Implications

The knowledge we have gained from research examining the effects of maltreatment on brain development can be helpful in many ways. With this information, we are better able to understand what is happening within the brains of children who have been abused and neglected. In fact, much of this research is providing further, solid evidence for what professionals and caregivers have been describing in behavioral, emotional, and psychological terms. We can use this information to improve our systems of care and to strengthen our prevention efforts.

There has been some encouraging progress in states' recognition of early brain development research and how this information can be used to improve services. In a survey conducted by the Child Welfare League of America in 2000, 31 states reported that they had reviewed relevant research findings (CWLA, n.d.). Many also reported that they had engaged in efforts to increase awareness about early brain development and that both legislative and policy changes had occurred to enhance prevention, early intervention, and healthy child development programs (CWLA, n.d.).

The Child Welfare System

While the goal of the child welfare system is to protect children, many child welfare interventions -- such as investigation, appearance in court, removal from home, placement in a foster home, etc. -- may actually reinforce the child's view that the world is unknown, uncontrollable, and frightening. These experiences can actually contribute to the traumatized child's "catalog" of fearful situations (Wolff & Brandt, 1998). In addition, many child welfare systems in the United States do not provide comprehensive assessments to all children in their care, and therefore the treatments provided may not be the most effective -- they may not accurately target each child's unique experience.

As much as possible, the child welfare system needs to address these deficits and reform practices to provide consistency, repetition, nurturance, predictability, and control (returned to the child) to diminish the fearful nature of the interventions (Wolff & Brandt, 1998). In addition, child welfare systems should provide comprehensive assessments for all children as soon as possible to examine their physical, cognitive, emotional, and social development (Committee on Early Childhood, Adoption and Dependent Care, 2000; Shonkoff & Phillips, 2000). Accomplishing these objectives will require the participation of all stakeholders, including policymakers; family court judges; managers; child welfare workers; medical, mental health, and education professionals; kinship, foster, and adoptive parents; and the parents and children themselves. Every group must examine its contribution to the development of the children served by the child welfare system, and strive to provide that contribution in a manner that will promote healthy development for each child.

The Role of Professionals

One of the first tasks for professionals who work with children who have been maltreated is to educate themselves about the effects of maltreatment on early brain development, as well as interventions likely to be effective. For example, "talk" therapy must do more than talk if the child is in a persistent hyper-arousal state; the child's brain may well be unresponsive to verbal interactions (Lott, 1998; Perry, 1999). According to Dr. Schore, "What will get through is tone of voice, demeanor, facial expressions and a sense of empathy that is rooted in the early psychobiological attunement between mother and infant" (Lott, 1998, p. 3).

Professionals who are knowledgeable about this issue need to educate others who work with and care for the children (Comfort, 1997; Committee on Early Childhood, Adoption and Dependent Care, 2000; Perry, 1996). Information can be provided to foster parents and other caregivers to help them understand the effects of maltreatment on children's brain development, how those early experiences may influence current behavior and functioning, and what can be done to help the children recover their lost potential. CPS workers, judges, and teachers also may not be knowledgeable about these issues; they can benefit from opportunities to understand the importance of their contributions to the child's environment. By working in a coordinated manner, professionals and caregivers can help to minimize unpredictable, unknown, and frightening experiences and assist the child's movement along a path of healthy development.

Human service professionals are increasingly receptive to new knowledge about human brain development (Shore, 1997). Professionals across disciplines are engaged in exciting new efforts to rethink the brain and apply the knowledge and ideas to support the healthy development and well being of children (Shore, 1997). As these efforts begin to offer meaningful information, that information must be translated into policies and practices for the front-line workers and caregivers in order to have the most impact on improving child well being in child welfare systems.

The Role of Caregivers

Many children who have suffered abuse and neglect are removed from their homes by the child welfare system for their safety. These children may be temporarily cared for by extended family, foster parents, or group home staff, and some will be adopted. While many caregivers have an innate sense about how to raise children, familiarity with the effects of maltreatment on brain development and the possible manifestations of those effects are not likely to be “common knowledge.”

It is important for caregivers to have realistic expectations for the children in their care. Children who have been abused or neglected may not be functioning at their chronological age in terms of their physical, social, emotional, and cognitive skills. They may also be displaying unusual and/or difficult coping behaviors. For example, abused or neglected children may:

• Be unable to control their emotions and have frequent outbursts 
• Be quiet and submissive 
• Have difficulties learning in school 
• Have difficulties getting along with siblings or classmates 
• Have unusual eating or sleeping behaviors 
• Attempt to provoke fights or solicit sexual experiences 
• Be socially or emotionally inappropriate for their age 
• Be unresponsive to affection. 

"It is easy for foster parents to become confused, frustrated, and sometimes devastated from the lack of response and reciprocity to the love, affection, attention, and care they offer" (Comfort, 1997, p. 29). Even caregivers with the best of intentions can misunderstand a child's behavior, fashion their response based on that misunderstanding, and then wonder why their response was not effective.

To be more effective in their roles, caregivers that serve abused and neglected children could benefit from training and support related to the effects of maltreatment on early brain development. 

Understanding some basic information about the neurobiology underlying many challenging behaviors may help caregivers shape their responses more effectively. But while a general understanding is helpful, foster parents and other caregivers need to know the history of their particular foster children's experiences in order to tailor their approaches (Comfort, 1997). They may need to develop some special skills to cope with the children's special needs.

In general, children who have been abused or neglected need nurturance, stability, predictability, understanding, and support (Committee on Early Childhood, Adoption and Dependent Care, 2000). They may need frequent, repeated experiences of this kind to begin altering their view of the world from one that is uncaring or hostile to one that is caring and supportive. Until that view begins to take hold in the child's mind, the child may not be able to truly engage in a positive relationship. And the longer the child lived in the abusive or neglectful environment, the harder it will be to convince his brain that his world can change. But one thing we have learned from research is that environment does make a difference. Consistent nurturing from caregivers who receive training and support may offer the best hope for the children who need it most.

