The Boy Who Was Raised as a Dog

by Bruce Perry

  The term used to describe babies who are born normal and healthy but don’t grow, or even lose weight following this form of emotional neglect, is “failure to thrive.” Even back in the eighties, when Laura was an infant, “failure to thrive” was a well-known syndrome in abused and neglected children, especially those raised without enough individualized nurturing and attention. The condition has been documented for centuries, most commonly in orphanages and other institutions where there is not enough attention and care to go around. If not addressed early, it can be deadly. One study in the forties found that more than a third of children raised in an institution without receiving individual attention died by age two—an extraordinarily high death rate. The children who survive such emotional deprivation—like the recent Eastern European orphans, one of whom we’ll meet later—often have severe behavioral problems, hoard food, and may be overly affectionate with strangers while having difficulty maintaining relationships with those who should be closest to them.

  When Virginia first sought medical attention for her baby eight weeks after she was born, Laura was correctly diagnosed with “failure to thrive” and was admitted to the hospital for nutritional stabilization. But the diagnosis wasn’t explained to Virginia. Upon being discharged she was only given nutritional advice, not advice on mothering. A social work consult had been suggested yet it was never ordered. The issue of neglect was ignored by the medical team in large part because many physicians find “psychological” or social aspects of medical problems less interesting and less important than the primary “physiological” issues. Further, Virginia didn’t seem like a neglectful mother. After all, would an uncaring mother seek out early intervention for her newborn?

  And so, Laura still didn’t grow. Several months later Virginia brought her back to the emergency room seeking help. Unaware of Virginia’s history of disrupted early attachment, the doctors who saw her child next thought Laura’s problems had to be related to her gastrointestinal system, not her brain. And so began Laura’s four-year medical odyssey of tests, procedures, special diets, surgeries and tube feeding. Virginia still didn’t realize that her baby needed to be held, rocked, played with and physically nurtured.

  Babies are born with the core elements of the stress response already intact and centered in the lower, most primitive parts of their developing brains. When the infant’s brain gets signals from inside the body—or from her external senses—that something is not right, these register as distress. This distress can be “hunger” if she needs calories, “thirst” if she is dehydrated, or “anxiety” if she perceives external threat. When this distress is relieved, the infant feels pleasure. This is because our stress-response neurobiology is interconnected with the “pleasure/reward” areas in the brain, and with other areas that represent pain, discomfort and anxiety. Experiences that decrease distress and enhance our survival tend to give us pleasure; experiences that increase our risk usually give us a sensation of distress.

  Babies immediately find nursing, being held, touched, and rocked soothing and pleasurable. If they are parented lovingly, and someone consistently comes when they are stressed by hunger or fear, the joy and relief of being fed and soothed becomes associated with human contact. Thus, in normal childhood, as described above, nurturing human interactions become intimately and powerfully connected with pleasure. It is through the thousands of times we respond to our crying infant that we help create her healthy capacity to get pleasure from future human connection.

  Because both the brain’s relational and pleasure-mediating neural systems are linked with our stress-response systems, interactions with loved ones are our major stress-modulating mechanism. At first babies must rely upon those around them not only to ease their hunger, but also to soothe the anxiety and fear that come from not being able to obtain food and otherwise care for themselves. From their caregivers they learn how to respond to these feelings and needs. If their parents feed them when they are hungry, calm them when they are frightened and are generally responsive to their emotional and physical needs, they ultimately build the baby’s capacity to soothe and comfort themselves, a skill that serves them well later when they face life’s ordinary ups and downs.

  We’ve all seen toddlers look to Mom after scraping a knee: if she doesn’t look worried, the child doesn’t cry; but if baby sees a look of concern, the loud wailing begins. This is only the most obvious example of the complex dance that occurs between caregiver and child that teaches emotional self-regulation. Of course some children may be genetically more or less sensitive to stressors and stimulation, but genetic strengths or vulnerabilities are magnified or blunted in the context of the child’s first relationships. For most of us, including adults, the mere presence of familiar people, the sound of a loved one’s voice, or the sight of their figure approaching, can actually modulate the activity of the stress-response neural systems, shut off the flood of stress hormones and reduce our sense of distress. Just holding a loved one’s hand is powerful stress-reducing medicine.

  There is also a class of nerve cells in the brain known as “mirror” neurons, which respond in synchrony with the behavior of others. This capacity for mutual regulation provides another basis for attachment. For example, when a baby smiles, the mirror neurons in his mother’s brain usually respond with a set of patterns that are almost identical to those that occur when Mom herself smiles. This mirroring ordinarily leads the mother to respond with a smile of her own. It’s not hard to see how empathy and the capacity to respond to relationships would originate here as mother and child synchronize and reinforce each other, with both sets of mirror neurons reflecting back each other’s joy and sense of connectedness.

