The Boy Who Was Raised as a Dog

by Bruce Perry

  I walked over to the boy, stood over him, looked down, and smiled, “Hi, Peter.” I put my hand out. Peter reached up to touch my hand.

  “Peter, stand up and shake Dr. Perry’s hand,” Jason said. Amy tried to push Peter off her lap to his feet. Peter went limp and laughed. It seemed like part of their game.

  “Peter, stand up,” Jason said again, his voice patient but firm. I could feel his frustration and exhaustion. I knew they had their hands full.

  “That’s OK. You guys just get comfortable. I just wanted to see how you think things went today.” I sat down across from them, “This first visit is really just to give Peter a chance to come and meet some of us and start to get familiar with us. Hopefully, you had some fun today.”

  Peter nodded.

  “Use words, honey,” Amy said.

  Peter sat up and said, “Yes.”

  The family had just spent three hours in our clinic for an intake appointment. They had come to see us because Peter had a long history of speech and language problems, as well as difficulties with attention and impulsivity. Not surprisingly, he also had social and academic problems in school. Occasionally he had bizarre and ferocious outbursts in which he seemed to completely lose control. They were terrifying and, unlike ordinary temper tantrums, could last for hours.

  Peter’s parents had adopted him from a Russian orphanage when he was three years old. They had immediately fallen in love with the blonde, blue-eyed boy with rosy cheeks who looked like a little angel. The operators of the orphanage had proudly shown off how well fed he was and how clean their facility was but, in truth, Peter and the other children who lived there had been profoundly neglected. Amy and Jason had heard about our work with maltreated children from other adoptive parents. We were at the end of the first day of a two-day consultation visit at our clinic. The family had traveled over five hundred miles for the evaluation.

  “So, Peter, will you come back and visit us tomorrow?” I asked.

  “Yes,” he said with a big smile.

  Our clinicians had a lot of work to do before then. During a typical evaluation, our interdisciplinary group of psychologists, social workers, child psychiatry fellows, and child psychiatrists usually spread multiple visits out over a few weeks to get to know a child and his family. In Peter’s case the process was condensed because he lived so far away. Records from the schools, the child’s pediatrician, previous mental health providers and other professionals were available to review, process and integrate into our impressions of the child and family. We also did a brain scan, an MRI, as part of a study we were working on to see how early neglect affected the brain. The data from our research has shown that significant early life neglect such as that seen in formerly institutionalized children like Peter leads to smaller brain size over all, brain shrinkage in certain regions, and a host of brain-related functional problems. By finding which areas were most affected in Peter’s case, we hoped to target our treatments to maximal effect.

  During the evaluation period, sometimes as many as a dozen staff members would meet to talk about what we were seeing and experiencing with this child. It was a process designed to identify the child’s strengths and vulnerabilities, and carefully determine his current developmental stage in a host of domains—from perceptual abilities to motor skills, from emotional, cognitive and behavioral abilities to moral sentiments. This enabled us to come to a preliminary diagnosis and make our initial recommendations for intervention. Although it would be too time consuming and expensive to replicate in many settings, we hoped to develop models of care based on this process that would be less staff intensive.

  At the time we began working with Peter and his family, we’d made good progress on our neurosequential approach to maltreated children. We’d recognized that victims of early trauma and neglect need experiences—such as rocking and being held—appropriate for the age at which they’d suffered damage or deprivation, not for their chronological age. We’d found that these developmentally appropriate enrichment and therapeutic experiences had to be provided repeatedly and consistently in a respectful and caring manner. Coercive, punitive and forceful delivery only made things worse. We’d also started to incorporate music, dance and massage in order to stimulate and organize the lower brain regions, which contain the key regulatory neurotransmitter systems involved in the stress response. As we’ve seen, these areas are more likely to be affected by early trauma because they undergo important, fast-paced development early in life. Finally, we’d begun to use medications to help children with troublesome dissociative or hyper-arousal symptoms.

  But while we had realized that ongoing relationships are critical to healing, we hadn’t yet fully understood how important peer relationships are, especially as children get older.

  The details of Peter’s past brought the critical role of relationships into vivid focus for me. Peter had been raised without adult attention for the first three years of his life. He’d been kept in what was basically a baby warehouse: a big, bright room with sixty infants in seemingly endless, straight rows of perfectly sanitized cribs. The two caretakers on duty for each shift would work methodically from one bed to the next, feeding each child, changing his or her diaper, then moving on. That was all the individual adult attention the babies received: roughly fifteen minutes each per eight-hour shift. The infants were rarely spoken to or held other than during these brief intervals; they were not rocked or cradled or cooed at because there simply wasn’t time for staff to do more than feed and change, feed and change. Even the toddlers spent their days and nights caged in their cribs.

  With no one but each other to turn to, the children would reach their tiny hands through the bars into the next crib, holding hands, babbling and playing patty-cake. In the absence of adults, they became parents to each other. Their interaction, as impoverished as it was, probably helped to mitigate some of the damage such severe deprivation can cause.

