Book Reviews‎ > ‎

Book Review - The Boy Who Was Raised As a Dog and Other Stories from a Child Psychiatrist’s Notebook

The Boy Who Was Raised As a Dog and Other Stories from a Child Psychiatrist’s Notebook: What Traumatized Children Can Teach Us About Loss, Love and Healing

by Bruce D. Perry, M.D., Ph.D., and Maia Szalavitz

Basic Books: New York, NY, 2007. ISBN-10: 0465056520; ISBN-13: 978-0465056521 (hardcover). $26.00. 288 pages.

Reviewed by Doni Whitsett, Ph.D., LCSW

The Boy Who Was Raised as a Dog reflects the culmination of knowledge gained in Dr. Bruce Perry’s almost 25 years of working with traumatized children. Each chapter of the book represents another step in the development of a treatment model he refers to as neurosequential: an integration of strategies that address both the physiological elements and  the psychological aspects of trauma. In the process of developing this approach, Dr. Perry had many teachers—a foster mother named Mama P. who, unsophisticated though she was, probably taught him the most valuable lesson of all, the value of physical affection and stimulation in the healing of unspeakable trauma. The children themselves were his greatest teachers—through their courage to trust him and work with him despite previous failed attempts by mental health professionals and betrayal by adults. The subtitle of the book, What Traumatized Children Can Teach Us About Loss, Love and Healing, acknowledges the children’s collective influence.

Since the 1980s, Perry’s work has taken him from Chicago to Texas to Canada. He is a founding member and Senior Fellow of the Child Trauma Academy in Houston, Texas (www.ChildTrauma.org) where he has treated hundreds of maltreated children over the past 15 years. He is also the Provincial Medical Director in Children’s Mental Health for the Alberta, Canada Mental Health Board.

Tina, Perry’s first child patient, aged 7, taught him about the enduring effects of early experience when neural networks are first forming. As Donald Hebb so aptly put it, “neurons that fire together wire together”; and when a child’s earliest experiences with men are sexualized, the neurons that fire when she is in the presence of a man are sexual ones. She learns—that is, her memories instruct her, that being seductive and sexual are the expected ways to relate to men in the world. And so it was that during the first 5 minutes of her first therapy session with Dr. Perry, this patient crawled into his lap (“ ‘What a sweet child,’ ” he thought”) and attempted to unzip his fly (p. 7).

The book is written for both lay and professional audiences, not an easy balance to achieve. The neurobiological information is especially well-crafted in that, despite the technical information, it is easy to understand. Apparently, the collaboration between Perry, a researcher, clinician, and educator, and Szalavitz, a journalist specializing in health and science, makes for good literary and academic chemistry.

However, to apply the adjective of “enjoyable” to this book would not quite be accurate, given the accounts of unspeakable horror described within its pages. Personally, I could read only a few chapters at a sitting without feeling overstimulated. Nevertheless, most of the stories are stories of success—“of hope, survival, and triumph” (p. 3); otherwise, one could neither get through the book nor continue the work of trauma recovery.

Perry’s journey on the road to becoming an international expert on child trauma began in the 1980s when little was known about the immediate effects of stress on the brain and its subsequent consequences. Children were considered “resilient” and thought to easily “bounce back” from even terrible experiences, partly because they adaptively learned to present in socially acceptable ways that enabled them to fly under the radar of well-intentioned but clueless adults. However, internally they were suffering. Their development was delayed, sometimes permanently, and their futures were in jeopardy. Findings from neuroscience had not yet filtered down to the clinical level in what is now termed “translational science.” There is typically a 20-year gap in that process (although, with the Internet, this gap is likely to shrink).

Perry began to question the “bouncing back” theory in his early training as he explored the effects of stress on baby animals. Noting that “even seemingly minor stress during infancy [appeared to] have a permanent impact on the architecture and chemistry of the brain and, therefore, on behavior…” (p. 1), he questioned why the same would not hold true for humans. Contrary to the rationalization that children would be unaffected by negative early experiences, Perry’s investigations showed that children are not less, but more affected by these experiences than baby animals are.

The brain is experience dependent. We are born with 100 billion neurons (brain cells), but the synaptic connections that join these brain cells together are not formed until the environment in which the child lives gives instructions about which neurons should wire together for easy and fast communication. The more often an event is experienced, the stronger that neural network becomes. In this way, young children are socialized into the accepted ways of their culture.

The problem comes in when neural “instructions” are contrary to the values of the larger society, such as in the case of Tina, whose earliest patterned, repetitive experiences resulted in body memory of how to be with men. The brain develops associations—that is, the visual cortex associates certain images with the other neurons that are activated at the time. So when one part of the association gets activated, the other parts follow. With repeated activation, these associations become stronger and less permeable to change. As an example, Tina was a child who had been raped and sodomized by a 16-year-old male neighbor over a prolonged period of time, and who had no loving male figure to counterbalance these experiences. Consequently, Tina associated the male image with fear, danger, pain, and sexual arousal. At the time she was referred to Perry, she had been “acting out” aggressively and sexually in school.

