and peers, Sroufe and his colleagues found that caregivers not only help keep arousal within manageable bounds but also help infants develop their own ability to regulate their arousal. Children who were regularly pushed over the edge into overarousal and disorganization did not develop proper attunement of their inhibitory and excitatory brain systems and grew up expecting that they would lose control if something upsetting happened. This was a vulnerable population, and by late adolescence half of them had diagnosable mental health problems. There were clear patterns: The children who received consistent caregiving became well-regulated kids, while erratic caregiving produced kids who were chronically physiologically aroused. The children of unpredictable parents often clamored for attention and became intensely frustrated in the face of small challenges. Their persistent arousal made them chronically anxious. Constantly looking for reassurance got in the way of playing and exploration, and, as a result, they grew up chronically nervous and nonadventurous.
Early parental neglect or harsh treatment led to behavior problems in school and predicted troubles with peers and a lack of empathy for the distress of others.22 This set up a vicious cycle: Their chronic arousal, coupled with lack of parental comfort, made them disruptive, oppositional, and aggressive. Disruptive and aggressive kids are unpopular and provoke further rejection and punishment, not only from their caregivers but also from their teachers and peers.23
Sroufe also learned a great deal about resilience: the capacity to bounce back from adversity. By far the most important predictor of how well his subjects coped with life’s inevitable disappointments was the level of security established with their primary caregiver during the first two years of life. Sroufe informally told me that he thought that resilience in adulthood could be predicted by how lovable mothers rated their kids at age two.24
THE LONG-TERM EFFECTS OF INCEST
In 1986 Frank Putnam and Penelope Trickett, his colleague at the National Institute of Mental Health, initiated the first longitudinal study of the impact of sexual abuse on female development.25 Until the results of this study came out, our knowledge about the effects of incest was based entirely on reports from children who had recently disclosed their abuse and on accounts from adults reconstructing years or even decades later how incest had affected them. No study had ever followed girls as they matured to examine how sexual abuse might influence their school performance, peer relationships, and self-concept, as well as their later dating life. Putnam and Trickett also looked at changes over time in their subjects’ stress hormones, reproductive hormones, immune function, and other physiological measures. In addition they explored potential protective factors, such as intelligence and support from family and peers.
The researchers painstakingly recruited eighty-four girls referred by the District of Columbia Department of Social Services who had a confirmed history of sexual abuse by a family member. These were matched with a comparison group of eighty-two girls of the same age, race, socioeconomic status, and family constellation who had not been abused. The average starting age was eleven. Over the next twenty years these two groups were thoroughly assessed six times, once a year for the first three years and again at ages eighteen, nineteen, and twenty-five. Their mothers participated in the early assessments, and their own children took part in the last. A remarkable 96 percent of the girls, now grown women, have stayed in the study from its inception.
The results were unambiguous: Compared with girls of the same age, race, and social circumstances, sexually abused girls suffer from a large range of profoundly negative effects, including cognitive deficits, depression, dissociative symptoms, troubled sexual development, high rates of obesity, and self-mutilation. They dropped out of high school at a higher rate than the control group and had more major illnesses and health-care utilization. They also showed abnormalities in their stress hormone responses, had an earlier onset of puberty, and accumulated a host of different, seemingly unrelated, psychiatric diagnoses.
The follow-up research revealed many details of how abuse affects development. For example, each time they were assessed, the girls in both groups were asked to talk about the worst thing that had happened to them during the previous year. As they told their stories, the researchers observed how upset they became, while measuring their physiology. During the first assessment all the girls reacted by becoming distressed. Three years later, in response to the same question, the nonabused girls once again displayed signs of distress, but the abused girls shut down and became numb. Their biology matched their observable reactions: During the first assessment all of the girls showed an increase in the stress hormone cortisol; three years later cortisol went down in the abused girls as they reported on the most stressful event of the past year. Over time the body adjusts to chronic trauma. One of the consequences of numbing is that teachers, friends, and others are not likely to notice that a girl is upset; she may not even register it herself. By numbing out she no longer reacts to distress the way she should, for example, by taking protective action.
Putnam’s study also captured the pervasive long-term effects of incest on friendships and partnering. Before the onset of puberty nonabused girls usually have several girlfriends, as well as one boy who functions as a sort of spy who informs them about what these strange creatures, boys, are all about. After they enter adolescence, their contacts with boys gradually increase. In contrast, before puberty the abused girls rarely have close friends, girls or boys, but adolescence brings many chaotic and often traumatizing contacts with boys.
