PDF Summary:The Boy Who Was Raised as a Dog, by Bruce D. Perry and Maia Szalavitz

In The Boy Who Was Raised as a Dog, child psychiatrist Bruce Perry describes a series of child abuse and neglect cases to illustrate how trauma impacts the developing brain and explain how he and his colleagues established a more effective therapy model for traumatized children.

In our guide, we’ll explain the psychiatric principles that Perry discovered during his years of working with traumatized children, including the stress response, the effects of trauma in infancy versus trauma at a later age, dissociation in response to trauma, and the role that relationships play in the treatment of traumatized children. We’ll also look at specific case studies that contributed to Perry’s Neurosequential Model of Therapeutics. Our commentary explores research supporting and expanding on Perry’s ideas, as well as scientific and social context on how trauma can manifest and the nuances of treatment.

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The Physical Consequences of Touch Deprivation in Infancy: Laura’s Case

Deprivation of physical stimulation in infancy can also have a major impact on infants’ physical development. As mentioned earlier, physical touch is initially stressful for infants, as it’s a sensation they’re not used to. In order to properly develop their stress response systems and make touch less stressful and ultimately soothing, infants need a great deal of loving physical touch. The stress response has a direct impact on the body’s hormone regulation, so a lack of touch can inhibit the release of growth hormone and stunt physical growth—a condition called “failure to thrive,” or the inability to develop physically despite receiving sufficient calories and nutrients.

This was the case with Laura, a four-year-old who weighed just 26 pounds when Perry met her. (Shortform note: For context, the average weight for a healthy four-year-old is about 40 pounds.) In talking with Laura’s mother Virginia, Perry discovered that the woman had no knowledge or experience of loving, attentive care herself, and she simply didn’t know that she needed to hold her baby during feeding, rock her when she cried, and so on. Laura’s stress response systems weren’t developing properly due to lack of physical touch, and as a result, her body wasn’t producing enough growth hormone, so it couldn’t develop or grow. Once Virginia learned to provide this vital stimulation, Laura began thriving.

(Shortform note: Research suggests that physical touch is so vital to our ability to thrive that infants will die if they’re not touched enough. Some children are able to overcome it, as Laura did. But for others, touch deprivation at an early age can have lifelong consequences. Children deprived of touch in infancy often grow up to have cognitive deficits, neurological impairments, and emotional and behavioral problems. Adults who were deprived of touch at an early age are more likely to be aggressive and to struggle with substance abuse problems and suicidal tendencies. )

Trauma at Later Ages: Associations and the Dissociative Response

These cases demonstrated that stress and trauma in infancy could have long-lasting impacts. Some of Perry’s other cases showed how trauma later in childhood could impact children’s behavior differently. Below, we’ll first explain how the brain stores information, including traumatic experiences. Then we’ll look at the dissociative stress response and how it differs from the hyperarousal response described earlier.

Traumatic Associations: Tina’s Case

Perry explains that the brain stores information in the form of memories and associations. Associations, like those between caregiving and the brain’s reward centers, occur when two neural patterns are activated at the same time again and again, eventually forming a new set of connections between areas of the brain. These connections then help us navigate future experiences that activate the same brain areas. Because these connections become stronger with each use, the connections we form from early experiences—and therefore have used more—are more difficult to change than the ones we acquire later.

To illustrate the role of associations in trauma, Perry describes the case of a young girl named Tina. At the age of seven, she was engaging in sexually inappropriate behaviors with peers and acting out in aggressive ways. She also behaved impulsively and had trouble paying attention in school. Tina’s mother explained her history, and Perry learned that Tina had been sexually abused by a neighbor’s teenage son over the course of two years.

The associations formed in Tina’s brain from this experience caused an automatic stress response when she was around men, and the memory template she had developed based on the traumatic experiences taught her to try to appease them (and thus reduce the threat they posed) with sex. This association is what led her to behave inappropriately even with men who had never preyed on her. Additionally, the constant engagement of her stress response system led her to be on high alert for threats at all times, making it difficult for her to focus on schoolwork and control her impulses.

Implicit vs. Explicit Associations

Mental associations can be either explicit or implicit. Explicit associations are conscious, meaning you’re aware of them, but implicit associations are unconscious, so they operate beyond your conscious awareness. For example, if you were asked if you think dogs make good pets, you might reflect on the explicit association of seeing a child delightedly playing with their pet poodle; but if you had a frightening experience with a dog at a young age, you might have internalized an implicit association between dogs and stress, causing you to have a negative attitude toward dogs that you may not consciously understand.

