Finding their footing

Innovative programs at the School of Medicine offer help for children scarred by trauma.

Randi Hutter Epstein ’90MD is the Writer in Residence at the Yale School of Medicine and the author, most recently, of Aroused: The History of Hormones and How They Control Just About Everything.

Anthony Russo

Anthony Russo

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One quiet afternoon last August when few people were on campus, Chase, a nine-year-old, climbed onto the platform of an MRI machine. He was at the Yale Brain Imaging Center, which is tucked into a windowless basement room of Dunham Laboratory on Hillhouse Avenue. Chase lay on his back as laboratory assistants Grace Hommel and Maya Barr taped electrodes to his bare feet, draped a weighted blanket over his slender body, and wiggled his head into a helmet-like contraption. He swapped his outer-space-themed mask for the standard blue disposable one. Then they slid him into the cavernous magnet.

Images of faces, some appearing afraid, others calm, flashed across a screen projected above Chase’s head. He held a box in one hand and pressed a button when he saw neutral expressions; nothing when frightened faces flashed by. During one session, his mother was by his side holding his hand. During the next one, Chase was on his own. That was part of the experimental design. He seemed upbeat and chatty, astonishingly relaxed for a kid who volunteered precisely because he’s got a lot of worries.

Chase is among several young participants in a series of ongoing experiments at Yale that aim to deepen our understanding of childhood stress. Some of the studies, such as this one, focus on children who are overly nervous. Other studies evaluate children who have endured severe trauma, such as sexual or physical abuse, witnessing violence, or surviving a natural disaster.

“There’s usually a gap between neuroscience and clinical practice,” says Dylan Gee, an assistant professor of psychology and director of the Clinical Affective Neuroscience and Development Lab. “How do we get what’s in my lab into the hands of people who need it? How do we bring our knowledge to bear so it has impact on the lives of children who experienced trauma?”

For years, scientists have tried to figure out why a  child’s brain seems to be particularly sensitive to stress. The thinking is that young brains are more malleable than old ones because they are undergoing so much change so quickly. A child’s brain has roughly the same number of brain cells as an older one, but by some estimates it has millions more neural connections. Trimming the unnecessary connections is part of the process of turning a kid’s brain into an adult brain.

Neuroscientists often speak in gardening metaphors. The nerve cells (neurons) are connected by dendrites—called branches—which send signals from one nerve cell to another. When a branch isn’t used much, the brain “prunes” it. Meanwhile, the well-trodden branches thicken. An infant’s brain is a forest of skinny branches going this way and that. An older one has fewer and thicker branches, transmitting signals faster and more directly.

Children who have endured chronic stress, such as living in a violent neighborhood or within an unstable home life, tend to have thick branches near the brain’s alarm system (the amygdala) and weaker ones near its off switches (the hippocampus and prefrontal cortex). The alarm system blares and there’s nothing to stop it. Some kids, who have not endured trauma but are for some reason simply anxious, may also have overly sensitive amygdalae, perceiving ordinary things as potential threats.  

Recently, the research has expanded to include the impact of therapy on the developing brain. If a child is susceptible to insults, perhaps they are just as susceptible to healing. Or, as Linda Mayes, a professor of child psychiatry, puts it, “Anything that is rapidly changing is more vulnerable to injury but also easier to repair.”

Both Mayes and Gee are part of Yale’s Early Stress and Adversity Consortium, launched three years ago by Carla Stover, an associate professor at the Child Study Center. The consortium meets monthly, bringing together faculty and fellows in psychiatry, psychology, neuroscience, pediatrics, primatology, nursing, emergency medicine, social work, and public policy. They brainstorm, share work in progress, and provide insights about childhood trauma—from vastly different perspectives.

Two examples: Professor Amy Arnsten is uncovering how stress causes molecular changes in the brain and seeking strategies for restoring brain connections.

Professors Arietta Slade and Lois Sadler ’79MSN developed Minding the BabyTM, an intensive in-home program designed to help young parents manage their own stress and model stress reduction for their infants and toddlers.

