Mother's Touch

Preface

This chapter is about Connor who was treated in a manner similar to the story of sixteen year old sociopathic Leon. But still Connor did not turn out that way. Let's see what life had in store for him.

Main

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 apparent indifference to relationships linked with some types of 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 often missing in genuine autism. He was socially inept, to be sure, but he was far more social than autistic boys tend to be. He 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 part 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.
Now it was time to work on his sense of rhythm. It may seem odd, but rhythm is extraordinarily important. If our bodies cannot keep the most fundamental rhythm of life—the heartbeat—we cannot survive. Regulating this rhythm isn’t a static, consistent task, either: the heart and the brain are constantly signaling each other in order to adjust to life’s changes. Our heart rate must increase to power fight or flight, for example, and it must maintain its rhythmic pulse despite the varying demands placed on it.
Regulating heart rate during stress and controlling stress hormones are two critical tasks that require that the brain keep proper time.
Also, numerous other hormones are rhythmically regulated as well. The brain doesn’t just keep one beat: it has many drums, which must all synchronize not only with the patterns of day and night (and in women, with menstrual cycles or phases of pregnancy and nursing), but also with each other. Disturbances of the brain’s rhythm-keeping regions are often causes of depression and other psychiatric disorders. This is why sleep problems (in some sense, a misreading of day and night) almost always accompany such conditions.
Most people don’t appreciate how important these rhythms are in setting the tone for parent/child interactions, either. If a baby’s primary metronome—his brainstem—doesn’t function well, not only will his hormonal and emotional reactions to stress be difficult to modulate, but his hunger and his sleep cycle will be unpredictable as well. This can make parenting him much more difficult. Babies’ needs are much easier to read when they reliably occur at predictable times: if their infants become hungry and tired at consistent times, parents can adjust to their demands more easily, reducing stress all around. The implications of poorly regulated bodily rhythms, then, are far greater than one would initially suspect.
In the usual course of development a baby gets into a rhythmic groove that drives these various patterns. The infant’s mother cuddles him while he eats, and he is soothed by her heartbeat. In fact, the infant’s own heart rhythm may be partly regulated by such contact: some Sudden Infant Death Syndrome (SIDS) deaths, according to one theory, occur when babies are out of physical contact with adults and thus lacking crucial sensory input. Some research even suggests that while in utero the child’s heart can beat in time with his mother’s. We do know that maternal heart rate provides the patterned, repetitive signals—auditory, vibratory, and tactile—that are crucial to organizing the brainstem and its important stress-regulating neurotransmitter systems.
When a baby gets hungry and cries his levels of stress hormones will move upward. But if Mom or Dad regularly comes to feed him, they go back down, and over time, they become patterned and repetitive thanks to the daily routine. At times, nonetheless, the baby will feel distress and cry: not hungry, not wet, not in discernible physical pain, she will appear inconsolable.
When this happens most parents hug and rock their children, almost instinctively using rhythmic motion and affectionate touch to calm the child. Interestingly, the rate at which people rock their babies is about eighty beats per minute, the same as a normal resting adult heart rate. Faster and the baby will find the motion stimulating; slower and the child will tend to keep crying. To soothe our children we reattune them physically to the beat of the master timekeeper of life.
In fact, some theories of language development suggest that humans learned to dance and sing before we could talk, that music was actually the first human language. It’s true that babies learn to understand the musical aspects of speech—the meanings of tones of voice, for example—long before they understand its content.
People universally speak to babies—and interestingly, to pets—in a high pitch that emphasizes a nurturing, emotional, musical tone.
In all cultures even mothers who cannot carry a tune sing to their babies, suggesting music and song play an important role in infant development.
Connor, however, had missed out on music and rhythm when he most needed it. When he cried during the day in his early infancy no one came to rock him and calm him and bring his stress response systems and hormones back down into the normal range. Though he did get normal care at night and on weekends during his first eighteen months, those lonely eight-hour stretches left a lasting mark.
In order to make up for what he’d lost, we decided to have Connor participate in a music and movement class that would help him consciously learn to keep a beat and, we hoped, help his brain get a more general sense of rhythm. The class itself was nothing unusual: it looked a lot like what you would see in any kindergarten or preschool music class, where children learn to rhythmically clap their hands, to sing together, to repeat sounds in patterns and tap out beats with objects like blocks or simple drums. Here, of course, the children were older; unfortunately, we had many other patients who had suffered early neglect with whom to study this approach.
At first Connor was remarkably arrhythmic: he couldn’t keep time with the most basic beat. His unconscious rocking had rhythm, but he couldn’t deliberately mark out a steady beat or imitate one. I believe this was caused by the missing early sensory input to the brainstem, which created a weak connection between his higher and lower brain regions. We hoped that by improving his conscious control over rhythm we could improve these links.
Early on the class was frustrating for him, and Jane became discouraged. At this point we had been treating Connor for about nine months. The frequency of his outbursts had lessened, but one day he had a ferocious temper tantrum in school. School officials called Jane at work, demanding that she pick her son up immediately. I’d gotten used to regular, frantic calls from her several times a week, but this incident brought her despair to a new level. She thought that this meant Connor’s treatment had failed, and I had to use all my persuasive powers to keep her committed to this admittedly unusual therapeutic approach. She had seen dozens of very good therapists, psychiatrists, and psychologists and what we were doing didn’t look remotely like any of these previous treatments. She, like so many parents of struggling children, just wanted us to find the “right” medications and teach Connor to “act” his age.
That weekend, when I saw her number come up on my pager again, I cringed. I didn’t want to call her back and learn about yet another setback or have to talk her out of trying some counterproductive alternate treatment from some new “expert” someone had told her about. I forced myself to return the call, taking a deep breath to calm myself first. I thought my worst fears were confirmed when it was immediately clear from her tone of voice that she’d been weeping.
“What’s wrong?” I asked quickly.
“Oh, Dr. Perry,” she said. She paused and seemed to have difficulty going on. My heart sank.
But then she continued, “I have to thank you. Today Connor came up to me, hugged me, and said he loved me.” It was the first time he’d ever done that spontaneously. Now Jane, rather than worrying about our approach, became one of our biggest fans.

