CerebrumThe Dana Forum on Brain Science

Volume 2 ■ Number 4 ■ Fall 2000

Cerebrum

©2000 Dana PressThe Dana Foundationwww.dana.org

About the Author:Martin H. Teicher, M.D., Ph.D., directs the Developmental Biopsychiatry ResearchProgram and is chief, Laboratory of Developmental Psychopharmacology, atMcLean Hospital. His recent studies have been of the neurobiological effects ofchildhood mistreatment and the neurobiology of attention deficit/hyperactivity disorder.

A R T I C L E

Wounds That Time Won’t Heal: The Neurobiology of Child AbuseMartin H. TeicherNeuropsychologist Teicher reveals the alarming connections scientists are discovering betweenchild abuse—even when it is psychological, not physical—and permanent debilitating changesin the brain that may lead to psychiatric problems. The discoveries are a wake-up call for oursociety, but they may also hold hope for new treatments for abused children and the adults thatthey become.

We easily understand how beating a childmay damage the developing brain, but whatabout the all-too-common psychological abuseof children? Because the abuse was not physi-cal, these children may be told, as adults, thatthey should just “get over it.”

But as developmental neuropsychiatristMartin H. Teicher reveals, scientists are dis-covering some startling connections betweenabuse of all kinds and both permanent debil-itating changes in the brain and psychiatricproblems ranging from panic attacks to post-traumatic stress disorder. In these surprisingphysical consequences of psychological trauma,Teicher sees not only a wake-up call for oursociety but hope for new treatments.

We know that the abuse orneglect of children is tragicallycommon in America today.

Nor are most of us surprised when studiespoint to a strong link between the physical,sexual, or psychological maltreatment of children and the development of psychi-atric problems. To explain how such problems come about, many mental healthprofessionals resort to personality theoriesor metaphors. Perhaps the child’s adaptive or protective mechanisms have become

by Martin H. Teicher, M.D., Ph.D.

Wounds That Time Won’t Heal:The Neurobiology of Child Abuse

counterproductive or self-defeating in theadult. Perhaps childhood abuse hasarrested psychosocial development, leaving

a “wounded child” within the adult.Although such explanations may offer gen-uine insight and may support patients intherapy, too often they instead minimizethe impact of early abuse. They make iteasy to reproach the victims, to say, in somany words, “Get over it.”

Research on the effects of early mal-treatment, including the work of my colleagues and myself at McLean Hospitalin Belmont, Massachusetts, appears to tell a different story: that early maltreatment,even exclusively psychological abuse, hasenduring negative effects on brain develop-ment. We see specific kinds of brain abnor-malities in psychiatric patients who wereabused as children. We are also beginningto understand how these abnormalities mayaccount directly for the personality traitsand other symptoms that patients manifest.

With The Etiology of Hysteria (1896),Sigmund Freud first introduced the topic of childhood sexual abuse in a scientificcontext. He was convinced that, as children,many of his patients had been sexuallyabused by their parents, older siblings, or

The Dana Forum on Brain Science

other relatives. Furthermore, he claimed,based on his new analytical method, thattheir hysterical and neurotic symptomscould be traced directly to repressed memo-ries of that early abuse. This hypothesismarked the birth of psychoanalysis. Freudlater retreated from this theory, though,refusing to believe that childhood abusecould be as prevalent as he had initiallyclaimed. He evolved the more complex theorythat “memories” of early sexual abuse were merely repressed childhood fantasies.This theory has so swayed psychiatry foralmost a century that it has largely blindedus to the frequency of real abuse in psychi-atric patients’ childhoods and to the role ofabuse in psychopathology.

Physical abuse of children by their par-ents remained a hidden problem until 1962,when C. Henry Kempe published The Bat-tered Child Syndrome, and an avalanche ofpublicity led to the enactment of child abusereporting laws. During the 1970s, casereports of sexual abuse and incest appearedwith increasing frequency in medical litera-ture. By the 1980s, scientifically valid studiesof the incidence and consequences of child-hood sexual abuse were being published.

Today, episodes of serious neglect and physical abuse are featured regularly in

the news, constantly reminding us of thehorrifying cruelty adults inflict on children.In separate surveys in San Francisco, Los Angeles, and Canada, and of collegestudents in New England and Texas, thepercentage of women reporting sexualabuse during childhood ranged from 19 to45. The medical literature is replete withresearch on this problem; clinicians, super-sensitized to it, increasingly suggest thatchildhood abuse lies behind a patient’sproblem, even in the absence of direct evidence. Despite occasional hysteria andmisuse of the diagnosis, however, the problem is all too real.

It is our hope that as we identify thespecific physiological pathways by whichabusive experiences alter brain develop-ment, our society will take more seriouslythe challenge of uprooting the violenceagainst the children in our midst.

