A Bulletin for

professionals

October 2001

What’s Inside:

• How the brain develops

Understanding • Effects of maltreatment on

brain development

the Effects of • Implications for practice and policy

• Summary and research
recommendations

Maltreatment
on Early Brain
Development
“Our brains are sculpted by our early experi-
ences. Maltreatment is a chisel that shapes a
brain to contend with strife, but at the cost of
deep, enduring wounds.”
—Teicher, 2000, p. 67

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Administration on Children, Youth and Families 703.385.7565 or 800.394.3366
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Understanding the Effects of Maltreatment on Early Brain Development www.childwelfare.gov

In recent years, there has been a surge of environment have a significant impact on how
research into early brain development. As our predispositions will be expressed; these
recently as the 1980s, many professionals interactions organize our brain’s development
thought that by the time babies are born, the and, therefore, shape the person we become
structure of their brains was already genetically (Shore, 1997).
determined. The role of experience on the
developing brain structure was under-appreci- Forming the Structure
ated, as was the active role of babies in their The raw material of the brain is the nerve cell,
own brain development through interaction called the neuron. When babies are born, they
with their environment (Shore, 1997). While have almost all of the neurons they will ever
much of the research examining brain func- have, more than 100 billion of them. Although
tioning has been done with animals, new there is research that indicates some neurons
technologies are enabling more non-invasive are developed after birth and well into adult-
research to be done with humans. Although hood (Shonkoff & Phillips, 2000), the neurons
there is still much to learn, we now know babies have at birth are primarily what they
much more about the brain’s development have to work with as they develop into chil-
and functioning. dren, adolescents, and adults.

One area that has been receiving increas- During fetal development, the neurons that are
ing research attention involves the effects of created migrate to form the various parts of
abuse and neglect on the developing brain the brain. While the basic structure is intact at
during infancy and early childhood. Much of birth, much of the brain’s growth occurs during
this research is providing biological expla- the first few years after birth. This process of
nations for what practitioners have been growth, or development, occurs sequentially
describing in psychological, emotional, and from the “bottom up” (Perry, Pollard, Blakely,
behavioral terms. We are beginning to see the Baker & Vigilante, 1995; Perry 2000a).
scientific “evidence” of altered brain function-
The first areas of the brain to fully develop
ing as a result of early abuse and neglect.
are the brainstem and midbrain; they govern
This emerging body of knowledge has many
the bodily functions necessary for life, called
implications for the prevention and treatment
the autonomic functions. The last regions
of child abuse and neglect.
of the brain to fully develop are the limbic
system, involved in regulating emotions, and
the cortex, involved in abstract thought. (See
How the Brain Develops Exhibit 1.) Each region manages its assigned
functions through complex processes, often
What we have learned about the process of using chemical messengers (such as neu-
brain development has helped us understand rotransmitters and hormones) to help transmit
more about the influence of genetics and information to other parts of the brain and
environment on our total development—the body (Perry, Pollard, Blakely, Baker & Vigilante,
“nature versus nurture” debate. It appears 1995; Perry 2000a).
that genetics predispose us to develop in
certain ways. But our interactions with our

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As the brain develops, it grows larger and feeling. This is the essence of post-natal devel-
more dense. By the age of 3, a baby’s brain opment, because at birth, very few synapses
has reached almost 90 percent of its adult size have been formed. The synapses present at
(Perry, 2000c). The growth in each region of the birth are primarily those that govern our bodily
brain largely depends on receiving stimulation, functions such as heart rate, breathing, eating,
which spurs activity in that region. This stimula- and sleeping. Almost all other functions are
tion provides the foundation for learning. developed as babies grow up into children
and adults (Shore, 1997).
Prenatal Exposure to
Alcohol and Other Drugs E xhibit 1
Abstract thought
Cortex Concrete Thought
Exposure to alcohol and other drugs in Affiliation
"Attachment"
utero can disrupt and significantly impair Limbic Sexual Behavior
the way a baby’s brain is formed (Shore, Emotional Reactivity
Motor Regulation
1997). Midbrain
"Arousal"
Appetite/Satiety
Sleep
Studies have shown that exposure to Blood Pressure
Brainstem
alcohol or other drugs, especially early in Bruce D. Perry, M.D., Ph.D.
Heart Rate
Body Temperature
pregnancy, can alter the development of
www.ChildTrauma.org

the cortex, reduce the number of neurons

that are created, and affect the way in The development of synapses occurs at an
which chemical messengers are used astounding rate during children’s early years.
(Shore, 1997). Although not all children By the time children are 3, their brains have
who are exposed develop neurobiological approximately 1,000 trillion synapses, many
problems, many do. These problems more than they will ever need. Some of these
include difficulties with attention, memory, synapses are strengthened and remain intact,
problem-solving, and abstract thinking. but many are discarded. By the time children
Many children born with Fetal Alcohol have reached adolescence, about half of their
Syndrome are mentally retarded (Shonkoff synapses have been discarded, leaving about
& Phillips, 2000). 500 trillion, the number they will have for most
of the rest of their lives (Shore, 1997).