Generally, Perry uses “associations” to refer to implicit rather than explicit associations.

We can infer that the memory templates that Tina had developed from her experiences were implicit: When she encountered men or boys, she didn’t experience a conscious thought process of, “This person could be a threat to me; this person probably wants sex; I should appease them by behaving sexually.” Rather, her behavior was the result of unconscious processes in her brain devoted to trying to keep her safe.

These processes may also have been closely related to Tina’s sexual self-concept—or how she perceived herself as a sexual being. Research suggests that child sexual abuse can cause a victim to view themself as a sexual object that exists only to satisfy others’ sexual desires. This can continue to affect victims in adulthood, resulting in feelings of shame, negative feelings toward sex, or feelings of validation through sex.

A Flaw in the Therapy Model: Short, Infrequent Treatment Sessions

After three years of working with Perry, Tina’s behavioral problems seemed to stop. However, at age 10, Tina got in trouble for giving oral sex to an older boy in school. Perry suggests that he had failed in his therapy with her and that, rather than helping her improve her behavior, he’d only taught her how to hide her problems.

(Shortform note: It’s common for people who’ve received therapy for trauma-related conditions to experience setbacks or backsliding like Tina did. According to experts, this is not a sign that therapy has failed—as Perry suggests—but is, in fact, a normal part of healing.)

Perry realized that the model of one hour per week of therapy wasn’t sufficient to undo the ingrained associations that Tina had. In fact, as Perry amended later, therapy can’t undo associations at all. Instead, you have to create new associations that will eventually replace the old ones in guiding the patient’s behavior. You can do this by providing the patient with frequent, repeated experiences to form and strengthen new neural connections. In Tina’s case, her experiences with sexual abuse by a man had formed a harmful association with males, so she needed repeated experiences with safe men in non-sexual contexts to help her form new templates and behave more appropriately.

Synaptic Pruning and Health Insurance

While therapy itself can’t undo associations, when you replace negative associations with positive ones, the old ones fall out of use and eventually disappear through a process called synaptic pruning. This is when the brain eliminates neural connections that have gone unused for a long time (and therefore are assumed unimportant for survival). This process frees up space for connections that are used more frequently. Pruning can take a long time, though it occurs more rapidly during certain periods of life: It’s very fast between the ages of two and ten, then slows down during early adulthood.

Frequent, long-term treatments that create new associations and prompt patients’ brains to engage in synaptic pruning can be financially difficult for patients, however. In the United States, the average therapy session costs $100 to $200, and many therapists don’t accept insurance so the costs are entirely out-of-pocket. And even in cases where a therapist does take insurance, claims denials are a frequent problem due to minor clerical errors like spelling or coding issues. The appeals process can be daunting and difficult to navigate, and it often feels overwhelming for people who are already struggling with their mental health.

Dissociation as a Stress Response

In many of the cases Perry describes in which children’s stress response systems become overactive due to excessive stimulation, physiological checks on the children showed that their heart rates were elevated, a sign of the fight or flight response.

However, the body has other ways to respond to stress depending on the situation. In cases where a threat is too great to escape or fight off, the brain may activate a dissociative response—a response particularly common in children, who often lack the physical or mental means to fight or flee from a threat. Dissociation prepares the body to endure physical harm: It slows breathing and reduces blood flow and heart rate, which can help the body avoid bleeding to death, and the brain releases natural opioids that can alleviate pain and help the person detach psychologically from what’s happening to them.

Both hyperarousal and dissociative responses occur on a spectrum: Hyperarousal may look like a slightly elevated heart rate and nervousness or full-blown panic. Dissociation may take the form of daydreaming, or in extreme cases may cause the person to completely detach from reality and withdraw into their own mind. They become calm and numb, time seems to slow, and it feels as if what’s happening to them isn’t real and like they’re watching it happen to someone else. Additionally, these responses rarely occur in complete isolation: Most trauma responses involve a combination of hyperarousal and dissociation.

Dissociative Disorders: How Dissociation Manifests When It Occurs Too Often

As with the hyperarousal response, activating the dissociative response too frequently can result in a disorder in which the response is activated even in the absence of a real threat. These are known as dissociative disorders. The DSM-5 recognizes three major types of dissociative disorders: depersonalization/derealization disorder, dissociative amnesia, and dissociative identity disorder.

Depersonalization-derealization disorder is characterized by feelings of detachment and numbness. With depersonalization, the person feels detached from their identity and their own existence, like they’re watching themself from a distance. With derealization, the person feels detached from reality itself. A person may experience just one of these types of dissociation or both.