A HARVEST OF PSYCHIATRIC DISORDERS

Physical, sexual, and psychological traumain childhood may lead to psychiatric diffi-culties that show up in childhood, adoles-cence, or adulthood. The victim’s anger,shame, and despair can be directed inwardto spawn symptoms such as depression,anxiety, suicidal ideation, and post-traumat-ic stress, or directed outward as aggression,impulsiveness, delinquency, hyperactivity,and substance abuse.1

Childhood trauma may fuel a range of persistent psychiatric disorders. Oneis somatoform disorder (also known as psychosomatic disorder), in which patientsexperience physical complaints with no discernible medical cause. Another is panic

Episodes of serious neglect and

physical abuse are featured

regularly in the news, constantly

reminding us of the horrifying

cruelty adults inflict on children.

Cerebrum

disorder with agoraphobia, in whichpatients experience the sudden, acute onsetof terror and may narrow their range ofactivities to avoid being outside, especiallyin public, in case they have an attack.

More complex, difficult-to-treat disorders strongly associated with child-hood abuse are borderline personality disorder2 and dissociative identity disorder3

Someone with borderline personality disor-der characteristically sees others in black-and-white terms, first putting them on apedestal, then vilifying them after some perceived slight or betrayal. Such peoplehave a history of intense but unstable rela-tionships, feel empty or unsure of theiridentity, often try to escape through sub-stance abuse, and experience self-destructiveimpulses and suicidal thoughts. They areplagued by anger, most often directed atthemselves.

In dissociative identity disorder, formerly called multiple personality disorder(the phenomenon behind Robert LouisStevenson’s “Dr. Jekyll and Mr. Hyde”), at

least two seemingly separate people occupythe same body at different times, each withno knowledge of the other. This can beseen as a more severe form of borderlinepersonality disorder. In borderline personal-ity disorder, there is one dramaticallychangeable personality with an intact mem-ory, as opposed to several distinct personali-ties, each with an incomplete memory. People with dissociative identity disorderhave two or more (on average, eight to fifteen) personalities or personality frag-ments that control their behavior at different times. Often there is a passive,depressed primary identity who cannotremember personal history as fully as canthe other more hostile, protective, or controlling identities.

Post-traumatic stress disorder (PTSD)afflicts some people who have undergone atraumatic event involving serious injury or a threat to life or limb. Initially identified incombat veterans, PTSD seems to result aswell from natural disasters, child abuse, andother devastating experiences. People withPTSD keep re-experiencing the traumaticevent in waking life or in dreams, and theyactively avoid situations that might bringback memories of the trauma. They mayalso suffer a general numbing of theirresponsiveness, show diminished interest insignificant activities, restrict the range oftheir emotions, or have feelings of detach-ment or estrangement from others. Finally,they may also experience increased arousal(such as difficulty falling or staying asleep),irritability or outbursts of anger, difficultyconcentrating, hyper vigilance, and an exaggerated startle response.

Initially identified in combat veterans,

PTSD seems to result as well from

natural disasters, child abuse, and

other devastating experiences.

People with PTSD keep re-experiencing

the traumatic event in waking

life or in dreams, and they actively

avoid situations that might bring

back memories of the trauma.

The Dana Forum on Brain Science

ABUSE AND THE DEVELOPING

HUMAN BRAIN

For a century or more, scientists have hotly contested the relative importance ofexperience versus genetic endowment in thedevelopment of the brain and behavior. Weknow now that our genes provide the foun-dation and overall structure of our brain,but that its myriad connections are sculptedand molded by experience. Based onanimal studies, scientists have long believed that early deprivation or abuse may result in neurobiological abnormalities, but untilrecently there has been little evidence forthis in humans.

Then, in 1983, A. H. Green and hiscolleagues suggested that many abused children evidenced neurological damage,even without an apparent or reported headinjury. Interestingly, although minor neuro-logical disturbances and mild brain-waveabnormalities were more common in children who had been abused than in thosewho had not, Green and his colleagues didnot believe that the abuse had caused them.Instead, they saw these neurological distur-bances as a possible additional source oftrauma, amplifying the damaging impactof an abusive environment. In 1979, R. K.Davies reported that in a sample of 22

patients involved as a child or as theyounger member in an incestuous relation-ship, 77 percent had abnormal brain wavesand 36 percent had seizures. In Davies’sinterpretation, however, these children weremore vulnerable to being sexually abusedby family members because of their neuro-logical handicap.

My hypothesis is that the trauma ofabuse induces a cascade of effects, includingchanges in hormones and neurotransmittersthat mediate development of vulnerablebrain regions. Testing this hypothesis inhumans is difficult because abuse is notalways a random act. If we observe an asso-ciation between a history of abuse and the presence of a physical abnormality, theabuse may have caused that abnormality.But it is also possible that the abnormalityoccurred first and elevated the likelihood of abuse, or that the abnormality ran in thefamily and led to more frequent abusivebehavior by family members or other relatives.To try to sort out these competinghypotheses, we conducted studies of analo-gous early stress in animals, where thepotentially confusing elements can be care-fully controlled. Observing parallel out-comes in animals and people has bolsteredour belief that trauma causes brain damage,not the other way around.