Plasticity—The Influence of
Organizing the Structure
Environment
Brain development, or learning, is actually
the process of creating, strengthening, and “Plasticity is a double-edged sword that leads to
discarding connections among the neurons; both adaptation and vulnerability.”
these connections are called synapses. —Shonkoff & Phillips, 2000, p. 94
Synapses organize the brain by forming
Researchers use the term plasticity to describe
neuronal pathways that connect the parts of
the way the brain creates, strengthens, and
the brain governing everything we do—from
discards synapses and neuronal pathways
breathing and sleeping to thinking and
in response to the environment (Ounce of

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Prevention Fund, 1996). The brain’s “plastic- to its environment, it will adapt to a negative
ity” is the reason that environment plays a vital environment just as readily as it will adapt to a
role in brain development. positive environment.
The early over-production of synapses Sensitive Periods
appears to be the result of evolution that has
led our brains to expect certain experiences “It is now clear that what a child experiences in
(Greenough, Black & Wallace, 1987). Our the first few years of life largely determines how
brains prepare us for these experiences by his brain will develop and how he will interact
forming the pathways needed to respond to with the world throughout his life.”
those experiences. For example, our brains —Ounce of Prevention Fund, 1996
are “wired” to respond to the sound of Researchers believe that during these years
speech; this is how we learn to talk. But these there may be “sensitive periods” for develop-
early synapses are weak; we must be repeat- ment of certain capabilities (Greenough, Black
edly exposed to the expected experiences & Wallace, 1987). Because synapses are being
within a certain time period to activate and formed at such an intense pace during this
strengthen them. If this does not happen, the time, the opportunities for learning are almost
pathways developed in anticipation of those limitless. But as the process of pruning syn-
experiences may be discarded, and the devel- apses starts to increase, especially after age 3,
opment of the related functions will not occur these opportunities begin to decrease (Shore,
as expected. This is often referred to as the 1997). If certain synapses and neuronal path-
“use it or lose it” principle (Greenough, Black ways are not repeatedly activated, they may be
& Wallace, 1987). discarded, and the capabilities they promised
In addition to strengthening or discarding may be diminished. For example, all infants
existing synapses, researchers theorize that have the capacity, indeed the genetic predis-
some synapses may be newly developed in position, to form strong attachments to their
response to unique environmental condi- primary caregivers. But if a child’s caregivers are
tions (Greenough, Black & Wallace, 1987). It is unresponsive or threatening, and the attach-
through these processes of creating, strength- ment process is disrupted, the child’s ability to
ening, and discarding synapses that our brains form any healthy relationships during his or her
adapt each of us to our unique environment. life may be impaired (Perry, 2001a).

The ability to adapt to our environment is a Although the first few years may be the “prime
part of normal development. Children growing time” for learning, children and adults can
up in cold climates or rural farms or large learn later in life, but it is more difficult. This is
sibling groups learn how to function in those especially true if a young child was deprived
environments. But regardless of the general of certain stimulation, which resulted in the
environment, all children need stimulation and pruning of synapses and the loss of neuronal
nurturance for healthy development. If these pathways. Helgeson (1997) offers the analogy
are lacking—if a child’s caretakers are indiffer- of a country that has a dense network of
ent or hostile—the child’s brain development branching streets; a traveler can go anywhere
may be impaired. Because the brain adapts he wants, even unfamiliar places, by following

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the roads. If there are few roads, the traveler memories that have been created allow for a
can still go places, but he has to travel “cross- smooth, efficient flow of information.
country” and break new ground. It is doable,
The creation of memories is part of our adap-
but much harder. As children progress through
tation to our environment. Our brains attempt
each developmental stage, they will learn and
to understand the world around us and fashion
master each step more easily if their brains
our interactions with that world in a way that
have built an efficient network of pathways.
promotes our survival and, hopefully, our
While research has shown that the brain is more growth. But if the early environment is abusive
malleable in the first few years than at any other or neglectful, our brains will create memories
time in life, researchers disagree on how flex- of these experiences that may adversely color
ible or rigid the sensitive periods are. But they our view of the world throughout our life.
do agree that the experiences of the first few
years form the foundation for children’s future
functioning. “While experiences may alter and Malnutrition
change the functioning of an adult, experience
literally provides the organizing framework for
an infant and child” (Perry, Pollard, Blakely, Malnutrition, both before and during the
Baker & Vigilante, 1995). first few years after birth, has been shown
to result in stunted brain growth and
Memories slower passage of electrical signals in the
The “organizing framework” for children’s brain (Pollitt & Gorman, 1994; Shonkoff
development is based on the creation of & Phillips, 2000). These effects on the
“memories.” When repeated experiences brain are linked to cognitive, social, and
strengthen a neuronal pathway, the pathway behavioral deficits with possible long-term
becomes “sensitized,” and, at some point, it consequences (Karr-Morse & Wiley, 1997).
becomes a memory. Memories are an indelible For example, iron deficiency (the most
impression of the world (Perry, 1999); they are common form of malnutrition in the
the way in which the brain stores information United States) can result in cognitive
for easy retrieval. and motor delays, anxiety, depression,
There are different types of memories, such social problems, and problems with
as motor, cognitive, and emotional memo- attention (Shonkoff & Phillips, 2000).
ries. Memories help us to navigate our world Protein deficiency can result in motor and
without having to really think about it (Perry, cognitive delays and impulsive behavior
1999). Children learn to put one foot in front (Pollitt & Gorman, 1994). The social and
of the other to walk. They learn words to behavioral impairments may be more
express themselves. And they learn that a difficult to “repair” than the cognitive
smile usually brings a smile in return. At some impairments, even if the nutritional
point, they no longer have to think much problems are corrected (Karr-Morse &
about these processes—their brains manage Wiley, 1997).
these experiences with little effort because the