Lacking friends in elementary school makes a crucial difference. Today we’re aware how cruel third-, fourth-, and fifth-grade girls can be. It’s a complex and rocky time when friends can suddenly turn on one another and alliances dissolve in exclusions and betrayals. But there is an upside: By the time
girls get to middle school, most have begun to master a whole set of social skills, including being able to identify what they feel, negotiating relationships with others, pretending to like people they don’t, and so on. And most of them have built a fairly steady support network of girls who become their stress-debriefing team. As they slowly enter the world of sex and dating, these relationships give them room for reflection, gossip, and discussion of what it all means.
The sexually abused girls have an entirely different developmental pathway. They don’t have friends of either gender because they can’t trust; they hate themselves, and their biology is against them, leading them either to overreact or numb out. They can’t keep up in the normal envy-driven inclusion/exclusion games, in which players have to stay cool under stress. Other kids usually don’t want anything to do with them—they simply are too weird.
But that’s only the beginning of the trouble. The abused, isolated girls with incest histories mature sexually a year and a half earlier than the nonabused girls. Sexual abuse speeds up their biological clocks and the secretion of sex hormones. Early in puberty the abused girls had three to five times the levels of testosterone and androstenedione, the hormones that fuel sexual desire, as the girls in the control group.
Results of Putnam and Trickett’s study continue to be published, but it has already created an invaluable road map for clinicians dealing with sexually abused girls. At the Trauma Center, for example, one of our clinicians reported on a Monday morning that a patient named Ayesha had been raped—again—over the weekend. She had run away from her group home at five o’clock on Saturday, gone to a place in Boston where druggies hang out, smoked some dope and done some other drugs, and then left with a bunch of boys in a car. At five o’clock Sunday morning they had gang-raped her. Like so many of the adolescents we see, Ayesha can’t articulate what she wants or needs and can’t think through how she might protect herself. Instead, she lives in a world of actions. Trying to explain her behavior in terms of victim/perpetrator isn’t helpful, nor are labels like “depression,” “oppositional defiant disorder,” “intermittent explosive disorder,” “bipolar disorder,” or any of the other options our diagnostic manuals offer us. Putnam’s work has helped us understand how Ayesha experiences the world—why she cannot tell us what is going on with her, why she is so impulsive and lacking in self-protection, and why she views us as frightening and intrusive rather than as people who can help her.
THE DSM-5: A VERITABLE SMORGASBORD OF “DIAGNOSES”
When DSM-5 was published in May 2013 it included some three hundred disorders in its 945 pages. It offers a veritable smorgasbord of possible labels for the problems associated with severe early-life trauma, including some new ones such as Disruptive Mood Regulation Disorder,26 Non-suicidal Self Injury, Intermittent Explosive Disorder, Dysregulated Social Engagement Disorder, and Disruptive Impulse Control Disorder.27
Before the late nineteenth century doctors classified illnesses according to their surface manifestations, like fevers and pustules, which was not unreasonable, given that they had little else to go on.28 This changed when scientists like Louis Pasteur and Robert Koch discovered that many diseases were caused by bacteria that were invisible to the naked eye. Medicine then was transformed by its attempts to discover ways to get rid of those organisms rather than just treating the boils and the fevers that they caused. With DSM-5 psychiatry firmly regressed to early-nineteenth-century medical practice. Despite the fact that we know the origin of many of the problems it identifies, its “diagnoses” describe surface phenomena that completely ignore the underlying causes.
Even before DSM-5 was released, the American Journal of Psychiatry published the results of validity tests of various new diagnoses, which indicated that the DSM largely lacks what in the world of science is known as “reliability”—the ability to produce consistent, replicable results. In other words, it lacks scientific validity. Oddly, the lack of reliability and validity did not keep the DSM-5 from meeting its deadline for publication, despite the near-universal consensus that it represented no improvement over the previous diagnostic system.29 Could the fact that the APA had earned $100 million on the DSM-IV and is slated to take in a similar amount with the DSM-5 (because all mental health practitioners, many lawyers, and other professionals will be obliged to purchase the latest edition) be the reason we have this new diagnostic system?