A CONSTELLATION OF ABNORMALITIES

Our research (and that of other scientists)delineates a constellation of brain abnor-malities associated with childhood abuse.There are four major components:

Limbic irritability, manifested bymarkedly increased prevalence of symptoms

Observing parallel outcomes in

animals and people has

bolstered our belief that trauma

causes brain damage, not the

other way around.

Cerebrum

suggestive of temporal lobe epilepsy (TLE)and by an increased incidence of clinicallysignificant EEG (brain wave) abnormalities.

Deficient development and differentiationof the left hemisphere, manifested throughoutthe cerebral cortex and the hippocampus, whichis involved in memory retrieval.

Deficient left-right hemisphere integration,indicated by marked shifts in hemisphericactivity during memory recall and byunderdevelopment of the middle portionsof the corpus callosum, the primary pathwayconnecting the two hemispheres.

Abnormal activity in the cerebellarvermis (the middle strip between the twohemispheres of the brain), which appears toplay an important role in emotional andattentional balance and regulates electricalactivity within the limbic system.

Let us look briefly at the main evidencefor each of these abnormalities.

Epilepsy-Like Symptoms

People with temporal lobe epilepsy (TLE)—.25 percent to .5 percent of the U.S. population—have seizures in the temporalor limbic areas of the brain. Because theseareas constitute a sizable, varied part of thebrain, TLE has a veritable catalog of possiblesymptoms, including sensory changes suchas headache, tingling, numbness, dizziness,or vertigo; motor symptoms such as staringor twitching; or autonomic symptoms such as flushing, shortness of breath, nausea,or the stomach sensation of being in an elevator. TLE can cause hallucinations or illusions in any sense modality. Commonvisual illusions are of patterns, geometricshapes, flashing lights, or “Alice-in-Wonder-

landlike” distortions of the sizes or shapesof objects. Other common hallucinationsare of a ringing or buzzing sound or repeti-tive voice, a metallic or foul taste, anunpleasant odor, or the sensation of some-thing crawling on or under the skin. Feelingsof déjà vu (the unfamiliar feels familiar) or jamais vu (the familiar feels unfamiliar)are common, as is the sense of being watched

or of mind-body dissociation—the feelingthat one is watching one’s own actions as adetached observer. Emotional manifestationsof temporal lobe seizures usually occur suddenly, without apparent cause, and ceaseas abruptly as they began; they include sadness, embarrassment, anger, explosivelaughter (usually without feeling happy),serenity, and, quite often, fear.4

TLE is difficult to diagnose becauseits symptoms can mimic those of other psychiatric and nonpsychiatric illnesses. Thecharacteristic electrical discharge of TLEcan be observed only in an electroen-cephalogram (EEG) during a seizure that isclose enough to the brain’s surface to bepicked up by scalp electrodes. Without this

Emotional manifestations of

temporal lobe seizures usually occur

suddenly, without apparent cause,

and cease as abruptly as they began;

they include sadness, embarrassment,

anger, explosive laughter (usually

without feeling happy), serenity,

and, quite often, fear.

The Dana Forum on Brain Science

objective EEG data, a diagnosis must be based on the frequency and severity ofsymptoms and the ruling out of other likelycauses of those symptoms.

To explore the relationship betweenearly abuse and dysfunction of the tem-porolimbic system, we devised the LimbicSystem Checklist-33 (LSCL-33), which calibrates the frequency with which patientsexperience symptoms of temporolimbicseizures.5 We studied 253 adults who cameto an outpatient mental health clinic for psy-chiatric assessment; slightly more than halfreported having been abused physically, sex-ually, or both. Compared to patients whoreported no abuse, average LSCL-33 scoreswere 38 percent greater in the patients withphysical (but not sexual) abuse, and were 49percent greater in the patients with sexual(but not other physical) abuse. Patients whoacknowledged both physical and sexualabuse had average scores 113 percent greaterthan patients reporting no abuse. Males andfemales were similarly affected by abuse.

As we expected, abuse before age 18,when the brain is still rapidly developing,had a greater impact on limbic irritabilitythan later abuse. Patients physically or sexually abused after age 18 had scores notsignificantly different from nonabusedpatients. Patients with both physical andsexual abuse, however, were strongly affect-ed regardless of when the abuse occurred,and those first abused after age 18 werealmost as affected as those first abused earlier.