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Chronic stress sensitizes neural pathways and

Effects of Maltreatment over-develops certain regions of the brain
involved in anxiety and fear responses, and
on Brain Development often results in the under-development of
other neural pathways and other regions of
“Harry Chugani observes ‘… We can have the brain (Shore, 1997). Children who experi-
individuals who, based on early experiences, are ence the stress of physical or sexual abuse will
in effect “hard-wired” for negative behaviors.’ focus their brains’ resources on survival and
Some neuroscientists consider this an overstate- responding to threats in their environment.
ment; others find it too mild” Children who experience the chronic stress
of neglect—e.g., remaining hungry, cold,
—Shore, 1997, p. 40
scared, or in pain—will also focus their brains’
Babies’ brains grow and develop as they resources on survival. This chronic stimulation
interact with their environment and learn how of the brain’s fear response means that the
to function within that environment. When regions of the brain involved in this response
babies’ cries bring food or comfort, they are are frequently activated. When they are, other
strengthening the neuronal pathways that regions of the brain, such as those involved in
help them learn how to get their needs met, complex thought, can not also be activated
both physically and emotionally. But babies and are therefore not “available” to the child
who do not get responses to their cries, and for learning (Shore, 1997).
babies whose cries are met with abuse, learn
Because the brain ultimately controls all bodily
different lessons. The neuronal pathways that
functions, experiences that alter brain devel-
are developed and strengthened under nega-
opment also alter our bodies’ responses.
tive conditions prepare children to cope in
Studies have shown that “… the overwhelming
that negative environment, and their ability
stress of maltreatment experiences in child-
to respond to nurturing and kindness may be
hood is associated with alterations of biologi-
impaired (Shonkoff & Phillips, 2000).
cal stress systems and with adverse influences
Stress on brain development” (DeBellis, et al., 1999).
One example of the effects of early maltreat-
Brief periods of moderate, predictable stress
ment on brain and body functions involves
are not problematic; in fact, they prepare the
the chemical cortisol. Cortisol is a hormone
child to cope with the general world. The
that helps the body prepare to cope with
body’s survival actually depends upon the
stress through its effects on metabolism and
ability to mount a response to stress (Shonkoff
the immune system (Hart, Gunnar & Cicchetti,
& Phillips, 2000). But prolonged, severe, or
1995). Studies have shown that many infants
unpredictable stress—including abuse and
and children who have been maltreated have
neglect—during a child’s early years is prob-
abnormal secretions of cortisol, indicating that
lematic. The brain’s development can literally
their bodies’ responses to stress have been
be altered by these experiences, resulting in
impaired (Hart, Gunnar & Cicchetti, 1995;
negative impacts on the child’s physical, cog-
Lott, 1998, citing Main, 1996). More research
nitive, emotional, and social growth.
is needed to understand why this occurs and

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what effects this may have on the children’s experience can impact and alter functioning in
emotional and social development, but this such a pervasive fashion” (Perry, 1999, p.3).
information provides some evidence of altered
Chronic stress or repeated traumas can result in
brain activity in maltreated children.
a number of biological reactions. Neurochemical
A key issue in understanding altered brain systems are affected which can cause a cascade
development in children who have been of changes in attention, impulse control, sleep,
maltreated is that the way in which their brains and fine motor control (Perry, 2000a; 2000c).
develop is often a very adaptive response to Chronic activation of certain parts of the brain
their negative environment, but it is maladap- involved in the fear response (such as the hypo-
tive in other environments (Hart, Gunnar & thalamic-pituitary-adrenal [HPA] axis) can “wear
Cicchetii, 1996). If a child lives in a threaten- out” other parts of the brain such as the hip-
ing, chaotic world, his brain will be hyper-alert pocampus, which is involved in cognition and
for danger; his survival may depend on it. But memory (Perry, 2000c). Early experiences of
if this environment persists, and the child’s trauma can also interfere with the development
brain is focused on developing and strength- of the subcortical and limbic systems which
ening its strategies for survival, other strate- can result in extreme anxiety, depression, and
gies may not develop as fully. If a child lives in difficulty forming attachments to other people
a world that ignores him, if he is not provided (Shore, 1997). And chronic activation of the
with appropriate stimulation for growth, his neural pathways involved in the fear response
brain will focus on survival from day to day can create permanent “memories” which shape
and may not fully develop healthy cognitive the child’s perception of and response to his
and social skills (Ounce of Prevention Fund, environment. While this adaptation may be
1996, citing Lieberman & Zeanah, 1995). The necessary for survival in a hostile world, it can
result may be a child who has great difficulty become a way of life that is difficult to change,
functioning when presented with a world even if the environment improves.
of kindness, nurturing, and stimulation. It is
an unfamiliar world to him; his brain has not Hyper-arousal
developed the pathways and the memories to When a child is exposed to chronic, traumatic
adapt to this new world. stress, his brain sensitizes the pathways for the
fear response and literally creates memories
Persistent Fear Response such that his fear response becomes almost
Fear is necessary to our basic survival. We automatic; he doesn’t really think about it. This
must be able to detect threats and respond. is called a state of “hyper-arousal.” His brain
Indeed, the brain is uniquely designed to has adapted to a world that is unpredictable
sense, process, and store threatening informa- and dangerous; it is hyper-vigilant, focused on
tion and to mobilize the body in response to non-verbal cues that may be threatening (Perry,
threats. All parts of the brain and body are 1996). The regions of the brain involved in the
used in this response. “This total neurobio- hyper-arousal response are always “on,” and
logical participation in the threat response is because of this, the child may frequently expe-
important in understanding how a traumatic rience hyperactivity, anxiety, impulsivity, and
sleep problems (Perry, Pollard, Blakely, Baker &