Dissociative amnesia occurs when the dissociative response results in significant memory loss, such as being unable to remember a certain period of time (like a traumatic incident) or being unable to remember details about one’s life.

Dissociative identity disorder (previously known as multiple personality disorder) occurs when a person has multiple identities. In such cases, the identities are referred to as alternate identities, or just alters, and a collection of alters is known as a multiple system. As with the other dissociative disorders, this tends to result from severe childhood trauma. When a situation is too overwhelming, an alter may appear or take control of the body to keep the person safe from what’s happening to them.

Experiencing dissociation doesn’t necessarily mean you have a dissociative disorder, and dissociation can be a symptom of other disorders or a side effect of some medications. Dissociative experiences can also co-occur with hyperarousal-type experiences such as panic attacks. Lastly, though dissociation and psychosis share some characteristics, they’re not the same thing. While they can both involve a sense of detachment from the world and may result from trauma—and a psychotic episode may be preceded by dissociation—psychosis usually involves delusions and hallucinations, which are not typically characteristics of dissociation.

A Natural Opioid Overdose: Amber’s Case

To illustrate the danger of dissociation, Perry describes the case of Amber, a teenage girl who was hospitalized after being found unconscious in the bathroom at her school. She remained comatose for several hours, and at one point her heart stopped and she had to be resuscitated. Tests showed no medical reason for her loss of consciousness, but in talking with Amber’s mother, Perry discovered that Amber had been sexually abused by one of her mother’s boyfriends over the course of two years, starting when she was seven.

Perry learned from Amber that during these instances of abuse, she dissociated in order to endure the trauma, retreating to a safe place in her mind. This safe place was so immersive that it kept her from feeling the physical sensations of what was happening to her body. Because of the associations she developed as a result of this, any reminder of that boyfriend could induce an involuntary dissociation, even long after the abuse ended.

(Shortform note: Amber’s experience doesn’t seem reflective of any of the three major dissociative disorders but might be described as a specified dissociative disorder—which refers to a dissociative disorder that doesn’t fit into any of the three major diagnoses described above. As with many coping mechanisms, Amber’s safe place was useful for her survival at the time but became problematic later. However, some people use a “safe place” for reasons unrelated to trauma: Some people like to consciously establish a safe place in their mind to help them relax or for meditative purposes. This can be a useful tool, but it’s different from the immersion of dissociation.)

The night before her hospitalization, Amber had answered a call from her mom’s abusive boyfriend, and he mentioned that he might come visit them. Perry theorized that this call had activated a serious threat response in Amber because her experiences had sensitized her to any stressors related to that boyfriend. Her brain released so many natural opioids to cope with the expected harm that she essentially overdosed on them. His suspicions were confirmed when they brought her back to consciousness by administering an anti-overdose drug.

(Shortform note: A sudden onset of mental illness symptoms is often preceded by an unexpected trigger like the call that Amber answered. Because of this, some experts suggest that asking a patient what was happening just before their symptoms were triggered is one of the most important things a therapist can do. This can help a patient get to the root cause of their issue rather than just treating the symptoms.)

Treating Childhood Trauma: Perry’s Neurosequential Model of Therapeutics

The model that Perry developed for psychiatric treatment—the Neurosequential Model of Therapeutics—is founded on the premise that neural development must occur in order, and that if a child misses a developmental milestone due to the effects of their environment (such as abuse, neglect, or other trauma), that milestone can’t be “skipped over.” For example, if a child is not spoken to during their early childhood years, they won’t develop the language skills needed to speak or understand others at the same time other children do, and depending on the extent of the deprivation, they may never develop their language faculties at all.

And, since brain development is cumulative, if a milestone is missed, the functions that build on that milestone won’t develop properly either. The brain will still require a specific type of stimulation to develop that foundational function or region. This means that we can’t treat traumatized children based on their chronological age; rather, we must treat them based on their developmental age.

(Shortform note: The psychological term used to describe the state of someone who hasn’t progressed past a certain point in their development is arrested development. Psychologists note that when children experience trauma, it can pause their emotional development in particular. For others, the trauma may also lead to age regression, which is when you achieve a certain level of developmental maturity but then revert back to feelings or behavior from an earlier period. Age regression may occur as an involuntary symptom of arrested development, but it can also be used as a voluntary coping mechanism or therapeutic treatment. For example, a therapist might have someone return to their childhood state of mind to process trauma from that time.)

What Does Effective Therapy Look Like?

According to Perry, effective trauma therapy must have certain characteristics: It must involve regular, repeated experiences that build on the patient’s existing skills and target their needs; it must take place in a predictable environment in which the patient feels safe; and it must be patient-directed and voluntary.

