MONKEYS CLARIFY OLD QUESTIONS ABOUT NATURE VERSUS NURTURE
One of the clearest ways of understanding how the quality of parenting and environment affects the expression of genes comes from the work of Stephen Suomi, chief of the National Institutes of Health’s Laboratory of Comparative Ethology.9 For more than forty years Suomi has been studying the transmission of personality through generations of rhesus monkeys, which share 95 percent of human genes, a number exceeded only by chimpanzees and bonobos. Like humans, rhesus monkeys live in large social groups with complex alliances and status relationships, and only members who can synchronize their behavior with the demands of the troop survive and flourish.
Rhesus monkeys are also like humans in their attachment patterns. Their infants depend on intimate physical contact with their mothers, and just as Bowlby observed in humans, they develop by exploring their reactions to their environment, running back to their mothers whenever they feel scared or lost. Once they become more independent, play with their peers is the primary way they learn to get along in life.
Suomi identified two personality types that consistently ran into trouble: uptight, anxious monkeys, who become fearful, withdrawn, and depressed even in situations where other monkeys will play and explore; and highly aggressive monkeys, who make so much trouble that they are often shunned, beaten up, or killed. Both types are biologically different from their peers. Abnormalities in arousal levels, stress hormones, and metabolism of brain chemicals like serotonin can be detected within the first few weeks of life, and neither their biology nor their behavior tends to change as they mature. Suomi discovered a wide range of genetically driven behaviors. For example, the uptight monkeys (classified as such on the basis of both their behavior and their high cortisol levels at six months) will consume more alcohol in experimental situations than the others when they reach the age of four. The genetically aggressive monkeys also overindulge—but they binge drink to the point of passing out, while the uptight monkeys seem to drink to calm down.
And yet the social environment also contributes significantly to behavior and biology. The uptight, anxious females don’t play well with others and thus often lack social support when they give birth and are at high risk for neglecting or abusing their firstborns. But when these females belong to a stable social group they often become diligent mothers who carefully watch out for their young. Under some conditions being an anxious mom can provide much needed protection. The aggressive mothers, on the other hand, did not provide any social advantages: very punitive with their offspring, there is lots of hitting, kicking, and biting. If the infants survive, their mothers usually keep them from making friends with their peers.
In real life it is impossible to tell whether people’s aggressive or uptight behavior is the result of parents’ genes or of having been raised by an abusive mother—or both. But in a monkey lab you can take newborns with vulnerable genes away from their biological mothers and have them raised by supportive mothers or in playgroups with peers.
Young monkeys who are taken away from their mothers at birth and brought up solely with their peers become intensely attached to them. They desperately cling to one another and don’t peel away enough to engage in healthy exploration and play. What little play there is lacks the complexity and imagination typical of normal monkeys. These monkeys grow up to be uptight: scared in new situations and lacking in curiosity. Regardless of their genetic predisposition, peer-raised monkeys overreact to minor stresses: Their cortisol increases much more in response to loud noises than does that of monkeys who were raised by their mothers. Their serotonin metabolism is even more abnormal than that of the monkeys who are genetically predisposed to aggression but who were raised by their own mothers. This leads to the conclusion that, at least in monkeys, early experience has at least as much impact on biology as heredity does.
Monkeys and humans share the same two variants of the serotonin gene (known as the short and long serotonin transporter alleles). In humans the short allele has been associated with impulsivity, aggression, sensation seeking, suicide attempts, and severe depression. Suomi showed that, at least in monkeys, the environment shapes how these genes affect behavior. Monkeys with the short allele that were raised by an adequate mother behaved normally and had no deficit in their serotonin metabolism. Those who were raised with their peers became aggressive risk takers.10 Similarly, New Zealand researcher Alec Roy found that humans with the short allele had higher rates of depression than those with the long version but that this was true only if they also had a childhood history of abuse or neglect. The conclusion is clear: Children who are fortunate enough to have an attuned and attentive parent are not going to develop this genetically related problem.11
Suomi’s work supports everything we’ve learned from our colleagues who study human attachment and from our own clinical research: Safe and protective early relationships are critical to protect children from long-term problems. In addition, even parents with their own genetic vulnerabilities can pass on that protection to the next generation provided that they are given the right support.
THE NATIONAL CHILD TRAUMATIC STRESS NETWORK
Nearly every medical disease, from cancer to retinitis pigmentosa, has advocacy groups that promote the study and treatment of that particular condition. But until 2001, when the National Child Traumatic Stress Network was established by an act of Congress, there was no comprehensive organization dedicated to the research and treatment of traumatized children.
In 1998 I received a call from Adam Cummings from the Nathan Cummings Foundation telling me that they were interested in studying the effects of trauma on learning. I told them that while some very good work had been done on that subject,12 there was no forum to implement the discoveries that had already been made. The mental, biological, or moral development of traumatized children was not being systematically taught to child-care workers, to pediatricians, or in graduate schools of psychology or social work.