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Vigilante, 1995). Hyper-arousal is most common better to control when it happens. They may
in older children and in males (Perry, Pollard, engage in aggressive, provocative behavior to
Blakely, Baker & Vigilante, 1995). elicit a predictable response (Perry, 1997).
In the state of hyper-arousal, similar to Post
Traumatic Stress Disorder (PTSD), the brain’s Dissociative and Hyper-
alarm system becomes particularly sensitive arousal Responses
to “threatening” environmental cues, and the
child may respond anxiously or aggressively. Dr. Bruce Perry, former head of the Child
The regions of the brain involved in the hyper- Trauma Academy at Baylor College of
arousal response become re-activated when Medicine in Houston, Texas, offers this
the child is exposed to a reminder of the earlier example of dissociative and hyper-arousal
trauma (such as thinking or dreaming about responses in the same child for different
it), to perceived threats (which may not seem events.
threatening to others), and sometimes to gener- “T is a twelve year old girl. From birth
alized reminders (signals) (Perry, Pollard, Blakely, until age five she lived in a household
Baker & Vigilante, 1995). Perry (1997) presents characterized by domestic violence.
an example of an 8-year-old boy who became During this time, she was noted to
extremely agitated—sobbing and hysteri- be quiet, compliant, “tuned out,”
cal—when the staff at his group home refused daydreamed and generally “a good little
to cut up his hot dog before he ate it. The child girl.” She reports little memory of the
had been sexually abused by his father and fighting but her mother describes finding
other men. Foods such as hot dogs, bananas, her in her bed, rocking, with covers over
and popsicles evoked his brain’s fear response, her head after some of the fights in the
and until the “signal” was removed or altered, home. At age 12, her mother re-married
his brain experienced it as a threat. Another but unfortunately, episodes of domestic
example is that of a child who had commit- violence resumed in this household. This
ted an impulsive, violent act and explained it time, however, T was loud, combative,
by saying “I could tell he was going to jump angry and would run away from the
me—he looked me in the eyes” (Perry, 1997, home each time these events took place.
p. 6). In his mind, his brain, the simple act of She was noted to have “attention”
looking him in the eye was perceived as a threat problems at school that turned out to
that required a defensive response. be hypervigilance. Rather than “tuning
Not only may children in a state of hyper- out” and withdrawing into a dissociative
arousal react anxiously or aggressively to shell, this child was sensitized to fighting
perceived threats, they may actually provoke and had dramatic and pronounced
threatening behavior from others in order to hyperarousal during conflict.”
have some control over it. Predictability of ­—Perry, 2000b, p. 8
threat is important (Perry, 1997). Children who
have been victims of unpredictable physical
or sexual abuse learn (consciously or uncon-
sciously) that if abuse is going to happen, it is

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Understanding the Effects of Maltreatment on Early Brain Development www.childwelfare.gov

For example, a girl who has suffered repeated with other people. One of the first priori-
sexual abuse from her father may attempt to ties of an infant is to form an attachment to
seduce a male teacher. She may believe that his primary caregiver (Kraemer, 1992). This
men will invariably try to have sex with her, so relationship not only ­provides the founda-
she tries to control when and with whom. tion for future emotional relationships, it also
provides the base for other learning, because
Dissociation babies and children learn best when they
While hyper-arousal is more common in older feel safe, calm, ­protected, and nurtured by
children and males, dissociation is more their ­caregivers. If the attachment process
common in younger children and in females— is disrupted, as can occur with abusive and
children who often feel or are immobile or ­neglectful caretakers, the child’s brain will
powerless (Perry, Pollard, Blakely, Baker & be more focused on meeting his day-to-day
Vigilante, 1995). Dissociation is characterized needs for survival rather than building the
by first attempting to bring caretakers to help, foundation for future growth.
and if this is unsuccessful, becoming motion-
Much of a child’s emotional development
less (freezing) and compliant and eventually
is rooted in his relationships with his early
dissociating; this is often called the “surren-
primary caregivers. For example, it appears
der” response (Perry, Pollard, Blakely, Baker &
that aggressive, submissive, and frustra-
Vigilante, 1995). People describe children in
tion behaviors may be genetically encoded
a dissociative state as numb, non-reactive, or
(Kraemer, 1992). If relationships with the
“acting like they aren’t there.”
caregivers are positive, the child’s cognitive
Just as children in a state of hyper-arousal structures learn to regulate these emotions
have sensitized neural pathways controlling and behaviors. If the relationships are negative
their response to a threatening environment, or weak, the lower-brain responses become
children in a state of dissociation have sen- dominant and the cognitive regulating struc-
sitized neural pathways that elicit a differ- tures do not develop to their full capac-
ent response. A child in a dissociative state, ity—the young child may not fully develop
when presented with a threat, may “freeze,” the cognitive ability to control his emotions,
both physically and cognitively (Perry, Pollard, nor develop an awareness of others’ emotions
Blakely, Baker & Vigilante, 1995). When an (Kraemer, 1992).
adult asks or tells them to do something, they
One example of a potential effect of poor
don’t respond. If the adult becomes angry
early attachments is impaired “social cog-
and more threatening, the child becomes
nition” (Kraemer, 1992). Social cognition
even more anxious and moves further into full
involves an awareness of oneself in relation to
dissociation (Perry, Pollard, Blakely, Baker &
others and an awareness of the emotions of
Vigilante, 1995).
others. If these abilities are poorly developed,
Disrupted Attachment Process many types of social interactions may be expe-
At the foundation of much of our develop- rienced as stressful—unfamiliar, strange situ-
ment is the concept of “attachment” which ations that are difficult for the child to incor-
refers to the emotional relationships we have porate because he does not have a strong
internal representation (memory) of what is

