The Boy Who Was Raised as a Dog

by Bruce Perry

  During this time speech and language therapists helped him begin to speak, providing the exposure to words he’d missed in his childhood. His once dormant, undeveloped neural networks began to respond to these new repetitive patterns of stimulation. His brain seemed to be like a sponge, thirsty for the experiences it required, and eagerly soaking them up.

  After two weeks, Justin was well enough to be discharged from the hospital and placed in a foster family. For the next few months he made remarkable progress. This was the most rapid recovery from severe neglect that we had yet seen. It changed my perspective on the potential for change following early neglect. I became much more hopeful about the prognosis for neglected children.

  SIX MONTHS LATER Justin was transferred to a foster family who lived much further away from the hospital. While we offered our consultation services to his new clinical team, ultimately we lost track of him in the massive caseload that our group was beginning to attract. But we often talked about Justin when we consulted with other families who had adopted severely neglected children; he had made us reevaluate how we assessed and treated such children. We now knew that at least some of them could improve more dramatically than we’d previously dared to dream.

  About two years after Justin’s hospital stay a letter came to the clinic from a small town—a brief note from the foster family giving us an update on the little boy. He was continuing to do well, rapidly hitting developmental milestones that no one had ever expected him to reach. Now eight, he was ready to start kindergarten. Enclosed was a picture of Justin all dressed up, holding a lunch box, wearing a backpack and standing next to a school bus. On the back of the note, in crayon, Justin himself had written, “Thank You, Dr. Perry. Justin.” I cried.

  TAKING WHAT I’D LEARNED from Justin’s case—that patterned, repetitive experience in a safe environment can have an enormous impact on the brain—I began to integrate Mama P.’s lessons about the importance of physical affection and stimulation into our care. One of the next cases that would help us develop the neurosequential approach was that of a young teenager whose early life experience turned out to have been similar to that which had started Leon on his destructive and ultimately murderous path.

  Like Leon, Connor had an intact nuclear family and an early childhood that, on the surface, did not seem traumatic. Connor’s parents were both successful, college-educated businesspeople. Like Leon, Connor had an above-average IQ but, unlike him, he did well in school. When we did a simple review of his previous psychiatric treatment, we noted that he had been given, at various points, more than a dozen different neuropsychiatric diagnoses starting with autism, then ranging from pervasive developmental disorder, childhood schizophrenia, bipolar disorder, ADHD, obsessive-compulsive disorder (OCD), major depression, anxiety disorder and more.

  When the fourteen-year-old was first brought in to see me he was labeled with the diagnoses of intermittent explosive disorder, psychotic disorder and attention deficit disorder. He was taking five psychiatric medications and was being treated by a psychoanalytically trained therapist. He walked with an uneven, awkward gait. When he was anxious or distressed he would sway, rhythmically flex his hands and hum to himself in a tuneless drone that set most people’s nerves on edge. He would frequently sit and rock back and forth, just like Justin had when I’d first seen him in that cage/crib. He had no friends: he hadn’t become a bully like Leon, but he was a favored target for them. Connor had been placed in a social skills group in an attempt to address his isolation and poor relational skills but, so far, it had been an utter failure. It was, I would soon discover, as though the group had been trying to teach an infant calculus.

  Connor was certainly relationally odd but he did not show the classic symptoms of either autism or schizophrenia. His behaviors were similar to children with those conditions, but he did not, for example, have the “mind-blindness” and indifference to relationships that mark autism or the disordered thought common to schizophrenia. When I examined him I could see that he sought to engage with other people, which is rare among those with genuine autism. He was socially inept, to be sure, but did not have the complete disinterest in social connection that is essentially the hallmark of autism. The boy was also on so many medications that no one could tell which of his “symptoms” were related to his original problems and which were caused by medication side effects. I decided to stop the drugs. If medication turned out to be necessary, I would reintroduce it.

  Connor’s peculiar symptoms and their lack of concordance with typical cases of autism or schizophrenia reminded me of those I’d seen in other children who had suffered early trauma or neglect, like Justin. In particular, I suspected from the curious slanting gait that whatever had gone wrong had started early in infancy, because coordinated walking relies on a well-regulated midbrain and brainstem, regions crucial for coordinating the stress response. Since the brainstem and midbrain are among the earliest regions to organize during development, if something had gone wrong here, it had probably gone wrong in the first year of life.

  I took a careful developmental history and questioned Connor’s mother, Jane,* about her son’s early childhood and about her own as well. She was a bright woman, but anxious and clearly near the end of her rope. Her own childhood hadn’t been troubled. She had been an only child, brought up by loving parents. Unfortunately for Connor, however, she didn’t live near extended family or spend much time babysitting as a teenager. As a result, until she had her own child, she had little experience with infants and toddlers. It’s common in our mobile modern society to have fewer offspring, live further away from our families and move in an increasingly age-segregated world, and therefore many of us aren’t around children enough to learn about how they should behave at each stage of development. Furthermore, our public education includes no content or training on child development, caregiving or the basics of brain development. The result is a kind of “child illiteracy,” which would unfortunately play a large role in what went wrong for Connor, just as it did for Leon.