Chase volunteered for a study assessing a new kind of therapy called SPACE, short for Supportive Parenting for Anxious Childhood Emotions. It was developed by associate professor Eli Lebowitz, director of the Program for Anxiety Disorders at the Yale Child Study Center. In SPACE, the parents go through therapy, not the child. The child goes into the MRI. The goal of the study is to find out whether the parents’ therapy has changed the child’s brain.

SPACE works by giving parents tools to encourage their children to cope with their fears. The first step is recognizing the child’s anxiety and conveying confidence that the child can manage: “I appreciate that you’re scared of X; I bet you can tolerate it.”

The second step is the most challenging. It encourages the parents to find ways to stop giving in to their anxious child’s desires.

Virtually every parent who has an anxious child caters to the kid’s needs, says Lebowitz. One of his studies, which included 75 parents in the United States and Israel, found that over 97 percent of the parents rearranged their lives to avoid anything that could upset their nervous child. (The findings were published in the September 2012 issue of Depression and Anxiety.)

We are hardwired to soothe. A child is afraid to sleep in their bed alone; they end up snuggling with their parents. The child who can’t separate at school ends up with a mom lingering by the doorway until a teacher pries her from the school grounds. We think we are doing what parents should do, but what we really need to do is teach children how to deal with their fears, even if it may be temporarily stressful for them.

Chase’s mother (who preferred that her name not be used, to protect her son’s identity) said that, with the help of Yale therapists, she and her husband wrote a letter to their son articulating their expectations with love and encouragement. In part, it said: “From now on, we are not going to go with you to get things out of other rooms, even if it’s dark, including at night. . . . We understand your fear and how hard it is for you, but we wouldn’t make this change if we didn’t think you could handle it.” His parents are learning how to help Chase overcome his nine-year-old fears with tactics he can eventually mold to help him conquer the inevitable stresses of adulthood.

Lebowitz created SPACE because he had realized that all too often, children do not want to go into therapy. Since then, he and his team have found that SPACE works just as well as cognitive behavioral therapy, a standard treatment for children. (They published the study in American Academy of Child and Adolescent Psychiatry, March 2020.)

This latest study aims to find out whether children’s reactions to seeing scary faces will change after their parents go through SPACE. The hypothesis is that before SPACE therapy, a child’s brain will calm down faster when a parent is in the MRI room compared with when the parent is absent. After therapy, the hope is that the child’s brain will calm down at the same quick pace—regardless of whether the parent is present. That would be a signal that the child is learning to cope on their own. In addition, clinicians will evaluate children on how they feel they’re progressing.  

For children who have endured severe trauma, one option is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Dylan Gee is involved in a study designed to assess TF-CBT. Previous studies have shown that it works very well for about half to two-thirds of those who go through it, but less well for others. Her goal is to figure out which children are most likely to benefit from TF-CBT and what might improve the process for those who don’t.  

Gee is assessing volunteers, aged 10 to 17, before and after therapy. The theory is that the reason many children show fewer symptoms of trauma after TF-CBT is because the therapy strengthened their regulatory centers. In other words, the children have better control over their brain’s alarm center than they had before.

TF-CBT is a multistep process. It includes teaching children how to manage their frustrations; working with parents so they can give support to their children; and providing children with practical strategies when they encounter triggers. The most distinctive part is what researchers call the “trauma narrative.” A child dictates their own mini-memoir with the aid of a therapist who elicits their story, transcribes their responses, and helps them process their thoughts and feelings during the writing.

During TF-CBT, says Carla Stover, “Children shift from their trauma being this terrible thing that has ruined their life and defines who they are, to it being this thing that happened to them and changed them in various ways, but they know they can be happy again and they can live their lives. It puts the trauma experience into the context of their whole lives.”

The point is the journey, not the result. The narrative is not meant to be an elaborate disquisition on their childhood, nor profound prose, or even a really good read. What matters is the process of understanding how their traumatic experience has impacted their feelings and thoughts, and talking about the experience to someone who listens, so that the trauma will no longer hold so much power over how they feel.  

Many of these studies were on hold during the pandemic, but now the researchers have returned to their work, excited to continue projects that they hope will lead to a more nuanced understanding of the developing child’s brain, from the inside and out.

“One of the really amazing things about being a researcher at a place like Yale,” says Lebowitz, “is that so many people at the top of their game, in different but related areas, are coming together around a topic as important as stress in children.”  

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