  When Peter’s adoptive parents first brought him home, they discovered that he was trying to communicate with them. Delighted, they sought a Russian translator. But the Russian translator said his speech wasn’t Russian—perhaps the orphanage workers had been immigrants from elsewhere in Eastern Europe who had taught the children to speak their native tongue? A Czech speaker said it wasn’t Czech, however, and soon Amy and Jason learned that Peter wasn’t speaking Hungarian or Polish, either.

  To their surprise, they found that the words Peter spoke didn’t belong to any known language. Apparently, the orphans had developed their own rudimentary language, like the private speech of twins or the improvised signing of deaf children raised together. Like King Psamtik of Egypt, who, according to Herodotus, isolated two children to learn what language they would “naturally” speak without the opportunity to learn from people around them, the operators of the orphanage had created a harsh and accidental experiment in linguistics. On their own, the children had apparently created and agreed upon several dozen words. One word the translators were able to figure out was that “Mum” meant “adult or caregiver,” just as similar sounds mean mother in almost every known human language, since the “mm” sound is the first one babies learn to make while suckling.

  In our clinical meeting, my team and I went over everything we knew about the boy’s early history, including his limited exposure to adults and his linguistic deprivation. We also discussed his adoptive parents. My initial impression of Amy and Jason was confirmed by the rest of the staff: everyone agreed that they were remarkable. Even before they’d adopted Peter, they had read parenting books, watched parenting videos and talked extensively with their pediatrician about what to expect when adopting a child like him. After they brought Peter home they worked with speech and language therapists, occupational therapists, physical therapists and mental health providers to help Peter catch up.

  They followed the advice they were given diligently. They spent money, time and energy trying to give Peter what he needed to grow up healthy, happy, productive and c
ompassionate. Yet, despite all of their best efforts, and the efforts of the dozens of specialists, Peter continued to struggle. He had improved dramatically in many regards, but his progress was spotty, slow and incremental.

  He would learn new skills only after hundreds of repetitions, not dozens like other children. He learned English but his enunciation was strange and his grammar was mangled. His movements were also uncoordinated, and even when he tried to sit still, he would sway. Also, he would rarely establish or maintain eye contact appropriately. At seven, he still had several primitive self-soothing behaviors, primarily rocking and sucking his thumb. He would sniff extensively at everything that he ate before putting it into his mouth and also tried noticeably to catch the scent of people whenever he met them. He was easily distracted and often laughed and smiled to himself, giving the impression that he was in “his own little world.” And in the last year he seemed to have hit a developmental plateau, and perhaps even regressed a bit.

  We first discussed Peter’s strengths, starting with his friendly, almost goofy manner. He was also well above average in some aspects of language and seemed to have some mathematical talents. He was extremely nurturing, but in a blatantly immature fashion, responding to peers and adults the way a toddler might.

  It became clear through our discussions that while Peter was in some ways cognitively seven, in other domains, he acted much younger. Confirming our observations regarding the use-dependent nature of brain development, the areas where he was doing better were related to brain regions that had received stimulation, and those where he had deficits represented brain regions that had either been more severely deprived or had not yet received enough stimulation to make up for the earlier neglect. The scans of his brain reinforced our observations of this fractured neurodevelopment: he had cortical atrophy, large ventricles (which meant that spinal fluid was taking up space that would normally have been occupied by brain tissue) and lower-brain structures that were small for his age and likely underdeveloped.

  Such splintered development is common in children who grow up in chaotic or neglectful environments. It causes tremendous confusion for parents, teachers and peers. From the outside, Peter looked like a seven-year-old boy, but in some ways he was only a three-year-old. In terms of other skills and capabilities, he was eighteen months old, and he was eight or nine years old in still other respects.

  This inconsistency was a major source of the family’s problems. There were also important differences in the way each parent interacted with Peter. When he was home and alone with Amy, she was extremely attuned to his needs. If he acted like a baby, she would engage him at that age level, and if he acted like an older child, she would interact with him that way. I believe that her intuitive capacity to meet his developmental needs was the primary reason he had made as much progress as he had.

  But as Peter got older Jason began to question some of Amy’s “babying” of the boy. This caused tension in the marriage, with Jason arguing that Amy was responsible for Peter’s lack of progress because she was “smothering” him, while Amy insisted that he needed the extra affection because of his past. Such differences are an almost universal feature of parenting. However, when disagreements are profound as they were becoming in Amy and Jason’s case, they can lead to serious marital problems.

  I had seen the conflict in my brief interaction with the family in the waiting room. Part of my job would be to help the couple understand Peter’s needs and explain to them how it was necessary to meet him where he was developmentally. That way, they would be able to learn to avoid overwhelming Peter and frustrating themselves by requiring age-appropriate behavior in a domain for which he did not yet have the capacity.

  When the family came in for the second day of the evaluation we gave Peter some formal psychological tests. Later we observed more parent/ child interactions and sent the boy off for another play break. Finally, it was time to tell the parents what we thought about Peter’s case and what we proposed to do to help him. I could see that Amy and Jason were anxious as soon as I walked into the room.