Diagnostic reliability isn’t an abstract issue: If doctors can’t agree on what ails their patients, there is no way they can provide proper treatment. When there’s no relationship between diagnosis and cure, a mislabeled patient is bound to be a mistreated patient. You would not want to have your appendix removed when you are suffering from a kidney stone, and you would not want have somebody labeled as “oppositional” when, in fact, his behavior is rooted in an attempt to protect himself against real danger.
In a statement released in June 2011, the British Psychological Society complained to the APA that the sources of psychological suffering in the DSM-5 were identified “as located within individuals” and overlooked the “undeniable social causation of many such problems.”30 This was in addition to a flood of protest from American professionals, including leaders of the American Psychological Association and the American Counseling Association. Why are relationships or social conditions left out?31 If you pay attention only to faulty biology and defective genes as the cause of mental problems and ignore abandonment, abuse, and deprivation, you are likely to run into as many dead ends as previous generations did blaming it all on terrible mothers.
The most stunning rejection of the DSM-5 came from the National Institute of Mental Health, which funds most psychiatric research in America. In April 2013, a few weeks before DSM-5 was formally released, NIMH director Thomas Insel announced that his agency could no longer support DSM’s “symptom-based diagnosis.”32 Instead the institute would focus its funding on what are called Research Domain Criteria (RDoC)33 to create a framework for studies that would cut across current diagnostic categories. For example, one of the NIMH domains is “Arousal/Modulatory Systems (Arousal, Circadian Rhythm, Sleep and Wakefulness),” which are disturbed to varying degrees in many patients.
Like the DSM-5, the RDoC framework conceptualizes mental illnesses solely as brain disorders. This means that future research funding will explore the brain circuits “and other neurobiological measures” that underlie mental problems. Insel sees this as a first step toward the sort of “precision medicine that has transformed cancer diagnosis and treatment.” Mental illness, however, is not at all like cancer: Humans are social animals, and mental problems involve not being able to get along with other people, not fitting in, not belonging, and in general not being able to get on the same wavelength.
Everything about us—our brains, our minds, and our bodies—is geared toward collaboration in social systems. This is our most powerful survival strategy, the key to our success as a species, and it is precisely this that breaks down in most forms of mental suffering. As we saw in part 2, the neural connections in brain and body are vitally important for understanding human suffering, but it is important not to ignore the foundations of our humanity: relationships and interactions that shape our minds and brains when we are young and that give substance and meaning to our entire lives.
People with histories of abuse, neglect, or severe deprivation will remain mysterious and largely untreated unless we heed the admonition of Alan Sroufe: “To fully understand how we become the persons we are—the complex, step-by-step evolution of our orientations, capacities, and behavior over time—requires more than a list of ingredients, however important any one of them might be. It requires an understanding of the process of development, how all of these factors work together in an ongoing way over time.”34
Frontline mental health workers—overwhelmed and underpaid social workers and therapists alike—seem to agree with our approach. Shortly after the APA rejected Development
al Trauma Disorder for inclusion in the DSM, thousands of clinicians from around the country sent small contributions to the Trauma Center to help us conduct a large scientific study, known as a field trial, to further study DTD. That support has enabled us to interview hundreds of kids, parents, foster parents, and mental health workers at five different network sites over the last few years with scientifically constructed interview tools. The first results from these studies have now been published, and more will appear as this book is going to print.35
WHAT DIFFERENCE WOULD DTD MAKE?
One answer is that it would focus research and treatment (not to mention funding) on the central principles that underlie the protean symptoms of chronically traumatized children and adults: pervasive biological and emotional dysregulation, failed or disrupted attachment, problems staying focused and on track, and a hugely deficient sense of coherent personal identity and competence. These issues transcend and include almost all diagnostic categories, but treatment that doesn’t put them front and center is more than likely to miss the mark. Our great challenge is to apply the lessons of neuroplasticity, the flexibility of brain circuits, to rewire the brains and reorganize the minds of people who have been programmed by life itself to experience others as threats and themselves as helpless.
Social support is a biological necessity, not an option, and this reality should be the backbone of all prevention and treatment. Recognizing the profound effects of trauma and deprivation on child development need not lead to blaming parents. We can assume that parents do the best they can, but all parents need help to nurture their kids. Nearly every industrialized nation, with the exception of the United States, recognizes this and provides some form of guaranteed support to families. James Heckman, winner of the 2000 Nobel Prize in Economics, has shown that quality early-childhood programs that involve parents and promote basic skills in disadvantaged children more than pay for themselves in improved outcomes.36
The Body Keeps the Score Page 21