Adam and I agreed that we had to address this problem. Some eight months later we convened a think tank that included representatives from the U.S. Department of Health and Human Services and the U.S. Department of Justice, Senator Ted Kennedy’s health-care adviser, and a group of my colleagues who specialized in childhood trauma. We all were familiar with the basics of how trauma affects the developing mind and brain, and we all were aware that childhood trauma is radically different from traumatic stress in fully formed adults. The group concluded that, if we hoped to ever put the issue of childhood trauma firmly on the map, there needed to be a national organization that would promote both the study of childhood trauma and the education of teachers, judges, ministers, foster parents, physicians, probation officers, nurses, and mental health professionals—anyone who deals with abused and traumatized kids.
One member of our work group, Bill Harris, had extensive experience with child-related legislation, and he went to work with Senator Kennedy’s staff to craft our ideas into law. The bill establishing the National Child Traumatic Stress Network was ushered through the Senate with overwhelming bipartisan support, and since 2001 it has grown from a collaborative network of 17 sites to more than 150 centers nationwide. Led by coordinating centers at Duke University and UCLA, the NCTSN includes universities, hospitals, tribal agencies, drug rehab programs, mental health clinics, and graduate schools. Each of the sites, in turn, collaborates with local school systems, hospitals, welfare agencies, homeless shelters, juvenile justice programs, and domestic violence shelters, with a total of well over 8,300 affiliated partners.
Once the NCTSN was up and running, we had the means to assemble a clearer profile of traumatized kids in every part of the country. My Trauma Center colleague Joseph Spinazzola led a survey that examined the records of nearly two thousand children and adolescents from agencies across the network.13 We soon confirmed what we had suspected: The vast majority came from extremely dysfunctional families. More than half had been em
otionally abused and/or had a caregiver who was too impaired to care for their needs. Almost 50 percent had temporarily lost caregivers to jail, treatment programs, or military service and had been looked after by strangers, foster parents, or distant relatives. About half reported having witnessed domestic violence, and a quarter were also victims of sexual and /or physical abuse. In other words, the children and adolescents in the survey were mirrors of the middle-aged, middle-class Kaiser Permanente patients with high ACE scores that Vincent Felitti had studied in the Adverse Childhood Experiences (ACE) Study.
THE POWER OF DIAGNOSIS
In the 1970s there was no way to classify the wide-ranging symptoms of hundreds of thousands of returning Vietnam veterans. As we saw in the opening chapters of this book, this forced clinicians to improvise the treatment of their patients and prevented them from being able to systematically study what approaches actually worked. The adoption of the PTSD diagnosis by the DSM III in 1980 led to extensive scientific studies and to the development of effective treatments, which turned out to be relevant not only to combat veterans but also to victims of a range of traumatic events, including rape, assault, and motor vehicle accidents.14 An example of the far-ranging power of having a specific diagnosis is the fact that between 2007 and 2010 the Department of Defense spent more than $2.7 billion for the treatment of and research on PTSD in combat veterans, while in fiscal year 2009 alone the Department of Veterans Affairs spent $24.5 million on in-house PTSD research.
The DSM definition of PTSD is quite straightforward: A person is exposed to a horrendous event “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” causing “intense fear, helplessness, or horror,” which results in a variety of manifestations: intrusive reexperiencing of the event (flashbacks, bad dreams, feeling as if the event were occurring), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia for important parts of it), and increased arousal (insomnia, hypervigilance, or irritability). This description suggests a clear story line: A person is suddenly and unexpectedly devastated by an atrocious event and is never the same again. The trauma may be over, but it keeps being replayed in continually recycling memories and in a reorganized nervous system.
How relevant was this definition to the children we were seeing? After a single traumatic incident—a dog bite, an accident, or witnessing a school shooting—children can indeed develop basic PTSD symptoms similar to those of adults, even if they live in safe and supportive homes. As a result of having the PTSD diagnosis, we now can treat those problems quite effectively.
In the case of the troubled children with histories of abuse and neglect who show up in clinics, schools, hospitals, and police stations, the traumatic roots of their behaviors are less obvious, particularly because they rarely talk about having been hit, abandoned, or molested, even when asked. Eighty two percent of the traumatized children seen in the National Child Traumatic Stress Network do not meet diagnostic criteria for PTSD.15 Because they often are shut down, suspicious, or aggressive they now receive pseudoscientific diagnoses such as “oppositional defiant disorder,” meaning “This kid hates my guts and won’t do anything I tell him to do,” or “disruptive mood dysregulation disorder,” meaning he has temper tantrums. Having as many problems as they do, these kids accumulate numerous diagnoses over time. Before they reach their twenties, many patients have been given four, five, six, or more of these impressive but meaningless labels. If they receive treatment at all, they get whatever is being promulgated as the method of management du jour: medications, behavioral modification, or exposure therapy. These rarely work and often cause more damage.