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happening and how to respond (Kraemer, Global Neglect

1992). Children who have been abused and The term “global neglect” is used when a
neglected often lack empathy and truly do not child has experienced deprivations in more
understand what others feel like when they do than one domain, i.e., language, touch, and
something hurtful. social interaction (Perry & Pollard, 1997).
Children who were adopted from Romanian
Neglect—Lack of Stimulation
orphanages in the early 1990s are often
While chronic abuse or neglect can result in considered to be globally neglected; they
sensitized fear response patterns, neglect had little contact with caregivers and little to
alone also can result in other problems. no stimulation from their environment—little
Although neglect often is thought of as a of anything required for healthy develop-
failure to meet a child’s physical needs for ment. One study found that these children
food, shelter, and safety, neglect also can had significantly smaller brains than the norm,
be a failure to meet a child’s cognitive, emo- suggesting decreased brain growth. (Perry &
tional, or social needs. For children to master Pollard, 1997). (See Exhibit 2.)
developmental tasks in these areas, they need
opportunities, encouragement, and acknowl- This type of severe, global neglect can have
edgement from their caregivers. If this stimula- devastating consequences. The extreme lack
tion is lacking during children’s early years, the of stimulation may result in fewer neuronal
weak neuronal pathways that had been devel- pathways available for learning; genetically
oped in expectation of these experiences may normal children may be at a permanent intel-
wither and die—the children may not achieve lectual disadvantage (Greenough, Black &
the usual developmental milestones. Wallace, 1987). The lack of opportunity to
form an attachment with a nurturing caregiver
For example, babies need to experience during infancy may mean that some of these
face-to-face baby talk and hear countless children will always have difficulties forming
repetitions of sounds in order to build the meaningful relationships with others (Perry,
brain circuitry that will enable them to start 2001a). But these studies also found that time
making sounds and eventually say words and played a factor—children who were adopted
form sentences (Helgeson, 1997). If babies as young infants have shown more recovery
are ignored, if their caregivers do not provide than children who were adopted as toddlers
this type of intense verbal interaction, their (Rutter, et al., 2000).
language development may be delayed. If a
child does not receive kindness as an infant, Pervasive and Long-term Effects
he may not know how to show kindness as an Maltreatment during infancy and early child-
adult. If a child’s cries for attention are ignored hood has been shown to negatively affect
as a toddler, he may not know how to interact early brain development and can have endur-
positively with others later. These capacities ing repercussions into adolescence and adult-
may not fully develop because the required hood. As mentioned earlier, the experiences
neuronal pathways were not activated enough of infancy and early childhood literally provide
to form the “memories” needed for future the organizing framework for the expression of
learning (Greenough, Black & Wallace, 1987). children’s intelligence, emotions, and person-

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Understanding the Effects of Maltreatment on Early Brain Development www.childwelfare.gov

Exhibit 2
“These images illustrate the negative 3-Year-O ld C hildren
impact of neglect on the developing
brain. In the CT scan on the left is
an image from a healthy three year
old with an average head size. The
image on the right is from a three
year old child suffering from severe
sensory-deprivation neglect. This
child’s brain is significantly smaller
than average and has abnormal
development of cortex.”
These images are from studies
conducted by a team of researchers N ormal E xtreme N eglect
© 1997 Bruce D. Perry, M.D., Ph.D., ChildTrauma Academy
from the Child Trauma Academy
(www.ChildTrauma.org) led by Bruce
D. Perry, M.D., Ph.D.