Brain Wave Abnormalities

Our second study tried to ascertain whetherchildhood physical, sexual, or psychological

abuse was associated with specific evidenceof neurobiological abnormalities. Wereviewed the records of 115 consecutiveadmissions to a child and adolescent psychi-atric hospital to search for a link betweendifferent categories of abuse and evidenceof abnormalities in brain-wave studies. Wefound clinically significant brain-wave abnor-malities in 54 percent of patients with a historyof early trauma but in only 27 percent ofnonabused patients. Among patients whohad been abused, abnormal EEG findingswere observed in 43 percent of those withpsychological abuse; 60 percent of the sample with a reported history of physicalabuse, sexual abuse, or both; and 72 percentof the sample in which serious physical or sexual abuse had been documented. Theoverall prevalence of abnormal EEG studiesin patients with a significant history ofabuse or neglect was the same for boys andgirls and for children and adolescents.

The salient specific difference betweenabused and nonabused patients was in left-sided EEG abnormalities. In the nonabusedgroup, left-sided EEG abnormalities wererare, whereas in the abused group theywere much more common, and more thantwice as common as right-sided abnormali-ties. In the psychologically abused group,all the EEG abnormalities were left-sided.

To dig deeper into the possibility that abuse may affect development of theleft hemisphere, we looked for evidence of right-left hemispheric asymmetries in theresults of neuropsychological testing. Wecompared patients’ visual-spatial ability(predominantly controlled by the righthemisphere) to their verbal performance

Cerebrum

(predominantly controlled by the left hemisphere). In the nonabused group,left-hemisphere deficits were about twice asprevalent as right-hemisphere deficits, but in patients with physical, sexual, or psychogical abuse, left-sided deficits were more than six times as prevalent as right. In patients with a history of psychologicalabuse, left-hemisphere deficits were eighttimes as prevalent as right-sided deficits.This corroborated our hypothesis that abuseis associated with an increased prevalence of left-sided EEG abnormalities and of left-hemisphere defects in neuropsycho-logical testing.

Problems on the Left

In order to investigate the effects of child-hood trauma on development of the lefthemisphere, we then used a sophisticatedquantitative method of analyzing EEG thatprovides evidence about the brain’s structure.7

In contrast to conventional EEG, whichreveals brain function, EEG coherence provided information about the nature ofthe brain’s wiring and circuitry. In general,abnormally high levels of EEG coherenceare evidence of diminished development ofthe elaborate neuronal interconnections inthe cortex that would process and modifythe brain’s electric signals.

We used this technique to study 15child and adolescent psychiatric inpatientswho had a confirmed history of intensephysical or sexual abuse compared with 15healthy volunteers. Patients and volunteerswere between 6 and 15 years of age, right-handed, and with no history of neurologicaldisorders or abnormal intelligence. Measuring

EEG coherence indicated that the left cortex of the healthy controls was moredeveloped than the right cortex, which isconsistent with what is known about theanatomy of the dominant hemisphere. The abused patients, however, were notablymore developed in the right than the leftcortex, even though all were right-handed.The right hemisphere of abused patients haddeveloped as much as the right hemisphereof the controls, but their left hemisphereslagged substantially, as though arrested intheir development.

This abnormality in the cortex showedup regardless of the patient’s primary diag-nosis, which could be depression, PTSD, orconduct disorder. It extended throughoutthe entire left hemisphere, but the temporalregions were most affected. This finding ofleft cortex underdevelopment is consistentwith our earlier finding that abused patientshad increased left-hemisphere EEG abnor-malities and left-hemisphere (verbal) deficitsas shown by neuropsychological testing.

Affects on the Hippocampus

The hippocampus, located in the temporallobe, is involved in memory and emotion.Developing very gradually, the hippocampusis one of the few parts of the brain thatcontinues to produce new cells after birth.Cells in the hippocampus have an unusuallylarge number of receptors that respond tothe stress hormone cortisol. Since animalstudies show that exposure to high levels ofstress hormones like cortisol has toxiceffects on the developing hippocampus, this brain region may be adversely affectedby severe stress in childhood.

The Dana Forum on Brain Science

negative emotions. We wondered, then,whether abused children might store theirdisturbing childhood memories in the right hemisphere, and whether recollectingthese memories would activate the righthemisphere more than it is activated inthose without such a history.

To test this hypothesis, we measuredhemispheric activity in adults during recallof a neutral memory, then during recall of an upsetting early memory.10 Those witha history of abuse appeared to use predomi-nantly their left hemispheres when thinkingabout neutral memories and their rightwhen recalling an early disturbing memory.Those in the control group had a moreintegrated bilateral response.