  A few years before their son’s birth, Jane and her husband, Mark,* moved from New Jersey to New Mexico to set up a new business, which thrived. Now that they were financially set, the couple decided to try for a child and soon Jane became pregnant. She received excellent prenatal care, had a normal delivery, and the child was born robust and healthy. But their family business was so demanding that Jane returned to the office just a few weeks after having her baby. Jane had heard horror stories about daycare, so she and her husband decided to hire a nanny. Coincidentally, a cousin of Jane’s had recently moved to the community and was looking for work, so hiring her seemed to be the ideal solution to both of their problems.

  Unfortunately, unbeknownst to Jane and Mark, the cousin took another job just after agreeing to work for them. Wanting to make extra money, she didn’t tell Jane or Mark that she was leaving the child on his own and working another job. She fed and changed the baby in the morning, left for work, fed and changed him at lunch time, and then returned just before his parents came home from their jobs. She worried about diaper rash, or about the possibility of a fire or other danger while the child was on his own, but not about how damaging her actions could be. This cousin was even more ignorant of child development than Jane was: she didn’t realize that infants need affection and attention just as much as they need nutrition, hydration, dry clothes and shelter.

  Jane told me she felt guilty about returning to work so soon. She described how, for the first two weeks after she returned to the office, Connor’s cries as she left him were terribly distressing. But after that, he stopped crying, so Jane thought everything was fine. “My baby was content,” she told me, describing how even when she accidentally stuck him with a safety pin, Connor didn’t even whimper. “He never cried,” she said, emphatically, not aware that if a baby never cries, this is as much a sign of potential problems as crying too much can be. Again, she was stymied by ignorance of basic child development. Like Maria,
she thought that a quiet baby meant a happy baby.

  Within a few months, however, Jane began to suspect that something was wrong. Connor didn’t seem to be maturing as fast as her friends’ babies did. He wasn’t sitting up or turning over or crawling at the ages that others reached those milestones. Concerned about his lack of progress, she took him to the family’s pediatrician, who was excellent at recognizing and treating physical diseases, but didn’t know much about how to check for mental and emotional difficulties. She didn’t have children of her own, so she was not personally familiar with their psychological development and, like most doctors, hadn’t been given much education on it. The doctor also knew the parents well, so she had no reason to suspect abuse or neglect. Consequently, she didn’t ask, for example, whether Connor cried or about how he responded to people. She simply told Jane that babies develop at different rates and tried to reassure her that he would catch up soon.

  One day, however, when Connor was about eighteen months old, Jane came home from work sick. The house was dark, so she assumed the nanny had taken the child out. There was a terrible smell coming from Connor’s room. The door was part way open, so she peeked in. She found her son sitting in the dark, alone, with no toys, no music, no nanny and a full, dirty diaper. Jane was horrified. When she confronted her cousin, the woman confessed that she had been leaving Connor and going to the other job. Jane fired the cousin and quit her job to stay home with the baby. She thought she’d dodged the bullet: she thought that because he hadn’t been kidnapped, harmed in a fire or become physically ill, the experience would have no lasting effects. She didn’t connect his increasingly odd behavior with over a year of near-daily neglect.

  As he grew socially isolated and began to engage in peculiar, repetitive behaviors, no one in the mental health system, no one in the school system, not one of the special education teachers or occupational therapists or counselors to whom he was sent discovered Connor’s history of early neglect. Hundreds of thousands of dollars and hundreds of hours were spent fruitlessly trying to treat his various “disorders.” The result was this fourteen-year-old boy, rocking and humming to himself, friendless and desperately lonely and depressed; a boy who didn’t make eye contact with other people, who still had the screaming, violent temper tantrums of a three- or four-year-old; a boy who desperately needed the stimulation that his brain had missed during the first months of life.

  When Mama P. had rocked and held the traumatized and neglected children she cared for, she’d intuitively discovered what would become the foundation of our neurosequential approach: these children need patterned, repetitive experiences appropriate to their developmental needs, needs that reflect the age at which they’d missed important stimuli or had been traumatized, not their current chronological age. When she sat in a rocking chair cuddling a seven-year-old, she was providing the touch and rhythm that he’d missed as an infant, experience necessary for proper brain growth. A foundational principle of brain development is that neural systems organize and become functional in a sequential manner. Furthermore, the organization of a less mature region depends, in part, upon incoming signals from lower, more mature regions. If one system doesn’t get what it needs when it needs it, those that rely upon it may not function well either, even if the stimuli that the later developing system needs are being provided appropriately. The key to healthy development is getting the right experiences in the right amounts at the right time.

  Part of the reason for Justin’s rapid response to our therapy, I soon recognized, was that he had had nurturing experiences during his first year of life, before his grandmother had died. This meant his lowest and most central brain regions had been given a good start. If he’d been raised in a cage from birth, his future might have been far less hopeful. It worried me that Connor, like Leon, had suffered neglect virtually from birth to eighteen months. The one hope was that during the evenings and weekend hours when his parents were caring for him there was at least some exposure to nurturing sensory experiences.