Therapists drawing on the Neurosequential Model of Therapeutics progress through the following four steps:

1. Understand the patient’s history, including the type of trauma they experienced and when they experienced it, as well as the patient’s relationships with others.
2. Understand the patient’s current status, including their strengths, needs, and the quality of their relationships with others.
3. Create a treatment plan that builds on the patient’s skills and targets their needs.
4. Implement the treatment plan and adjust it as needed.

(Shortform note: Even with the best therapist and a plan that includes the steps that Perry describes, therapy may not be effective if the patient can’t adhere to the treatment plan. Experts suggest that patients’ ability and willingness to adhere to a therapeutic treatment plan depends on six factors: 1) believing the therapy will work, 2) understanding how the therapy will help them, 3) understanding how to use the plan, 4) having the ability to act when needed, 5) having the resources to act when needed, and 6) having a reward to reinforce the desired behavior and beliefs. Because child therapy may be more adult-directed, adults will need to help facilitate these conditions.)

Implementing the Neurosequential Model: Justin’s Case

We’ll explore a few cases to see how the Neurosequential Model can be applied in the real world. Perry explains that one of the first cases in which he employed his Neurosequential Model was the case of Justin, whose story lent itself to the title of this book.

For the first 11 months of his life, Justin was raised by a loving grandmother, but her death left him in the care of her boyfriend Arthur, who had no child-rearing experience or knowledge. Arthur raised dogs, and because this was the only way he knew to care for another being, he raised Justin in a cage along with them. By age six, Justin couldn’t speak or walk.

(Shortform note: While Justin’s case was important confirmation of the effectiveness of Perry’s model, some reviewers have criticized its use in the book’s title—they see it as a sensationalization of trauma and abuse rather than an accurate description of the book’s content. This generally aligns with widespread criticism of the way the media sensationalizes these topics, which research suggests can re-traumatize victims and cause distress and post-traumatic stress symptoms in children.)

The Importance of Patient History

Noticing his poor development, Arthur brought Justin to the hospital many times. Justin’s head and brain were significantly smaller than the average child his age, but the doctors never thought to ask Arthur about his living situation. They believed he had a birth defect that had caused permanent damage to his brain. They failed to consider the patient’s history, which, as explained earlier, is the vital first step in treating traumatized children.

When Perry met him, Justin—who had been brought to the hospital to be treated for pneumonia—was in a cage-like crib, where he would scream and throw food and feces at anyone who came in to see him.

(Shortform note: Patient history is vital not only to understanding what triggered the patient’s current status, but also to preventing any harm from befalling the patient as a result of the therapy. For example, failing to learn a patient’s history could lead a doctor to prescribe a medication the patient is allergic to, or to prescribe a treatment plan that the patient has already tried and found ineffective in the past.)

The Importance of a Safe Environment

The first thing Perry did was create an environment in which Justin felt safe. He had him moved to a private hospital room, reduced the number of staff who saw him to increase the consistency among his carers, and began treatments like speech and physical therapy. Justin showed rapid improvement—he stopped throwing things and began smiling and responding to verbal communication within days. Shortly after that, he began walking and learned basic skills like using silverware and dressing himself. Perry says his mind seemed to be soaking up these new experiences like it was starving.

Perry had learned the importance of repeated and patterned stimulation of the brain in creating neural changes, but this case highlighted how necessary it was that such stimulation take place in an environment that felt both safe and predictable to the patient. This, too, formed a fundamental piece of Perry’s therapeutic model.

(Shortform note: Since so much of children’s time is spent in school, teachers may have a positive effect on their development by creating safe, predictable environments that meet their students’ needs—particularly those affected by trauma. Experts suggest that teachers can do this by collaborating with their students in establishing the classroom environment. Students feel safer when they can have a say in the class’s rules and routines, which, as Perry’s model suggests, makes it easier for them to function and heal.)

Trusting Children as Patients and Carers

Perry’s model involves placing a great deal of trust in children. As explained earlier, understanding a patient’s history of trauma and development is essential to their treatment. In the cases discussed so far, Perry was able to gain a workable understanding of these patients’ histories based on talking with their parents or caregivers. But sometimes, parents’ stories differ from the ones their children tell. It’s often our first instinct to believe parents and other adults over children when it comes to misbehavior. However, Perry recommends always listening to the child to truly understand their experiences.