A Deficient Pathway

Since childhood abuse (as we found) isassociated with diminished right-left hemi-sphere integration, we wanted to knowwhether there was some deficiency in theprimary pathway connecting the two hemi-spheres, the corpus collosum. We found in boys who had been abused or neglectedthat the middle portions of the corpus collosum were significantly smaller than inthe control groups. Furthermore, in boys,neglect exerted a far greater effect than any other type of maltreatment; physicaland sexual abuse exerted relatively minimaleffects. In girls, however, sexual abuse was a more powerful factor, associated witha major reduction in size of the middle por-tions of the corpus collosum. These resultswere independently replicated by MichaelDe Bellis at the University of Pittsburgh,and the effects of early experience on the

J. Douglas Bremner and his colleaguesat Yale Medical School compared magneticresonance imaging (MRI) scans of 17 adultsurvivors of childhood physical or sexualabuse, all of whom had PTSD, with 17healthy subjects matched for age, sex, race,handedness, years of education, body size,and years of alcohol abuse.8 The left hip-pocampus of abused patients with PTSD was12 percent smaller than the hippocampus ofthe healthy controls, but the right hippocam-pus was of normal size, as were other brainregions, including the amygdala, caudatenucleus, and temporal lobe. Not surprisingly,given the role of the hippocampus in memory, these patients also had lower verbalmemory scores than the nonabused group.

Murray Stein and his colleagues alsofound left hippocampal abnormalities in women who had been sexually abused aschildren. Their left hippocampal volumewas significantly reduced, but the right hip-pocampus was relatively unaffected. Fifteenof the 21 sexually abused women hadPTSD; 15 had a dissociative disorder. Theysuffered a reduction in the size of the lefthippocampus proportionate to the severityof their symptoms.

These studies suggest that child abusemay alter development of the left hippocampuspermanently and, in so doing, cause deficitsin verbal memory and dissociative symptomsthat persist into adulthood.

Shifting from Left to Right

The left hemisphere is specialized for per-ceiving and expressing language, the righthemisphere for processing spatial informationand also for processing and expressing

Testing this hypothesis, we found thatthe vermis seems to become activated tocontrol— and quell—electrical irritability inthe limbic system. It appears less able to dothis in people who have been abused. If,indeed, the vermis is important not only forpostural, attentional, and emotional balance,

but in compensating for and regulatingemotional instability, this latter capacity maybe impaired by early trauma. By contrast,stimulation of the vermis through exercise,rocking, and movement may exert additionalcalming effects, helping to develop the vermis.

ATTENTION, HORMONES, AND THE BRAIN

We know that through their effects on hormone levels, early experiences influencebrain development. Fifty years ago, SeymourLevine and Victor Denenberg showed thatsmall alterations in their environment led to lasting changes in rats’ development,behavior, and response to stress. Somethingas seemingly inconsequential as five minutesof human handling during a rat’s infancy produced lifelong beneficial changes. Wenow understand through the reserach effortsof Michael Meany and Paul Plotsky that theeffects of brief handling were highly beneficialand were due to increased maternal attention.Those pups whose mothers spontaneously

Cerebrum

development of the corpus collosum havebeen confirmed by research in primates.

Calming Irritability in the Brain

Decades ago, Harry Harlow compared mon-keys raised with their mothers to monkeysraised with wire or terrycloth “surrogatemothers.” Monkeys raised with the surro-gates became socially deviant and highlyaggressive adults. Building on this work,other scientists discovered that these conse-quences were less severe if the surrogatemother swung from side to side, a type ofmovement that may be conveyed to thecerebellum, particularly the part called thecerebellar vermis, located at the back of thebrain, just above the brain stem. Like thehippocampus, this part of the brain developsgradually and continues to create new neu-rons after birth. It also has an extraordinarilyhigh density of receptors for stress hormone,so exposure to such hormones can markedlyaffect its development.

New research suggests that abnormal-ities in the cerebellar vermis may beinvolved in psychiatric disorders includingdepression, manic-depressive illness, schizophrenia, autism, and attention-deficit/ hyperactivity disorder. We havegone from thinking of the entire cerebel-lum as involved only in motor coordinationto believing that it plays an important rolein regulating attention and emotion. Thecerebellar vermis, in particular, seems to be involved in the control of epilepsy orlimbic activation. Couldn’t maltreating children produce abnormalities in the cerebellar vermis that contribute to laterpsychiatric symptoms?

Something as seemingly inconse-

quential as five minutes of

human handling during a rat’s

infancy produced lifelong

beneficial changes.

The Dana Forum on Brain Science

lick and groom them the most (about one-third in a laboratory setting) displaythe same benefits as the rats with the humanhandling. By contrast, long isolation pro-duces stress that has a deleterious effect onbrain and behavior development.

If we assume that lots of attention,licking, and grooming are the natural stateof affairs and that lower levels of attentionare a form of neglect, we can use this mod-el to explore some of the biological conse-quences of neglect or abuse in children.Low rates of maternal attention decreasethe production of thyroid hormone by therat pups. This, in turn, decreases serotoninin the hippocampus and affects the devel-opment of receptors for the stress hormoneglucocorticoid. Since corticosterone, one of our primary stress hormones, is kept incheck by a complicated feedback mechanismthat depends on these same stress hormonereceptors, their inadequate developmentincreases the risk of an excessive stress hor-mone response to adversity. For this andcertain other reasons, lack of maternalattention predisposes the animals to have aheightened level of fear and a heightenedadrenaline response. Some of the conse-quences of this are altered metabolism andsuppressed immune and inflammatoryresponses, neuronal irritability, and enhancedsusceptibility to seizures. Still other conse-quences of an abnormally intense corticos-terone response are reduced brain weightand DNA content, suppressed cell growthin the cerebellum and hippocampus, and interference with myelinization—theprocess of sheathing nerve fibers to enhance conduction of electrical impulses.