alities. When those experiences are primarily Children who have experienced chronic abuse
negative, children may develop emotional, and neglect during their first few years may
behavioral, and learning problems that persist live in a persistent state of hyper-arousal or
throughout their lifetime, especially in the dissociation, anticipating threats around every
absence of targeted interventions. corner, and their ability to benefit from social,
emotional, and cognitive experiences may be
While some children seem unaffected or mini-
impaired (Perry, 1996). The various regions of
mally affected by their traumatic experiences,
the brain can not grow without being acti-
in reality, it is often the adults around them
vated, and certain regions can not be acti-
who are misreading their cues. These children
vated when others are. To learn and incorpo-
are communicating non-verbally with us, and
rate new information, whether it be a lesson
we need to learn the language and educate
in the classroom or a new social experience,
others who work with children who have been
the child’s brain must be in a state of “atten-
maltreated about this language (Perry, 1999).
tive calm,” a state the traumatized child rarely
Children do not just “get over it.” As they
achieves. It is not uncommon for teachers who
attempt to cope, as their brains adapt to the
work with traumatized children to observe that
negative environments, their true emotional,
the children are really smart, but they do not
behavioral, cognitive, and social potential may
learn easily; they are often diagnosed with
be diminished (Perry, Pollard, Blakely, Baker &
learning disabilities (Perry, 1996). Children
Vigilante, 1995).
who have not been able to develop healthy
attachments with their caregivers, and whose

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early emotional experiences have not laid the be at risk for Sensory Integration Disorder
necessary groundwork for healthy emotional (SID) (Parent Network for the Post-
development, may have a limited capacity Institutionalized Child, 1995).
for empathy (Perry, 1997). The ability to feel
• Children who have been raised in environ-
remorse and empathy are built on experience.
ments that totally disregarded their needs
In the extreme, if a child feels no emotional
for comfort, stimulation, and affection
attachment to any human being, he can not
may be at risk for Reactive Attachment
be expected to feel remorse for hurting or
Disorder (Parent Network for the Post-
even killing someone. Perry (1997) offers the
Institutionalized Child, 1995).
example of a 15-year-old boy who felt no
remorse for having committed murder. The We are learning more about the serious, long-
boy had been neglected and humiliated by term consequences of abuse and neglect on
his primary caretakers as a child. “He is liter- brain development, and subsequent physi-
ally emotionally retarded. The part of his brain cal, cognitive, emotional, and social growth.
which would have allowed him to feel con- What do we do with this information? What
nected to other human beings—empathy— does it mean for biological parents, foster
simply did not develop” (Perry, 1997, p. 4). and adoptive parents, professionals, the child
welfare system, and for society? How can we
The effects of abuse and neglect on the devel-
use this knowledge to improve our interven-
oping brain during children’s first few years
tions with children who have been abused and
can result in various mental health problems.
neglected, and, most importantly, to prevent
For example:
abuse and neglect from occurring? While
• Diminished growth in the left hemisphere these questions may be challenging, this
may increase the risk for depression growing body of knowledge compels us to
(Teicher, 2000). work towards finding the answers.
• Irritability in the limbic system can set the
stage for the emergence of panic disorder
and post-traumatic stress disorder (PTSD) Implications for Practice
(Teicher, 2000).
and Policy
• Smaller growth in the hippocampus and
limbic abnormalities can increase the risk
“The new developments in brain research show
for dissociative disorders and memory
us what children need; our challenge is to ensure
impairments (Teicher, 2000).
that every child receives it.”
• Impairment in the connection between the —Ounce of Prevention Fund, 1996
two brain hemispheres has been linked to
symptoms of attention-deficit/hyperactivity The knowledge we have gained from research
disorder (ADHD) (Teicher, 2000). examining the effects of maltreatment on
brain development can be helpful in many
• Severely neglected children who have been ways. With this information, we are better able
deprived of sensory stimulation—includ- to understand what is happening within the
ing touch, movement, and sound—may

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brains of children who have been abused and practice to provide consistency, repeti-
neglected. In fact, much of this research is pro- tion, nurturance, predictability, and control
viding further, solid evidence for what profes- (returned to the child) to diminish the fearful
sionals and caregivers have been describing nature of the interventions (Wolff & Brandt,
in behavioral, emotional, and psychological 1998). In addition, child welfare systems
terms. We can use this information to improve should provide comprehensive assessments
our systems of care, and to strengthen our for all children as soon as possible to examine
prevention efforts. their physical, cognitive, emotional, and social
development (Committee on Early Childhood,
There has been some encouraging progress in
Adoption and Dependent Care, 2000;
States’ recognition of early brain development
Shonkoff & Phillips, 2000). Accomplishing
research and how this information can be used
these objectives will require the participation
to improve services. In a survey conducted by
of all stakeholders including policymakers;
the Child Welfare League of America in 2000,
family court judges; managers; child welfare
31 States reported that they had reviewed
workers; medical, mental health, and educa-
relevant research findings (CWLA, n.d.). Many
tion professionals; kinship, foster, and adop-
also reported that they had engaged in efforts
tive parents; and the parents and children
to increase awareness about early brain devel-
themselves. Every group must examine its
opment, and that both legislative and policy
contribution to the development of the chil-
changes had occurred to enhance prevention,
dren served by the child welfare system, and
early intervention, and healthy child develop-
strive to provide that contribution in a manner
ment programs (CWLA, n.d.).
that will promote healthy development for
The Child Welfare System each child.
While the goal of the child welfare system is The Role of Professionals
to protect children, many child welfare inter-
One of the first tasks for professionals who
ventions—such as investigation, appearance
work with children who have been maltreated
in court, removal from home, placement in a
is to educate themselves about the effects of
foster home, etc.—may actually reinforce the
maltreatment on early brain development, as
child’s view that the world is unknown, uncon-
well as interventions likely to be effective. For
trollable, and frightening. These experiences
example, “talk” therapy must do more than
can actually contribute to the traumatized
talk if the child is in a persistent hyper-arousal
child’s “catalog” of fearful situations (Wolff &
state; the child’s brain may well be unrespon-
Brandt, 1998). In addition, many child welfare
sive to verbal interactions (Lott, 1998; Perry,
systems in the United States do not provide
1999). According to Dr. Schore, “What will
comprehensive assessments to all children in
get through is tone of voice, demeanor, facial
their care, and therefore the treatments pro-
expressions and a sense of empathy that is
vided may not be the most effective—they
rooted in the early psychobiological attun-
may not accurately target each child’s unique
ement between mother and infant” (Lott,
experience.
1998, p. 3).
As much as possible, the child welfare system
needs to address these deficits and reform