Intensive, Early Intervention

Intensive, early interventions are key to minimizing the long-term effects of early trauma on children's brain development (Committee on Early Childhood, Adoption and Dependent Care, 2000). Two studies that have shown this impact include the following:

Craig Ramey of the University of Alabama at Birmingham reported that vulnerable children who received services from 4 months to 5 years of age showed better cognitive development than those receiving services from age 5 to age 8; the difference was even more pronounced at age 12 than at age 8 (Shore, 1997). 

Rutter et al. (2000) studied the development of children adopted from Romanian orphanages. When each child was 6 years old, the researchers assessed what proportion of the adopted children was functioning "normally." They found that 69% of the children adopted before the age of 6 months, 43% of the children adopted between the ages of 7 months and 2 years, and 22% of the children adopted between the ages of 2 years and 3.5 years were functioning normally. 

Indeed, many studies have shown the effectiveness of early intervention, but we now have a better understanding of why early intervention makes a difference. And taking a neuro-developmental approach in early intervention can decrease the "intensity and severity of the response to trauma [which] will decrease the probability of developing . . . sensitized neural systems resulting in a persisting hyper-arousal or dissociative symptoms or both" (Perry, Pollard, Blakely, Baker & Vigilante, 1995).

In order to heal a "damaged" or altered brain, interventions must activate those portions of the brain that have been altered (Perry, 2000c). Because brain functioning is altered by repeated experiences that strengthen and sensitize neuronal pathways, interventions cannot be constrained to weekly therapy appointments. Interventions must address the totality of the child's life, providing frequent, consistent "replacement" experiences so that the child's brain can begin to incorporate a new environment -- one that is safe, predictable and nurturing.

Although early interventions show the most promise for significant recovery from abuse and neglect, later interventions are not futile. However, as children get older, recovery from lost or altered brain functioning may be slower and less complete than recovery attempted earlier in the children's lives (Shore, 1997). But some recovery is certainly possible; while a negative environment may contribute to deficits, a positive environment can contribute to growth (Teicher, 2000).

Prevention

While early intervention with maltreated children can minimize the effects of abuse and neglect, it is equally or even more important to prevent problems before they start. "Clearly, the costs (in human suffering, loss of potential, and real money) of trying to repair, remediate, or heal these children is far greater than the costs of preventing these problems by promoting healthy development of the brain during the first few years of life" (Ounce of Prevention Fund, 1996, p. 3).

Prevention efforts can target the general population ("primary" or "universal" prevention), educating the public and changing policies to promote healthy brain development. For example, one prevention strategy might involve expanding education efforts that target women who may become pregnant about the effects of alcohol on the developing brain of the fetus. An example of a policy change might involve expanding family leave to allow more parents time off from work to care for and build an attachment to a newborn or adopted child.

Prevention efforts also can target children and families considered to be "at-risk" for developing problems before problems develop ("secondary" or "selected" prevention). By the time a child who has been abused or neglected comes to the attention of professionals, it is likely that some damage already has been done. Secondary prevention efforts must reach out to at-risk families before this point. There are many home visitation programs that provide services to at-risk families before and after the birth of a child -- services that support children's healthy development and have proven to be successful in preventing future problems (Ounce of Prevention Fund, 1996, citing MacMillan, 1994).

Many researchers examining the effects of maltreatment on early brain development agree that this knowledge should be used to expand and strengthen prevention efforts (Ounce of Prevention Fund, 1996; Perry, 1996; Shonkoff & Phillips, 2000; Teicher, 2000). Without expanded prevention, our society will continue to fight an uphill battle to "repair" the damage that has been done to thousands of children who have been abused and neglected. Society cannot continue to ignore the laws of biology (Perry, 1996); the more we learn about early brain development, the more responsibility we have to act on that knowledge.

Summary & Research Recommendations

In 1999, approximately 826,000 children were determined to be victims of abuse and/or neglect (U.S. Department of Health and Human Services, 2001), but it is likely that many more children are actually suffering under adverse conditions. Each one of these children already may have suffered damage to their growing brains. Their brains may be locked into perceiving the world as a cold or dangerous place. They may have great difficulties responding to the caring concern of others. Because their brains' energies have been focused on survival, on meeting their own needs, these children may not have developed the physical, cognitive, social, and emotional capabilities one would expect of them. But their future, and the futures of countless others to come, need not be so bleak.

One lesson we have learned from the research on brain development is that environment has a powerful influence on development. Stable, nurturing caregivers and knowledgeable, supportive professionals can have a significant impact on these children's development. And using this growing body of knowledge in prevention efforts can potentially reduce the number of children who will require "reparative" 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 the following:

• Bring together biological and psychosocial researchers to bridge the divide between these fields. 
• Understand more about the contribution of genetics to the development process that may explain susceptibility to risk and capacity for resilience.   
• Understand more about how biological processes interact with the environment to affect behavior. 
• Fund collaborative research projects to study the effect of environment on brain development to learn more about what are deprived, sufficient, and enriched environments.
• Direct program-based research and evaluation to document and test interventions to ensure full effectiveness, and use knowledge from ineffective programs to spur more experimentation (Shonkoff & Phillips, 2000). 

While we continue to study and learn more about the effects of maltreatment on early brain development, we can begin to use the knowledge that is already available. We can use this knowledge to strengthen our prevention and intervention strategies, our support of caregivers, and our commitment to provide all children with the nurturance and stimulation they need to grow up healthy and happy.