These consequences seem consistentwith inadequate development of the corpuscollosum, which is a highly myelinatedstructure, and abnormal development ofthe hippocampus and cerebellum. High levelsof cortisol can also hinder development of the cerebral cortex, the extent of vulner-ability dependent on how rapidly the brainwas growing at the time of the insult. Duringthe years of rapid language acquisition(approximately 2-10 years of age), the leftbrain develops more rapidly than the right,making it more vulnerable to the effects ofearly maltreatment.

Finally, diminished maternal attentionalso appears to be associated with a lifelongdecrease in production of the hormone oxy-tocin in the brain, and enhanced productionof the stress hormone vasopressin. Recentresearch by Thomas Insel suggests that oxytocin is a critical factor in affiliative loveand maintaining monogamous relationships.Both hormones may also help control sexual response, with vasopressin enhancingsexual arousal and oxytocin triggering climax and release. By affecting these hor-mones, early neglect or abuse theoreticallycould predispose mammals to experienceenhanced sexual arousal, diminished capacityfor sexual fulfillment, and deficient commit-ment to a single partner.

FROM NEUROBIOLOGY TO

SYMPTOMATOLOGY

In summary, we now know that childhoodabuse is linked with excess neuronal irri-tability, EEG abnormalities, and symptomssuggestive of temporal lobe epilepsy. It isalso associated with diminished development

Cerebrum

childhood abuse appears particularly likelyto be associated with emergence of ADHD-like behavior problems. Interestingly, one of the most reliable neuroanatomical findingsin ADHD is reduced size of the cerebellarvermis. Some studies have also found anassociation between reduced size of the midportions of the corpus callosum and emer-gence of ADHD-like symptoms of impulsivity.Hence, early abuse may produce brainchanges that mimic key aspects of ADHD.

Our discoveries that abused patientshave diminished right-left hemisphere inte-gration and a smaller corpus callosum suggestan intriguing model for the emergence ofone of psychiatry’s least understood afflictions:borderline personality disorder. With less well integrated hemispheres, borderlinepatients may shift rapidly from a logical andpossibly overvaluing left-hemisphere state to a highly negative, critical, and emotionalright hemisphere state. This seems consistentwith the theory that early problems of mother-child interaction undercut the integration of right and left hemispheric function. Veryinconsistent behavior of a parent (for exam-ple, sometimes loving, sometimes abusing)might generate an irreconcilable mentalimage in a young child. Instead of reachingan integrated view, the child would form twodiametrically opposite views—storing thepositive view in the left hemisphere, the neg-ative view in the right. These mental images,and their associated positive and negativeworld views, may remain unintegrated, andthe hemispheres remain autonomous, as thechild grows up. This polarized hemisphericdominance could cause a person to see significant others as overly positive in one

of the left cortex and left hippocampus,reduced size of the corpus callosum, andattenuated activity in the cerebellar vermis.We see a close fit between the effects of early stress on the brain’s transmitters—ourdiscoveries about the negative effects of early maltreatment on brain development—and the array of psychiatric symptoms that we actually observe in abused patients.

Many disorders are associated withchildhood abuse. One is depression orheightened risk for developing it. Many scientists believe that depression may be aconsequence of reduced activity of the left frontal lobes. If so, the stunted devel-opment of the left hemisphere related toabuse could easily enhance the risk of devel-oping depression. Similarly, excess electricalirritability in the limbic system, and alter-ations in development of receptors thatmodulate anxiety, set the stage for theemergence of panic disorder and increasethe risk of post-traumatic stress disorder.Alterations in the neurochemistry of theseareas of the brain also heighten the hormonalresponse to stress, producing a state ofhyper vigilance and right-hemisphere activa-tion that colors our view with negativityand suspicion. Alterations in the size of thehippocampus, along with limbic abnormalitiesshown on an EEG, further enhance the risk for developing dissociative symptomsand memory impairments.

We have also found that 30 percent ofchildren with a history of severe abuse meetthe diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD),although they are less hyperactive than children with classic ADHD. Very early

The Dana Forum on Brain Science

state and as resoundingly negative in another. Couple this with possible alterationsin oxytocin- and vasopressin-mediated sexual arousal, and you see why patients withborderline personality disorder have tumul-tuous relationships.

DEALING WITH THE DAMAGE

I hope that new understanding of childhoodabuse’s impact on the brain will lead to new ideas for treatment. The most immediateconclusion from our work, however, is the crucial need for prevention. If childhoodmaltreatment exerts enduring negativeeffects on the developing brain, fundamentallyaltering one’s mental capacity and personality,it may be possible to compensate for theseabnormalities—to succeed in spite of them—but it is doubtful that they can actually bereversed in adulthood.