As the NCTSN treated more and more kids, it became increasingly obvious that we needed a diagnosis that captured the reality of their experience. We began with a database of nearly twenty thousand kids who were being treated in various sites within the network and collected all the research articles we could find on abused and neglected kids. These were winnowed down to 130 particularly relevant studies that reported on more than one hundred thousand children and adolescents worldwide. A core work group of twelve clinician/researchers specializing in childhood trauma16 then convened twice a year for four years to draft a proposal for an appropriate diagnosis, which we decided to call Developmental Trauma Disorder.17
As we organized our findings, we discovered a consistent profile: (1) a pervasive pattern of dysregulation, (2) problems with attention and concentration, and (3) difficulties getting along with themselves and others. These children’s moods and feelings rapidly shifted from one extreme to another—from temper tantrums and panic to detachment, flatness, and dissociation. When they got upset (which was much of the time), they could neither calm themselves down nor describe what they were feeling.
Having a biological system that keeps pumping out stress hormones to deal with real or imagined threats leads to physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound. Being so agitated or shut down keeps them from being able to focus their attention and concentration. To relieve their tension, they engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled). It also leads to difficulties with language processing and fine-motor coordination. Spending all their energy on staying in control, they usually have trouble paying attention to things, like schoolwork, that are not directly relevant to survival, and their hyperarousal makes them easily distracted.
Having been frequently ignored or abandoned leaves them clinging and needy, even with the people who have abused them. Having been chronically beaten, molested, and otherwise mistreated, they can not help but define themselves as defective and worthless. They come by their self-loathing, sense of defectiveness, and worthlessness honestly. Was it any surprise that they didn’t trust anyone? Finally, the combination of feeling fundamentally despicable and overreacting to slight frustrations makes it difficult for them to make friends.
We published the first articles about our findings, developed a validated rating scale,18 and collected data on about 350 kids and their parents or foster parents to establish that this one diagnosis, Developmental Trauma Disorder, captured the full range of what was wrong with these children. It would enable us to give them a single diagnosis, as opposed to multiple labels, and would firmly locate the origin of their problems in a combination of trauma and compromised attachment.
In February 2009 we submitted our proposed new diagnosis of Developmental Trauma Disorder to the American Psychiatric Association, stating the following in a cover letter:
Children who develop in the context of ongoing danger, maltreatment and disrupted caregiving systems are being ill served by the current diagnostic systems that lead to an emphasis on behavioral control with no recognition of interpersonal trauma. Studies on the sequelae of childhood trauma in the context of caregiver abuse or neglect consistently demonstrate chronic and severe problems with emotion regulation, impulse control, attention and cognition, dissociation, interpersonal relationships, and self and relational schemas. In absence of a sensitive trauma-specific diagnosis, such children are currently diagnosed with an average of 3–8 co-morbid disorders. The continued practice of applying multiple distinct co-morbid diagnoses to traumatized children has grave consequences: it defies parsimony, obscures etiological clarity, and runs the danger of relegating treatment and intervention to a small aspect of the child’s psychopathology rather than promoting a comprehensive treatment approach.
Shortly after submitting our proposal, I gave a talk on Developmental Trauma Disorder in Washington DC to a meeting of the mental health commissioners from across the country. They offered to support our initiative by writing a letter to the APA. The letter began by pointing out that the National Association of State Mental Health Program Directo
rs served 6.1 million people annually, with a budget of $29.5 billion, and concluded: “We urge the APA to add developmental trauma to its list of priority areas to clarify and better characterize its course and clinical sequelae and to emphasize the strong need to address developmental trauma in the assessment of patients.”
I felt confident that this letter would ensure that the APA would take our proposal seriously, but several months after our submission, Matthew Friedman, executive director of the National Center for PTSD and chair of the relevant DSM subcommittee, informed us that DTD was unlikely to be included in the DSM-5. The consensus, he wrote, was that no new diagnosis was required to fill a “missing diagnostic niche.” One million children who are abused and neglected every year in the United States a “diagnostic niche”?
The letter went on: “The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact. This statement is commonly made but cannot be backed up by prospective studies.” In fact, we had included several prospective studies in our proposal. Let’s look at just two of them here.
HOW RELATIONSHIPS SHAPE DEVELOPMENT
Beginning in 1975 and continuing for almost thirty years, Alan Sroufe and his colleagues tracked 180 children and their families through the Minnesota Longitudinal Study of Risk and Adaptation.19 At the time the study began there was an intense debate about the role of nature versus nurture, and temperament versus environment in human development, and this study set out to answer those questions. Trauma was not yet a popular topic, and child abuse and neglect were not a central focus of this study—at least initially, until they emerged as the most important predictors of adult functioning.
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