Bessell van der Kolk, M.D., a psychiatrist and leading brain researcher on the effects of chronic trauma on development, presented a highly interesting and informative series of workshops at the recent 8th annual ATTACh conference in Omaha, Nebraska. This article will attempt to summarize his 4 1/2 hours of presentation, but readers should keep in mind that it will be difficult to completely summarize all of his valuable information in the space available here. Therefore, we will break his presentation down into two primary components; the effects of chronic trauma on development, and the implications of chronic trauma on treatment (which will be presented in the Spring 98 edition of Attachments).

First, Dr. van der Kolk noted that the tasks of normal infancy and childhood are to learn to attach to and trust others, to learn how to play and share with others, to have conflicts and learn ways to resolve them, to learn to dream and to imagine, to learn to have empathy for oneself and others, to learn how to settle oneself down when upset, and to learn how to regulate one's level of arousal. Serious, chronic trauma during infancy and early childhood dramatically interferes with each of these tasks. Trauma experiences put children outside the rest of human experience, inducing a degree of loneliness and isolation who depth and sense of despair cannot be imagined or understood by those who have not had similar experiences. These children feel different from others from the time of the onset of the trauma, and (unless drastic steps are taken in later therapy to change this) will continue to go through life feeling deeply lonely and apart from others.

Healthy attachment cannot take place when a child's midbrain (the limbic system and amygdala primarily) is under a constant state of arousal, is constantly subjected to the demands of stress hormones, and is unable to go about the process of normal branching out and connecting to other brain cells. As a result, traumatized children do not learn how to play, to relax, to regulate their own level of arousal, and how to understand and have empathy and compassion for either themselves or others. He notes, "To be dependent on others is extremely shame-producing for traumatized children". They have learned to have a "cocoon of self-sufficiency", and hate and mistrust anyone who tries to penetrate this cocoon. The moment they are required to trust others, they feel as though their defense systems have failed, and they respond to what feels to them like an attack from others by attacking those who desire their trust. As a result, their behavior is often quite unpredictably aggressive.

Because they learned to soothe themselves as infants and young children, their brains and bodies have become adapted to self-stimulating and self-soothing behaviors that can appear to be quite odd to others, but which usually have some relationship to a soothing behavior that made sense to them when they were being traumatized. These children will go to anyone for care and attention, but resist close relationships with others because they interfere with self-stimulating and self-soothing behaviors. "Getting your needs met becomes the building block of the capacity to regulate your internal biological systems", and attachment is related to teaching children how to regulate those systems. What goes wrong in attachment disorders is that children don't learn how to do this, and teaching them how at a later age than infancy is a very difficult task.

Chronic trauma also affects the development of the brain, immune system, threat response systems, and memory systems of children. First, the midbrain comes to expect that most life events will be traumatic, and so it lives in a state of constant hyperarousal and causes children to be overly active and overly responsive to life events. "The task of parents is to teach their children how to regulate their own internal biological and trauma systems, and to move a child from one state to another without triggering hyperarousal". When a child's brain has already been pre-set to expect trauma and danger, parents are unable to teach the child how to settle down and relax. As a result, traumatized children often appear quite inattentive and hyperactive, and are often diagnosed with ADHD or bipolar disorder, when their problem is actually one of hyperarousal. These children have great difficulty settling down once they have been stimulated, and even minor upsets can result in hyperarousal and the inability to settle down. Most of these kids are also experts at dissociation (a self-soothing behavior), and they feel safer when they can dissociate from others and comfort themselves in their own little world.

Traumatized children store traumatic memories in the right half of the brain (normal people use both sides to store both positive and negative memories, while traumatized people store positive memories in the left half, and negative memories in the right half) and in the limbic system (normal people use the limbic system to store memory until about age 3, and then higher-level brain systems take over memory functions). For traumatized children, the limbic system is constantly triggered by emotions and arousal, so others areas of the brain never develop to store and make sense of memory. The function of memory is supposed to be to help people cope with future events by relying on past coping strategies. For traumatized children, this doesn't happen, as they instead get caught up repeatedly in traumatic memories, and so are unable to respond appropriately to current events.

Traumatic memories are also more distorted by time than positive memories, and traumatized children continue to respond to new events as if they were past events, so their behavior can often appear to be quite odd and delusional. In fact, these children become obsessed by their traumatic memories, split them off from conscious awareness, and express them somatically. When compared with non-traumatized children (about 100 children in each group), traumatized children are more often diagnosed with depression (25%; 11% in control group), ADHD (32%; 4% of controls), and conduct disorder (25%; 10% of controls). In addition, animal research shows that traumatized rats had levels of stress hormones that were five times those of nontraumatized rats. If the same thing is true for humans, we can assume that the stress response systems of these children is on constant hyperalert, leading to startling differences between groups in frequencies of somatic disorders. Fifty percent of traumatized children had digestive problems (10% of controls), 60% had skin problems like acne (16% of controls), 50% had asthma (4% of controls), and migraine headaches were also quite common in the traumatized group. Interestingly, traumatized children seldom get sick because hyperarousal in the stress response systems gets the immune system working at a high level (which may explain why attachment disordered children seldom get sick until they become attached to their families). Eventually, however, chronic stress leads to breakdowns in the immune system, and as adults there is a high frequency of autoimmune diseases (like asthma and arthritis in this population).

The memory systems of traumatized children are also affected in other ways. Normal people rely on three types of memory; semantic (ways of behaving that are learned from parents and that are adaptive and functional), episodic (a primitive system in which memories are stored according to the emotions and events that were going on at the time the memory was stored), and procedural (the routine, unconscious actions and responses to every day life). Traumatized children have access to only procedural and episodic memory, and even procedural memory can be disrupted by flashbacks and sensory cues that trigger episodic memories. This leaves them with few options for learning new responses to life events, and an inability to utilize parents as models for new, more adaptive behaviors. They are essentially stuck with old behaviors, and cannot rely on memory systems to help them to learn new ones. This is one reason why traumatized children are so difficult to treat with traditional therapies.

In addition, because these children are so subject to sensory triggers of traumatic memories, and these memories are stored in the right brain (leaving the child unable to access the verbal abilities of the left brain), they cannot verbally explain what is going on for them. Instead, they withdraw into self-soothing and self-stimulating behaviors, resenting and becoming angry at the attempts of others to help and soothe them. They essentially become "struck speechless", or resort to immature speech generated from the right brain that can appear quite odd and meaningless to others. Many of these children also talk non-stop when not having traumatic memories, as talking keeps the left brain engaged and prevents access to right brain memories that constantly threaten to flood the person.

Children have even more difficulty than adults do trying to make sense out of flashbacks, and so behave in quite odd ways when they are having flashbacks. They often respond with tantrums and aggressive behaviors, as they don't know any other way to manage the disruptive influence of the flashbacks. They feel totally isolated from others during flashbacks, as adults have become meaningless to them, as they are totally unaware of the presence of others.

Again because traumatic memories allow the child access only to the right brain (and the left brain is responsible for organizing and making sense of information), traumatized children often give odd and bizarre explanations for their behavior that seems the same as lying. However, it is an odd kind of lying because it is caused by an inability to transfer knowledge from one area of the brain to another (this may account for the "crazy lying" that is common in attachment disordered children).

It is easy to recognize many of the traits and behaviors of attachment disordered children in Dr. van der Kolk's description of traumatized children. In the next issue of "Attachments", we will present the treatment implications for traumatized children, and how this can help us in our work with attachment disordered children.

© The Attachment Center at Evergreen