Listening to the Child: James’s Case

Perry describes a case of a six-year-old boy named James with severe medical and behavioral problems, including running away from home, jumping out of moving cars, and an attempted suicide via drug overdose. He was initially diagnosed with reactive attachment disorder (RAD), but Perry doubted this, due to the boy’s ability to form close personal bonds.

James told the medical staff in confidence that his mom was lying and hurting him, and he asked them to call the police. Perry realized the issue was James’s mother—she had Munchausen by proxy syndrome and was harming him to get attention for herself. Had Perry and the medical staff not listened to James, his mother may have ultimately killed him.

Parents Who Hide Their Abuse From Medical Staff

While it’s essential for medical staff to listen to children and be on the lookout for abuse, they may not always have the opportunity to do so; some abusive parents will refrain from seeking medical treatment for their children because they don’t want to be caught. For example, in A Child Called It, Dave Pelzer explains how his mother brutally abused him, and even when she inflicted potentially life-threatening injuries, she never took him to the hospital.

Similarly, in If You Tell, Gregg Olsen describes how convicted murderer Shelly Knotek subjected her children to years of violence and cruelty—and, like Dave’s mother, she refrained from taking them to the hospital for serious injuries because she knew she wouldn’t be able to explain the many other injuries on their bodies.

In these cases, the adults who had the opportunity to report this vicious child abuse were not medical staff but rather school staff who saw the children frequently. Knotek’s daughters often wore long tights and sleeves to cover the bruises on their bodies, hiding their injuries from people at school. However, in Pelzer’s case, school staff were aware of the ever-present injuries on Dave’s body, but they didn’t report them to the police until Dave admitted they came from his mother’s abuse (and due to the laws at the time, the school staff were risking their jobs by reporting the abuse).

Today, most states legally require teachers and other school staff to immediately report any suspected child abuse or neglect to authorities. To help prevent abuse, school staff should be on the lookout for signs such as the following: unexplained bruises or other injuries, breathing problems, aggression or behavioral changes, signs of self-harm, hygiene problems, or social withdrawal. Teachers may also note signs in the way caregivers interact with their child, such as belittling, isolating, or harshly disciplining the child.

Children Helping Each Other: Peter’s Case

Perry also explains how children can help each other in their treatment, using the case of Peter, who was born in a Russian orphanage and only received a few minutes of basic interaction per day. As such, he missed out on vital caregiving responses like those described earlier. When he started school in America, he had severe deficits in language and social skills and was prone to long, frightening, and aggressive outbursts.

Peter’s peers feared him and didn’t interact with him, which made things worse. Once Perry visited Peter’s class and explained Peter’s background and why he behaved the way he did, the other children opened up to Peter. They invited him to play, sometimes even arguing over who got to be his partner in class activities. Peter improved rapidly as a result of these supportive relationships, and Perry explains that these children gave him more therapeutic treatment than the adults in his life ever could have.

(Shortform note: Behaviors that lead to social ostracism may result from trauma, but they can also be characteristic of neurodivergent conditions like autism: Research suggests that autistic children are eight times more likely to experience social ostracism than their non-autistic peers. Being ostracized by peers results in lower self-esteem, emotional and academic difficulties, misbehavior, and social avoidance. In the same way that educating Peter’s peers about trauma helped them accept him socially, it’s possible that educating children about neurodivergent conditions could reduce the amount of alienation and isolation such children experience.)

The Importance of Community

Many of these cases highlight another major point that Perry emphasizes: the importance of community in child-rearing. He explains that humans are extremely social creatures, and because of this, relationships are the most important factor in both facilitating healthy development and healing trauma. Unfortunately, he says, our society has become more and more isolated over the past few centuries. Whereas people used to exist in small communities that all contributed to childcare, people today are increasingly living in isolation, leading to higher rates of mental illness and fewer caregiving resources for families.

In older societies, a parent’s lack of knowledge about child-rearing would have been supplemented by the community, but because we’ve shifted so far away from communal living, it tends to fall solely on parents (and especially mothers) to provide for children’s vast and complex needs. Perry suggests that societal changes conducive to creating high-quality relationships between people would go a long way in protecting and healing children from trauma.

(Shortform note: Research supports Perry’s theories about the importance of community in raising healthy children: Experts note a decline in empathy and an increase in mental illness and aggression in young people over the past 50 years. They suggest this change may be the result of a shift away from our ancestors’ model of childcare, which included near-constant nurturing physical touch for infants, prompt—and even pre-emptive—responses to babies’ distress signals, plenty of play, and the collaboration of several adults (not just parents) in childcare. Similar to Perry’s argument, other experts suggest that returning to the traits of this more communal model could greatly improve the well-being of children and young adults.)