Perry also notes the effects of stress on the normal stress response. Designed to alert us when danger is present and prepare the body for flight or fight, the normal stress response obviously has survival value. However, if chronic stress occurs, the body remains in a constant state of preparedness. The hormones that flood the body and brain under stress might be helpful in the short run, but they are damaging in the long run, resulting in burnt-out synaptic connections, illnesses (e.g., heart disease), and psychological problems (e.g., aggression, depression).

The title chapter, The Boy Who Was Raised As a Dog, is not as bad as it sounds at first, conjuring up as it does images of feral children raised in the woods by wild dogs. Justin, a 6-year-old, actually had had a fairly positive early first year with a grandmother who loved him dearly. Unfortunately, when he was 11 months old, she died. As a result of losing both his mother (a 15-year-old who left him permanently with her mother when he was two months of age) and his grandmother during his first year of life, Justin’s behavior became very difficult. The caregiver, grandmother’s live-in boyfriend, a well-meaning but ignorant man in his late sixties, had no idea how to take care of a child, let alone a difficult one. His only experience taking care of vulnerable creatures was as a dog breeder. Although the man fed and clothed Justin, he rarely spoke to him, never held or played with him, and kept him in a dog cage like he did his other charges. With only the other dogs as companions, Justin’s speech, not to mention his other social skills, never developed. His brain began to atrophy. All attempts to help him were naively based upon a medical diagnosis of encephalopathy, or shrinking of the brain. No one thought to inquire about his home life or to take a developmental history (p. 128). Only through the interventions of the neurosequential therapy did he improve and go on to lead a productive life.

Best known to the regular readers of this journal is Perry’s work with the Branch Davidian children, which he recounts in chapter 3: Stairway to Heaven. “The seeds of a new way of working with traumatized children were sown in the ashes of Waco,” Perry concludes (p. 80). In 1993 he was asked to consult with the agencies that were taking care of the Waco children. These dozen or so children had been sent out of the compound before the conflagration started, leaving behind mothers, fathers, siblings, and playmates, who died at the hands of the “Babylonians,” as David Koresh had predicted. These “infidels” arrived in the form of the Bureau of Alcohol, Tobacco, and Firearms. The assumed one-time consultation turned into a six-week experience, from which Perry learned much about traumatized children. Based on his follow-up interviews over a period of 14 years, Perry believes that the experience has left its mark on all of them. However, not surprisingly, the ones who have done best were those who were subsequently raised in loving homes; they have gone on to college, careers. and families of their own. Others were not so lucky and have lived lives of chaos and disorganization. The “take home” message of this chapter is that “people, not programs, change people” (p. 80).

The rationale behind the neurosequential treatment model can best be described in Perry’s own words: “These children need patterned, repetitive experiences [in a safe environment] appropriate to their developmental needs, needs that reflect the age at which they’d missed important stimuli or had been traumatized, not their current chronological age” (p. 138). The brain develops in a predictable sequential order, so damage at a particular time will result in damage to that part of the brain that is developing at that time. By observing the child’s behavior and symptoms, the Perry group attempts to identify “the areas of the brain that have sustained the most damage, and then target their interventions appropriately” (p. 139).

The earliest sensory pathways are those involving touch, so children with early neglect often can’t stand to be touched. Thus, the first stage of treatment often involves development of these pathways of touch through the use of massage therapy. Next in the sequence, rhythm is addressed. Found to be important in regulating homeostatic states—heart beats, breathing, and so on—the normal rhythmic movements of more typical parents, such as rocking a crying child, were absent in the histories of neglected children. Without these early experiences, the developing infant brain does not learn to regulate itself; this lack results in awkward gaits and other uncoordinated movements. To assist the development of the rhythm of the body, music and movement classes are prescribed. Next in the sequence is socialization—that is, teaching skills such as eye contact that enable a child to live appropriately, and more joyfully, in his/her world. Subsequent levels of the model include more traditional therapeutic interventions, such as play and talk therapy. The book is filled with other therapeutic insights for mental health professionals, especially those who work with children.

This is a very human book; it brings to life the data that has been accumulating over the past 15 years regarding the neurobiological effects of trauma and child maltreatment. It confirms clinical wisdom that “relationships matter” (p. 80). As important as oxygen, relationships provide the necessary ingredients for the soul to sustain itself. An infant brain requires a loving adult brain to nurture it; otherwise it will wither and die, maybe not always physically but almost assuredly emotionally. This book is a must read for all mental health professionals, as well as for parents who are the guardians of little spirits.