  However, if a baby’s smiles are ignored, if she’s left repeatedly to cry alone, if she’s not fed, or fed roughly without tenderness or without being held, the positive associations between human contact and safety, predictability and pleasure may not develop. If, as happened in Virginia’s case, she begins to bond with one person, but is abandoned as soon as she feels comfortable with her particular smell, rhythm and smile, and then abandoned again once she acclimates to a new caregiver, these associations may never gel. Not enough repetition occurs to clinch the connection; people are not interchangeable. The price of love is the agony of loss, from infancy onward. The attachment between a baby and his first primary caregivers is not trivial: the love a baby feels for his caregivers is every bit as profound as the deepest romantic connection. Indeed, it is the template memory of this primary attachment that will allow the baby to have healthy intimate relationships as an adult.

  As a baby Virginia never really got the chance to learn that she was loved; as soon as she grew used to one caretaker, she was whisked off to another one. Without one or two consistent caregivers in her life she never experienced the particular relational repetitions a child needs to associate human contact with pleasure. She did not develop the basic neurobiological capacity to empathize with her own baby’s need for physical love. However, because she did live in a stable, loving home when the higher, cognitive regions of her brain were most actively developing, she was able to learn what she “should” do as a parent. Still, she didn’t have the emotional underpinnings that would make those nurturing behaviors feel natural.

  So when Laura was born, Virginia knew that she should “love” her baby. But she didn’t feel that love the way most people do, and so she failed to express it through physical contact.

  For Laura, this lack of stimulation was devastating. Her body responded with a hormonal dysregulation that impeded normal growth, despite receiving more than adequate nutrition. The problem is similar to what in other mammals is called “runt syndrome.” In litters of rats and mice and even in puppies and kittens, without outside intervention the smallest, weakest animal often dies in the few weeks following birth. The runt doesn’t have the strength to stimulate the mother’s nipple to produce adequate milk (in many species, each baby prefers and suckles exclusively from a particu
lar nipple) or to elicit adequate grooming behaviors from the mother. The mother neglects the runt physically, not licking or grooming him as much as she does the others. This, in turn, further limits his growth. Without this grooming his own growth hormones turn off, so even if he does somehow get enough to eat, he still doesn’t grow properly. The mechanism, rather cruelly for the runt, directs resources to those animals best able to utilize them. Conserving her resources, the mother feeds the healthier animals preferentially, since they have the best chance of surviving and passing on her genes.

  Infants diagnosed with “failure to thrive,” are often found to have reduced levels of growth hormone, which explains Laura’s inability to gain weight. Without the physical stimulation needed to release these hormones, Laura’s body treated her food as waste. She didn’t need to purge or exercise to avoid gaining weight: the lack of physical stimulation had programmed her body do so. Without love, children literally don’t grow. Laura wasn’t anorexic; like the scrawny runt in a litter of puppies, she just wasn’t receiving the physical nurturing her body needed to know that she was “wanted,” and that it was safe to grow.

  WHEN I’D FIRST ARRIVED in Houston, I’d gotten to know a foster mother who often brought children to our clinic. A warm, welcoming person who didn’t stand on ceremony and always spoke her mind, Mama P.* seemed to know intuitively what the maltreated and often traumatized children she took in needed.

  As I considered how to help Virginia help Laura, I thought back on what I’d learned from Mama P. The first time I met her I was relatively new to Texas. I had set up a teaching clinic where we had a dozen or more psychiatrists, psychologists, pediatric and psychiatry residents, medical students and other staff and trainees. This was a teaching clinic designed, in part, to allow trainees to observe senior clinicians and “experts” doing clinical work. I was introduced to Mama P. during the feedback part of an initial evaluation visit for one of her foster children.

  Mama P. was a large, powerful woman. She moved with confidence and strength. She wore a large brightly colored muumuu and had a scarf around her neck. She’d come for a consultation about Robert, a seven-year-old child she was fostering. Three years before our visit, this boy had been removed from his mother’s custody. Robert’s mom was a prostitute who’d been addicted to cocaine and alcohol for her son’s whole life. She had neglected and beaten him; the boy had also seen her beaten by customers and pimps and had himself been terrorized and abused by her partners.

  Since being removed from his home Robert had been in six foster homes and in three shelters. He had been hospitalized for out-of-control behaviors three times. He had been given a dozen diagnoses including attention deficit hyperactivity disorder (ADHD), oppositional deficit disorder (ODD), bipolar disorder, schizoaffective disorder and various learning disorders. He was often a loving and affectionate child, but he had episodic “rages” and aggression that scared peers, teachers and foster parents enough for them to reject him and have him removed from whatever setting he was in after he went on one of his rampages. Mama P. had brought him to us because once again, his inattentiveness and aggression had gotten him into trouble at school and the school had demanded that something be done. He reminded me of many of the boys I had worked with in Chicago at the residential treatment center.