  “What do you think?” Jason said, clearly wanting to get bad news out of the way.

  “I think Peter is really a very lucky boy,” I began, “You are wonderful parents. And he has shown remarkable progress over the last four years.” I paused for a moment to let that sink in. Then, I added, “Your efforts are heroic. You must be exhausted.” Amy started to cry. Her husband tenderly put his arm around her. I got some tissue and handed it to her. She wiped her eyes.

  I began to tell them what I thought, asking them to interrupt if I said anything that they thought wasn’t accurate or didn’t make sense. I related Peter’s history as I understood it, recounting the details of the orphanage and the list of developmental delays he had experienced.

  Then I asked if I was right in suspecting that when Peter became upset, all of his developmental progress would seem to disappear and he would act in primitive, almost frightening ways. Perhaps he’d lie on the floor in the fetal position, moaning and rocking, or perhaps he’d let out unearthly screams. I added that I thought that once he started to get stirred up or overwhelmed he probably reached a “point of no return,” and that he seemed to regress before slowly coming back to himself. They nodded. That’s when I explained how changes in our emotional state can affect how we learn. Skills that we’ve mastered like comprehension of certain concepts or even use of language itself may dissipate when we get “worked up.” I talked about how new or frightening situations would be stressful to a child like Peter and would likely prompt this kind of regression.

  Wrapping up what we’d learned from the evaluation, I said, “So, I think we have a pretty good idea about Peter’s problems and how he ended up with them. We also know some of his strengths—not all, but some. The key now is whether we can use what we know to help him.” I paused, struggling to strike a balance between hope and caution.

  “Let me take a moment and talk with you about how the brain develops,” I began, “I think if you understand this a little bit more you will feel better about the progress that Peter has made, and I think you will better understand why progress now seems so slow.” As I spoke, my thoughts about the theory and practice I’d been working on for so many years seemed to crystallize for the first time as a coherent whole.

  I drew several charts on a blank piece of paper. The first (See Appendix, Figure 1) showed a simple comparison of the growth of the brain relative to the growth of the rest of the body, making the point that while the body doesn’t reach its adult height and weight until adolescence, the brain’s growth follows a much different path. By age three it has reached 85 percent of its full adult size.

  “The human brain grows most rapidly early in life,” I explained, “In fact, the majority of brain growth takes place in the first three years of life.” I wanted to help them understand the full significance of the fact that Peter had been in a sterile, neglectful institution during that critical period when the brain is rapidly organizing itself.

  Then I drew a pyramid and turned the page upside down (See Appendix, Figure 2). “The brain is organized from the bottom to the top,” I said. “The top part here,” I noted as I pointed to the wide base of the upside-down pyramid, “is the cortex, the most complex part of the brain, responsible for our ability to think and for integrating many of our functions.” I also described how some of the lower regions work, how the central emotional areas allow us to make social connections and control our stress and how the core brainstem areas drive the stress response itself. I explained how these regions “awaken” sequentially during development, starting from the innermost brainstem and moving out toward the cortex as the child grows. I discussed how the development of higher, more complex brain regions relies on proper organization of the lower, simpler areas. I explained how deprivation could affect these regions and cause the wide variations in their son’s behavior.

  “The key is to parent Peter where he is developmentally, not wh
ere he is chronologically,” I said.

  Jason nodded, beginning to understand what I was saying.

  “Which is a very difficult thing to do, right?”

  Now, both parents nodded.

  “The challenge is that, in one moment, you will need to have expectations and provide experiences that are appropriate for a five-year-old, for example, when you are teaching him a specific cognitive concept. Ten minutes later, however, the expectation and challenges will have to match those for a younger child, for example, when you are trying to teach him to interact socially. He is, developmentally, a moving target. This is why parenting these children is such a frustrating experience. One moment you are doing the correct thing and the next, you are out of sync.”

  Amy and Jason had experienced this dichotomy many times, but until this conversation they hadn’t been able to articulate it. My explanations helped them enormously, immediately reducing their conflict over “babying” Peter and helping Jason not worry when his wife engaged in it. Now, in fact, he could allow himself to do it as well. Amy, however, could also see from what we’d taught her that there were times when Jason’s more demanding parenting style would be useful.

  But explanations alone would not be enough. The core challenges of parenting Peter would remain the same—and it would be close to impossible for either parent to be attuned to him always or even most of the time without more support. Both parents were spent, emotionally and physically. We would need to help them get some respite care. We suggested bolstering their social network, taking time for themselves as a couple and doing things they enjoyed so that they could “recharge their batteries” for their time with Peter.

  Amy and Jason were open to all of our suggestions. Since they did not live near our clinic, we had to work with and through their local providers. Fortunately, most of the pieces of a good clinical team were in place. Peter had an excellent speech therapist, occupational therapist, master’s level therapist and an understanding pediatrician. We had talked with all of them. We wanted to add therapeutic massage and a music and movement class to his routine, which had been useful for other children who suffered early neglect, such as Connor.