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Professionals who are knowledgeable about group home staff, and some will be adopted.
this issue need to educate others who work While many caregivers have an innate sense
with and care for the children (Comfort, 1997; about how to raise children, familiarity with
Committee on Early Childhood, Adoption the effects of maltreatment on brain devel-
and Dependent Care, 2000; Perry, 1996). opment and the possible manifestations of
Information can be provided to foster parents those effects are not likely to be “common
and other caregivers to help them understand knowledge.”
the effects of maltreatment on children’s brain
It is important for caregivers to have realistic
development, how those early experiences
expectations for the children in their care.
may influence current behavior and function-
Children who have been abused or neglected
ing, and what can be done to help the chil-
may not be functioning at their chronological
dren recover their lost potential. CPS workers,
age in terms of their physical, social, emo-
judges, and teachers also may not be knowl-
tional, and cognitive skills. They may also be
edgeable about these issues; they can benefit
displaying unusual and/or difficult coping
from opportunities to understand the impor-
behaviors. For example, abused or neglected
tance of their contributions to the child’s envi-
children may:
ronment. By working in a coordinated manner,
professionals and caregivers can help to mini- • Be unable to control their emotions and
mize unpredictable, unknown, and frightening have frequent outbursts
experiences and assist the child’s movement
• Be quiet and submissive
along a path of healthy development.
• Have difficulties learning in school
Human service professionals are increas-
ingly receptive to new knowledge about • Have difficulties getting along with siblings
human brain development (Shore, 1997). or classmates
Professionals across disciplines are engaged
• Have unusual eating or sleeping behaviors
in exciting new efforts to rethink the brain and
apply the knowledge and ideas to support • Attempt to provoke fights or solicit sexual
the healthy development and well-being of experiences
children (Shore, 1997). As these efforts begin
• Be socially or emotionally inappropriate for
to offer meaningful information, it must be
their age
translated into policies and practices for the
front-line workers and caregivers in order to • Be unresponsive to affection.
have the most impact on improving child well-
being in child welfare systems. “It is easy for foster parents to become con-
fused, frustrated, and sometimes devastated
The Role of Caregivers from the lack of response and reciprocity to
Many children who have suffered abuse the love, affection, attention, and care they
and neglect are removed from their homes offer” (Comfort, 1997, p. 29). Even caregiv-
by the child welfare system for their safety. ers with the best of intentions can misunder-
These children may be temporarily cared stand a child’s behavior, fashion their response
for by extended family, foster parents, or based on that misunderstanding, and then
wonder why their response was not effective.

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To be more effective in their roles, caregiv- Intensive, early interventions are key to mini-
ers who serve abused and neglected chil- mizing the long-term effects of early trauma
dren could benefit from training and support on children’s brain development (Committee
related to the effects of maltreatment on early on Early Childhood, Adoption and Dependent
brain development. Understanding some Care, 2000). Two studies that have shown this
basic information about the neurobiology impact include the following:
underlying many challenging behaviors may
• Craig Ramey of the University of Alabama
help caregivers shape their responses more
at Birmingham reported that vulnerable
effectively. But while a general understanding
children who received services from 4
is helpful, foster parents and other caregivers
months to 5 years old showed better cog-
need to know the history of their particular
nitive development than those receiving
foster children’s experiences in order to tailor
services from age 5 to age 8; the difference
their approaches (Comfort, 1997). They may
was even more pronounced at age 12 than
need to develop some special skills to cope
at age 8 (Shore, 1997).
with the children’s special needs.
• Rutter, et al. (2000) studied the develop-
In general, children who have been abused
ment of children adopted from Romanian
or neglected need nurturance, stability,
orphanages. When each child was 6 years
predictability, understanding, and support
old, the researchers assessed what propor-
(Committee on Early Childhood, Adoption
tion of the adopted children were function-
and Dependent Care, 2000). They may need
ing “normally.” They found that 69 percent
frequent, repeated experiences of these kinds
of the children adopted before the age of
to begin altering their view of the world from
6 months were functioning normally, 43
one that is uncaring or hostile to one that is
percent of the children adopted between
caring and supportive. Until that view begins
the ages of 7 months and 2 years, and 22
to take hold in the child’s mind, the child may
percent of the children adopted between
not be able to truly engage in a positive rela-
the ages of 2 years and 3½ years.
tionship. And the longer the child lived in the
abusive or neglectful environment, the harder Indeed, many studies have shown the effec-
it will be to convince his brain that his world tiveness of early intervention, but we now have
can change. But one thing we have learned a better understanding of why early interven-
from research is that environment does make tion makes a difference. And taking a neuro-
a difference. Consistent nurturing from care- developmental approach in early intervention
givers who receive training and support may can decrease the “intensity and severity of the
offer the best hope for the children who need response to trauma [which] will decrease the
it most. probability of developing . . . sensitized neural
systems resulting in a persisting hyper-arousal
Intensive, Early Intervention or dissociative symptoms or both” (Perry,
“The brain itself can be altered . . . with appro- Pollard, Blakely, Baker & Vigilante, 1995).
priately timed, intensive interventions” In order to heal a “damaged” or altered brain,
—Shore, 1997, p. 36 interventions must activate those portions
of the brain that have been altered (Perry,