  As I began talking I tried to engage Mama and make her feel comfortable. I knew that people can “hear” and process information much more effectively if they feel calm. I wanted her to feel safe and respected. Thinking back now, I must have seemed very patronizing to her. I was too confident; I thought I knew what was going on with her foster child and the implicit message was, “I understand this child, and you don’t.” She looked at me defiantly, her face unsmiling, her arms folded. I went into long-winded and very likely unintelligible explanation of the biology of the stress response and how it could account for the boy’s aggression and hyper-vigilance symptoms. I had not yet learned how to clearly explain the impact of trauma on a child.

  “So what can you do to help my baby?” she asked. Her language struck me: why was she calling this seven-year-old child a baby? I wasn’t sure what to make of it.

  I suggested clonidine, the medication I’d used with Sandy and the boys at the center. She interrupted quietly but firmly, “You will not use drugs on my baby.”

  I tried to explain that we were quite conservative with medications, but she wouldn’t hear it. “No doctor is going to drug up my baby,” she said. At this point the child psychiatry fellow, Robert’s primary clinician, who was sitting next to me, started to fidget. This was awkward. Mr. Bigshot Vice-Chairman and Chief of Psychiatry was making an ass of himself. I was alienating this mother and getting nowhere. I again tried to explain the biology of the stress response system, but she cut me off.

  “Explain what you just told me to the school,” she said pointedly. “My baby does not need drugs. He needs people to be loving and kind to him. That school and all those teachers don’t understand him.”

  “OK. We can talk to the school.” I retreated.

  And then I surrendered. “Mama P., how do you help him?” I asked, curious about why she didn’t have the problems with his “rages” that had gotten him expelled from prior foster homes and schools.

  “I just hold him and rock him. I just love him. At night when he wakes up scared and wanders the house, I just put him in bed next to me, rub his back and sing a little and he falls asleep.” The fellow was now stealing looks at me, clearly concerned: seven-year-olds should not sleep in bed with their caregivers. But I was intrigued and continued to listen.

  “What seems to calm him down when he gets upset during the day?” I asked.

  “Same thing. I just put everything down and hold him and rock in the chair. Doesn’t take too long, poor thing.”

  As she said this I recalled a recurring pattern in Robert’s records. In every one of them, including the latest referral from the school, angry staff reported frustration with the boy’s noncompliance and immature “baby-like” behaviors, and complained about his neediness and clinginess. I asked Mama P., “So when he acts like that, don’t you ever get frustrated and angry?”

  “Do you get angry with a baby when a baby fusses?” she asked. “No. That is what babies do. Babies do the best they can and we always forgive them if they mess, if they cry, if they spit up on us.”

  “And Robert is your baby?”

  “They are all my babies. It’s just that Robert has been a baby for seven years.”

  We ended the session and made another appointment for a week later. I promised to call the school. Mama P. looked at me as I walked with Robert down the clinic hall. I joked that Robert needed to come back to teach us more. At that, she finally smiled.

  Over the years Mama P. continued to bring her foster children to our clinic. And we continued to learn from her. Mama P. discovered, long before we did, that many young victims of abuse and neglect need physical stimulation, like being rocked and gently held, comfort seemingly appropriate to far younger children. She knew that you don’t interact with these children based on their age, but based on what they need, what they may have missed during “sensitive periods” of development. Almost all of the children sent to her had a tremendous need to be held and touched. Whenever my staff saw her in the waiting room holding and rocking these children, they expressed concern that she was infantilizing them.

  But I came to understand why her overwhelmingly affectionate, physically nurturing style, which I’d initially worried might be stifling for older children, was often just what the doctor should order. These children had never received the repeated, patterned physical nurturing needed to develop a well-regulated and responsive stress response system. They had never learned that they were loved and safe; they didn’t have the internal security needed to safely explore the world and grow without fear. They were starving for touch—and Mama P. gave it to them.

  NOW, A S ISAT with Laura and her mother, I knew that they both could benef
it, not only from Mama P.’s wisdom about childrearing, but also from her own incredibly maternal and affectionate nature. I went back to the nurse’s station, dug out her phone number, and called. I asked her if she’d be willing to have a mother and her child move in with her, so that Virginia could learn how to raise Laura. She immediately agreed. Fortunately, both families were involved in a privately funded program that allowed us to pay for this kind of care, which the foster care system is usually too inflexible to permit.

  Now, I had to convince Virginia—and my colleagues. When I returned to the room where she was waiting, Virginia seemed anxious. My psychiatry colleague had given her one of the papers I had written that focused on our clinical work with abused children. Virginia assumed that I had deemed her an incompetent parent. Before I could even speak, she said, “If it will help make my baby better, please take her.” Virginia did love her baby—so much that she was willing to let her go if that’s what it took for her to recover.