The costs to society are enormous.Psychiatric patients who have suffered fromchildhood abuse or neglect are far moredifficult and costly to treat than patientswith a healthy childhood. Furthermore,childhood maltreatment can be an essentialingredient in the makeup of violentindividuals, predisposing them to bouts ofirritable aggression.

One day we will find ways to chartthe progress of brain development so thatwe can spot early signs of stress-mediatedabnormalities and monitor each patient’sprogress and response to treatment. In themeantime, early intervention should be ourpriority. The brain is more plastic and mal-leable before puberty, increasing our chancesof minimizing or reversing consequences ofabuse. If we are right that many abuse-related

changes result from a cascade of stress-medi-ated neuronal and hormonal responses, then we could minimize the impact of abuseby finding ways to reduce ongoing stress orsuppressing an excessive stress response.

One consequence of childhood mal-treatment is limbic irritability, which tends toproduce dysphoria (chronic low-level unhap-piness), aggression, and violence towardoneself or others. Even into adulthood, drugscan be useful in alleviating this set of symp-toms. Anticonvulsant agents can help, as candrugs that affect the serotonin system.

Abuse also causes alterations in left-right hemisphere integration. Some researchsuggests that anticonvulsant drugs may facilitate the bilateral transmission of informa-tion. Left-right hemisphere integration mayalso improve through activities that requireconsiderable left-right hemisphere coopera-tion, such as playing a musical instrument.Certain existing psychotherapies may behelpful. Cognitive-behavioral psychotherapy,which emphasizes correcting illogical, self-defeating perceptions, may work bystrengthening left-hemisphere control overright-hemisphere emotions and impulses.Traditional, dynamic psychotherapy may work by enabling patients to integrate right-hemisphere emotions while maintaining left-hemisphere awareness, strengtheningthe connection between the two hemispheres.

A powerful new tool for treating PTSDis eye-movement desensitization and repro-cessing (EMDR), which seems to quell flashbacks and intrusive memories. A movingvisual stimulus is used to produce side-to-sideeye movements while a clinician guides the patient through recalling highly disturbing

Cerebrum

At the extreme, the coupling of severechildhood abuse with other neuropsychiatrichandicaps (for example, low intelligence,head trauma, or psychosis) is repeatedlyfound in cases of explosive violence. DorothyOtnow Lewis and Jonathan Pincus haveanalyzed the neurological and psychiatrichistory of violent adolescents and adults. In one study they evaluated all 14 juvenilescondemned to death in four states andfound that all had suffered head injuries,most had major neurological impairment,12 had subnormal IQ’s, 12 had beenseverely physically abused as children, and 5had been sodomized by relatives. In anotherstudy, they reviewed the childhood neuropsy-chiatric records and family histories of incarcerated delinquents. What might havebeen a tip-off to those who later werearrested for murder? The future murdererswere distinguished from other delinquentsby psychotic symptoms, major neurologicalimpairment, a psychotic first-degree relative,violent acts during childhood, and severephysical abuse.

In a follow-up study of 95 formerlyincarcerated juvenile delinquents, theyfound that the combination of intrinsicneuropsychiatric vulnerabilities and a historyof childhood abuse or family violence effec-tively predicted which adolescents would go on to commit violent crimes. Lewis con-cludes that child abuse can engender allpivotal factors associated with violentbehavior, namely, impulsivity, irritability,hyper vigilance, paranoia (which she interpretsas an extreme version of hypervigilance),decreased judgment and verbal ability, anddiminished recognition of pain in oneself

memories. For reasons we do not yet fullyunderstand, patients seem able to toleraterecall during these eye movements and canmore effectively integrate and process theirdisturbing memories. We suspect that thistechnique works by fostering hemispheric

integration and activating the cerebellar vermis(which also coordinates eye movements),which in turn soothes the patient’s intenselimbic response to the memories.

THEIR CHOICE—OR OURS?

Society reaps what it sows in nurturing itschildren. Whether abuse of a child is physical,psychological, or sexual, it sets off a ripple ofhormonal changes that wire the child’s brain to cope with a malevolent world. It predisposesthe child to have a biological basis for fear, though he may act and pretend otherwise.Early abuse molds the brain to be more irrita-ble, impulsive, suspicious, and prone to be swamped by fight-or-flight reactions that the rational mind may be unable to control. The brain is programmed to a state of defensive adaptation, enhancing survival in a world of constant danger, but at a terrible price. To a brain so tuned, Eden itself would seem to hold its share of dangers; building a secure, stable relationship may later require virtually super-human personal growth and transformation.

Whether abuse of a child is

physical, psychological, or sexual,

it sets off a ripple of hormonal

changes that wire the child’s brain

to cope with a malevolent world.