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2000c). Because brain functioning is altered about the effects of alcohol on the develop-
by repeated experiences that strengthen and ing brain of the fetus. An example of a policy
sensitize neuronal pathways, interventions can change might involve expanding family leave
not be constrained to weekly therapy appoint- to allow more parents time off from work to
ments. Interventions must address the totality care for and build an attachment to a newborn
of the child’s life, providing frequent, consis- or adopted child.
tent “replacement” experiences so that the
Prevention efforts also can target children and
child’s brain can begin to incorporate a new
families considered to be “at-risk” of develop-
environment—one that is safe, predictable
ing problems before problems develop (“sec-
and nurturing.
ondary” or “selected” prevention). By the time
Although early interventions show the most a child who has been abused or neglected
promise for significant recovery from abuse comes to the attention of professionals, it is
and neglect, later interventions are not futile. likely that some damage already has been
However, as children get older, recovery from done. Secondary prevention efforts must
lost or altered brain functioning may be slower reach out to at-risk families before this point.
and less complete than recovery attempted There are many home visitation programs that
earlier in the children’s lives (Shore, 1997). But provide services to at-risk families before and
some recovery is certainly possible; while a after the birth of a child—services that support
negative environment may contribute to defi- children’s healthy development—that have
cits, a positive environment can contribute to proven to be successful in preventing future
growth (Teicher, 2000). problems (Ounce of Prevention Fund, 1996,
citing MacMillan, 1994).
Prevention
Many researchers examining the effects of
While early intervention with maltreated
maltreatment on early brain development
children can minimize the effects of abuse
agree that this knowledge should be used
and neglect, it is equally or even more impor-
to expand and strengthen prevention efforts
tant to prevent problems before they start.
(Ounce of Prevention Fund, 1996; Perry, 1996;
“Clearly,… the costs (in human suffering,
Shonkoff & Phillips, 2000; Teicher, 2000).
loss of potential, and real money) of trying
Without expanded prevention, our society will
to repair, remediate, or heal these children is
continue to fight an uphill battle to “repair”
far greater than the costs of preventing these
the damage that has been done to thou-
problems by promoting healthy development
sands of children who have been abused and
of the brain during the first few years of life”
neglected. Society can not continue to ignore
(Ounce of Prevention Fund, 1996, p. 3).
the laws of biology (Perry, 1996); the more
Prevention efforts can target the general we learn about early brain development, the
population (“primary” or “universal” preven- more responsibility we have to act on that
tion), educating the public and changing knowledge.
policies to promote healthy brain develop-
ment. For example, one prevention strategy
might involve expanding education efforts
that target women who may become pregnant

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• Bring together biological and psychosocial

Summary and Research researchers to bridge the divide between
these fields.
Recommendations
• Understand more about the contribution of
genetics to the development process that
In 1999, approximately 826,000 children were
may explain susceptibility to risk and capac-
determined to be victims of abuse and/or
ity for resilience.
neglect (U.S. Department of Health and
Human Services, 2001), but it is likely that • Understand more about how biological
many more children are actually suffering processes interact with the environment to
under adverse conditions. Each one of these affect behavior.
children already may have suffered damage
• Fund collaborative research projects to
to their growing brains. Their brains may be
study the effect of environment on brain
locked into perceiving the world as a cold or
development to learn more about what
dangerous place. They may have great dif-
are deprived, sufficient, and enriched
ficulties responding to the caring concern of
environments.
others. Because their brains’ energies have
been focused on survival, on meeting their • Direct program-based research and evalu-
own needs, these children may not have ation to document and test interventions
developed the physical, cognitive, social, to ensure full effectiveness, and use knowl-
and emotional capabilities one would expect edge from ineffective programs to spur
of them. But their future, and the futures more experimentation (Shonkoff & Phillips,
of countless others to come, need not be 2000).
so bleak.
While we continue to study and learn more
One lesson we have learned from the research about the effects of maltreatment on early
on brain development is that environment has brain development, we can begin to use the
a powerful influence on development. Stable, knowledge that is already available. We can
nurturing caregivers and knowledgeable, use this knowledge to strengthen our preven-
supportive professionals can have a signifi- tion and intervention strategies, our support
cant impact on these children’s development. of caregivers, and our commitment to provide
And using this growing body of knowledge in all children with the nurturance and stimulation
prevention efforts can potentially reduce the they need to grow up healthy and happy.
number of children who will require “repara-
tive” work.
There is still much to learn, however. Some
of the recommendations from the National
Academy of Sciences, Committee on
Integrating the Science of Early Childhood
Development include:

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