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PACEs in Pediatrics

Bruce Perry, Melissa Merrick discuss "What Happened to You?"


Child psychiatrist Dr. Bruce Perry and Oprah Winfrey have known each other for more than 30 years. Both are deeply interested in childhood trauma and healing. But it was following a 60 Minutes segment Winfrey did in 2018 on childhood trauma, for which she interviewed Perry, that the two decided to take their work together to the next level. They tapped Oprah’s star power and worldwide reach and Perry’s deep expertise in brain science to collaborate on a book project, the recently released, “What Happened To You?: Conversations on Trauma, Resilience, and Healing.”

In an Aug. 31 webinar, Melissa Merrick, president and CEO of Prevent Child Abuse America, where Perry is a board member, interviewed Perry about the book and his collaboration with Winfrey. They talked about what it means to be brain aware; what sets the stage for healing from childhood adversity and how preventing childhood adversity and child abuse are necessarily tied to radical changes in institutional approaches to healing. Merrick interspersed her questions with audio clips of Perry and Winfrey reading sections from the book.

Perry is principal of the Neurosequential Network, a senior fellow of The ChildTrauma Academy and an adjunct professor in the departments of psychiatry and behavioral sciences at the Feinberg School of Medicine at Northwestern University in Chicago.

The plan for the book project evolved quickly following the 60 Minutes segment, Perry said. After talking with her book publisher at Flatiron Press, Winfrey called Perry to inquire if he might be interested in writing a book about trauma. He said he had already written about trauma, but that Winfrey’s worldwide influence would give such a book greater reach, and he recommended that they collaborate.

She agreed, and soon they were recording conversations at Winfrey’s ranch in Hawaii. Those conversations became the book.

Part of Perry’s approach to understanding how trauma affects the course of a child’s life is looking beyond the initial, life-changing, traumatic event. He recalled an example of a young man he had known when he was a teen who, while drunk, got into a car accident that killed someone. “That literally led to this spiral of self-loathing and deterioration, and he ultimately committed suicide,” Perry said. “We shouldn’t be so imperious or patronizing about interpreting the present moment or the way a person is functioning right now without understanding how they’ve gotten to this point.”

While such traumatic experiences are embedded into memory, the brain also has the opportunity to store hopeful experiences – even if they’re fleeting -- that help children heal from trauma.

“If you're a little child and some adult interacts with you in a truly sincere way, where you feel like you're really seen and you're really valued, your cortex can store that in a way that you can revisit that [experience] even when that person is gone,” said Perry “And so in that very brief, meaningful, but true moment, an adult can provide an inflection point for a child to move down a hopeful trajectory.

“Even if a child thinks to himself such thoughts as, ‘Hardly anybody in my life cares for me, I'm invisible. I'm not the right color. I'm not smart enough, I'm not a good enough athlete, I get marginalized at lunch,’ they can still think to themselves, ‘But you know what, that guy thought I was awesome!’ And that can keep kids on a healthy trajectory,” Perry said. “And I think that is something that we underestimate in therapy; we underestimate as teachers and as coaches.”

Beyond the healing powers of one-on-one interactions with children that may occur randomly, Perry advocates intentional planning to build connections that help promote resilience:

“High-quality urban planning that puts people together in the same space is as important a prevention program as a home visiting program. That same family that has a home visitor should be able to walk out into a beautiful park and sit on a park bench next to a person who will start talking with them, while their children can play with some other kids in the neighborhood. That density of relational connection is really what creates health in a community.”

A hallmark of Perry’s work focuses on the neurosequential model of therapeutics. This “allows identification of the key systems and areas in the brain which have been impacted by adverse developmental experiences and helps target the selection and sequence of therapeutic, enrichment, and educational activities,” Perry said in an article published in the Journal of Loss and Trauma.

A tenet of this approach is mapping a child’s past experiences. Merrick played the following audio clip from the book to explain why it’s so important to track exactly when a child -experienced adversity:

The basic finding is that the experiences of the first two months of life have a disproportionately important impact on your long-term health and development. This has to do with the remarkably rapid growth of the brain early in life, and the organization of those all-important core regulatory networks [that regulate the body’s response to stress]. If, in the first two months of life, a child experienced high adversity with minimal relational buffering, but was then put into a healthier environment for the next 12 years, their outcomes were worse than the outcomes of children who had low adversity and healthy relational connection in the first two months of life, but then spent the next 12 years with high adversity. Think of that! The [baby] who had two months of really bad experiences does worse than the child with almost 12 years of bad experiences. All because of the timing of the experience.

That specific section of the book, said Merrick, led many who registered for the webinar to submit questions with concerns about adoption. Some wondered, she said, what Perry would advise for parents adopting older children who may have experienced early trauma.

Perry reminded participants of the benefits of a sincere adult interacting with a child who has experienced adversity and recommended that those children be met where they are developmentally. As an example, he said, a child may be 10 years old, but if the child experienced developmental trauma early in life, “They're likely to have a 10-year-old’s motor skills, but a 4-year-old’s social skills and a 2-year-old’s [emotional] regulatory skills, so they can't act their age.”

The notion of children being met where they are without being judged was also captured in a reflection by Winfrey in the following audio clip played by Merrick:

Most people who are in the process of excavating the reasons they do what they do are met at some point with resistance. You're blaming the past. Your past is not an excuse. This is true. Your past is not an excuse. But it is an explanation, offering insight into the questions so many of us ask ourselves: Why do I behave the way I behave? Why do I feel the way I do? For me, there is no doubt that our strengths, vulnerabilities and unique responses are an expression of what happened to us. Very often what happened takes years to reveal itself, it takes courage to confront our actions, peel back the layers of trauma in our lives, and expose the raw truth of our past. But this is where healing begins.

Merrick said Winfrey’s reflections about the messy yet necessary work of confronting one’s own trauma reveals that there is often a push-pull struggle between confronting it and avoiding it. This made her wonder, she said, where Perry thought the emphasis needed to be around healing and trauma.

“I think that there are a lot of things about working in the prevention and trauma arena that we're going to have to get better at,” Perry responded. “One of the key things is I don't think that we can continue to ask individuals to bear all of this process, all the healing, all the assessment, all the education, and that's kind of what has happened.

“You'll find one individual at a university who decides to go and study this and be specialized in it clinically, and maybe build a little specialty clinic. But our systems are not organizing themselves in a way that's truly going to be responsive to these big problems. And I think that's something that we need to focus on and be better at.”

In particular, Perry explained, “We exist in a power hierarchy that was created by previous generations, and systems always reflect the people that create them. Those who are empowered to create systems were wealthy white males,” he said. “To this day, our universities, our academic institutions, all of our social service organizations have the residue and the remnants of that kind of organization, where there’s power at the top, and utilization of people at the bottom, and we’ll wear them down and replace them with other lowcost workers.

“It's a discussion that makes a lot of people get incredibly defensive,” continued Perry. “But it's a discussion that has to be had about how we're going to solve some of these complex problems.”

A recording of the webinar is available here and on the Prevent Child Abuse website.

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