The Dana Forum on Brain Science

(dissociation) and others. As our reviewshows, these factors fit closely with theenduring neurobiological consequences of abuse.

To be convicted of a crime in theUnited States, one supposedly must havethe capacity both to know right fromwrong and to control one’s behavior. Thosewith a history of childhood abuse mayknow right from wrong, but their brainsmay be so irritable and the connectionsfrom the logical, rational hemisphere soweak that intense negative (right-hemisphere)emotions may incapacitate their use of

logic and reason to control their aggressiveimpulses. Is it just to hold people criminallyresponsible for actions that they lack theneurological capacity to control?

Prosecutors and pundits are quick tocoin catchphrases like the “abuse excuse” todismiss childhood trauma’s pervasive andenduring consequences for behavior. This isas unthinking as the exhortation to “getover it.” Childhood trauma is not a passingpsychological slight that one can choose to ignore. Even if the abused person comesto terms with the traumatic memories andchooses (for the sake of sanity) to forgivethe perpetrator, this will not reverse the

neurobiological abnormalities. The onlysound legal approach to a person with ahistory of abuse who commits a violentcrime is to take into account the person’sneurobiological capacity to control hisbehavior. If it is irrational and hypocriticalto hold a minor to the same standard ofbehavioral control as a mature adult, it isequally unjust to hold a traumatized andneurologically impaired adult to the samestandard as one not so afflicted. Childhoodabuse, age, and neurological impairmentscan be critical mitigating factors that a justsociety should not ignore.

If we know that the roots of violenceare fertilized by childhood abuse, can wemake a long-term commitment to reduceviolence by focusing on our children ratherthan our criminals? What if we set a goal ofreducing the cases of childhood abuse andneglect by 50 percent a year? What if wemonitored statistics on childhood abuse asavidly as we track housing starts, inflation,or baseball scores? We would have to commitourselves, seriously, to improving access toquality day care and after-school programs.We might need to educate and support parents so they could know how to nurturetheir children more effectively. We certainlywould need to foster better relationshipsamong peers and siblings.

Think of what we could save if weneeded fewer prisons and fewer mentalhealth professionals. Think of the benefitsof moving one step closer to a society that everyone could experience and enjoy.

Our brains are sculpted by our early experiences. Maltreatment is a chisel that shapes a brain to contend with

If we know that the roots of

violence are fertilized by childhood

abuse, can we make a long-term

commitment to reduce violence by

focusing on our children rather

than our criminals?

Cerebrum

strife, but at the cost of deep, enduringwounds. Childhood abuse isn’t somethingyou “get over.” It is an evil that we mustacknowledge and confront if we aim to do anything about the unchecked cycle ofviolence in this country. �

Author’s note: Rebecca Feldman and Sydney Sauber assisted in writing this article.

References

1 Finkelhor DA. A Sourcebook on Child Sexual Abuse.Beverly Hills, CA: Sage Publications; 1986.

2 Herman JL, Perry JC, van der Kolk BA. Childhoodtrauma in borderline personality disorder. AmericanJournal of Psychiatry. 1989;146:490-5.

3 Putnam RW, Post RM, Guroff JJ. One hundred casesof multiple personality disorder. Journal of ClinicalPsychiatry. 1986;47:285-93.

4 Spiers PA, Schomer DL, Blume HW, Mesulam MM.Temporolimbic epilepsy and behavior. In: MesulamMM, ed. Principles of Behavioral Neurology.Philadelphia: F.A. Davis; 1985:289-326.

5 Teicher MH, Glod CA, Surrey J, Swett C. Early Child-hood Abuse and Limbic System Ratings in Adult Psychiatric Outpatients. Journal of Neuropsychiatryand Clinical Neurosciences. 1993;5:301-6.

6 Ito Y, Teicher MH, Glod CA, Harper D, Magnus E, Gelbard HA. Increased prevalence of electrophysio-logical abnormalities in children with psychological,physical, and sexual abuse. Journal of Neuropsychiatryand Clinical Neurosciences. 1993;5:401-8.

7 Ito Y, Teicher MH, Glod CA, Ackerman E. Preliminaryevidence for aberrant cortical development inabused children: a quantitative EEG study. The Journalof Neuropsychiatry and Clinical Neurosciences.1998;10:298-307.

8 Bremner JD, Randall P, Vermetten E, et al. Magnetic resonance imaging-based measurement ofhippocampal volume in posttraumatic stress disorder related to childhood physical and sexualabuse—a preliminary report. Biological Psychiatry.1997;41:23-32.

9 Stein MB. Hippocampal volume in women victimizedby childhood sexual abuse. Psychology Medicine.1997;27:951-9.

10 Schiffer F, Teicher MH, Papanicolaou AC. Evokedpotential evidence for right brain activity during therecall of traumatic memories. Journal of Neuropsychi-atry and Clinical Neurosciences. 1995;7:169-75.