  Drawing on these insights, we decided that we would systematize our approach to match the developmental period at which the damage had first started. By looking carefully at Connor’s symptoms and his developmental history, we hoped we could figure out which regions had sustained the most damage and target our interventions appropriately. We would then use enrichment experiences and targeted therapies to help the affected brain areas in the order in which they were affected by neglect and trauma (hence, the name neurosequential). If we could document improved functioning following the first set of interventions, we would begin the second set appropriate for the next brain region and developmental stage until, hopefully, he would get to the point where his biological age and his developmental age would match.

  In Connor’s case it was clear that his problems had started in early infancy when the lower and most central regions of the brain are actively developing. These systems respond to rhythm and touch: the brainstem’s regulatory centers control heartbeat, the rise and fall of neurochemicals and hormones in the cycle of day and night, the beat of one’s walk and other patterns that must maintain a rhythmic order to function properly. Physical affection is needed to spur some of the region’s chemical activity. Without it, as in Laura’s case, physical growth (including the growth of the head and brain) can be retarded.

  Like Leon and others who have suffered early neglect, Connor couldn’t stand to be touched. At birth human touch is a novel and, initially, stressful stimulus. Loving touch has yet to be connected to pleasure. It is in the arms of a present, loving caregiver that the hours upon hours of touch become familiar and associated with safety and comfort. It seems that when a baby’s need for this nurturing touch isn’t satisfied, the connection between human contact and pleasure isn’t made and being touched can become actively unpleasant. In order to overcome this and help provide the missing stimuli, we referred Connor to a massage therapist. We would focus first on meeting his needs for skin-to-skin contact; then, we hoped, we could further address his asynchronous bodily rhythms.

  As we saw in Laura’s case, touch is critical to human development. Sensory pathways involved in the experience of touch are the first to develop and are the most fully elaborated at birth compared to sight, smell, taste and hearing. Studies of premature babies find that gentle, skin-to-skin contact helps them gain weight, sleep better and mature more quickly. In fact, preemies who received such gentle massage went home from the hospital almost a week earlier on average. In older children and adults massage has also been found to lower blood pressure, fight depression and cut stress by reducing the amount of stress hormones released by the brain.

  Our reason for starting with massage was also strategic: research finds that parents who learn infant and child massage techniques develop better relationships with their children and feel closer to them. With children who have autism or other conditions that make them seem remote, creating this sense of closeness can often rapidly improve the parent-child relationship and thus escalate the parents’ commitment to therapy.

  This was particularly important in Connor’s case because his mother was very anxious about our approach to his treatment. After all, previous psychologists, psychiatrists, counselors and well-meaning neighbors and teachers kept telling her not to indulge his “babyish” behavior and to ignore his tantrums. He needed more structure and limits, they said, not more cuddles. Everyone else had told her that Connor was immature and must be forced to abandon his primitive self-soothing methods like rocking and humming. Now we were saying he should be treated gently, which seemed to her overindulgent. In fact, rather than ignore him when his behavior threatened to escalate out of control, as behavioral therapists often suggested, we were saying that he should actually be “rewarded” with massage. Our approach seemed radically counterintuitive, but because nothing else had helped, she agreed to give it a try.

  Connor’s mom was present during his massage sessions, and we made her an active participant in this p
art of his therapy. We wanted her there to comfort him and help him if he found the touch stressful. We also wanted her to learn this physically affectionate way of showing her love for her son, to help make up for the hugs and nurturing touches he’d missed during his infancy. This massage approach was gradual, systematic and repetitive. The initial motions involved Connor’s own hands, guided in massaging his arm, shoulders and trunk. We used a heart rate monitor to track the level of his distress. When his own touch to his own body did not cause changes in his heart rate we started to use his mother’s hands in the same repetitive, gradual massage process. Finally, once his mother’s massaging touch was no longer anxiety-provoking, the massage therapist started with more conventional therapeutic massage. The approach was very slow and gentle: the idea was to acclimate Connor to physical touch and, if possible, help him begin to enjoy it. After being taught to give her son neck and shoulder massages Jane would continue the therapy at home, especially when Connor seemed upset or asked for a massage. We explained to both of them why we were trying this approach.

  Nothing was forced. We knew that Connor found touch aversive at first and instructed the therapist to carefully respond to any signals from him that it was “too much.” She would progress to more intense stimulation only when the previous form and degree of touch had become familiar and safe. She would always start her work by having him use one of his own hands to “test” the massage, and then, when he was used to that, she began massaging his fingers and hands. She was gradually able to touch and then massage more deeply all of the appropriate bodily zones. Connor’s mom was also instructed to follow her son’s lead and not push contact if he found it overwhelming.

  Over the course of six to eight months Connor gradually began to tolerate and then enjoy physical contact with others. I could tell he was ready to move on to the next phase of treatment when he came up to me and reached his hand out, as if to shake my hand. He wound up patting my hand, like a granny would do with a young child, but for him, even a bizarre type of handshake was progress. He would never previously have sought—let alone initiate—physical contact. In fact, he would have actively avoided it.