AS CONNOR PROGRESSED IN THE MUSIC and movement class, we began to see other positive changes as well. For one, his gait became much more normal, even when he was nervous. Also, over time the rocking and humming gradually lessened. When we first got to know him, these behaviors were almost constant if he wasn’t engaged in a task like schoolwork or playing a game. But now he only reverted to them if something seriously frightened or upset him. I wish all of my patients were as easy to read! Because of this trait I was able to know instantly if we had gone too far with any challenge and pull back until he could comfortably face it. After he’d been in treatment for about a year, his parents and his teachers began to see the real Connor, not just his weird behavior.
After he’d learned to successfully sustain a rhythm, I began parallel play therapy with him. The music and movement class and massage therapy had already improved his behavior: so far, he had had no further tantrums after the incident that had almost prompted Jane to end his therapy with us. But he still lagged in social development, was still being bullied, and still had no friends.
A typical treatment for adolescents with such problems is a social skills group like the one Connor had been in when he first came to us. However, because of the developmental lag he’d experienced due to his early neglect, this was still too advanced for him.
The first human social interaction begins with normal parent/infant bonding. The child learns how to relate to others in a social situation in which the rules are predictable and easy to figure out. If a child doesn’t understand what to do, the parent teaches him. If he persists in misunderstanding, the parent corrects him.
Repeatedly. Mistakes are expected and rapidly and continually forgiven. The process requires enormous patience. As Mama P.
reminded me, babies cry, they spit up, they “mess,” but you expect it and love them anyway.
In the next social arena the child must learn to master—the world of peers—violating social rules is far less tolerated. Here, rules are implicit and are picked up mostly by observation rather than direct instruction. Mistakes can result in long-term negative consequences as peers rapidly reject those who are “different,” those who don’t understand how to connect and respond to others. If someone hasn’t developed the ability to understand the clearly defined rules of the parent/child relationship, trying to teach him peer relations is almost impossible. Just as higher motor functions, such as walking, rely upon rhythmic regulation from lower brain areas like the brainstem, more advanced social skills require mastery of elementary social lessons.
I had to approach Connor carefully because, at first, he was skeptical about me: talking to shrinks hadn’t done him much good, and he found relating to others difficult in general. So I didn’t attempt to engage him directly. I gave him control of our interaction; if he wanted to talk to me, I would talk to him, but if he didn’t, I would let him be. He’d come in for therapy and would sit down in my office. I would continue to work at my desk. We simply spent time in the same space. I demanded nothing, he asked for nothing.
As he became more comfortable, he became more curious.
He’d move a little bit closer to me, and then closer still, and pretty soon he’d come over and stand near me. Finally, after many weeks, he’d ask, “What are you doing?” And I’d say, “I’m working.
What are you doing?”
“Uh, I’m in therapy?” he’d say questioningly. “Well, what’s therapy to you?”
“We sit and talk?”
“OK,” I’d say, “What do you want to talk about?”
“Nothing,” he’d reply at first. I’d tell him that was fine, I was busy, he should do his homework and I’d do my work.
After a few more weeks, however, he said he did want to talk. We sat face to face and he asked, “Why are we doing this?” This had not been at all like the therapy he was familiar with. So I began to teach him about the brain and brain development. I told him what I thought happened to him when he was an infant. The science made sense to him, and he immediately wanted to know,
“What’s the next step? What do we do next?” That’s when I talked about forming relationships with other people, saying that he didn’t seem very good at it.
He said emphatically, but with a smile, “I know, I suck!” Only then did I start to do explicit social coaching, which he was instantly eager to start. It was harder than I’d thought it would be.
Body language and social cues were unintelligible to Connor: they simply didn’t register. Working with Connor, it hit me over and over again how sophisticated and subtle much of human communication is. I told him, for example, that people find eye contact engaging during a social interaction, so it is important to look at people while you listen to them and when you talk to them.
He agreed to try it, but this resulted in him staring fixedly at me, just as he’d formerly fixed his gaze on the floor.
I said, “Well, you don’t want to look at people all the time.”
“Well, when do I look at them?”
I tried to explain that he should look for a little while, and then look away, because lasting eye contact is actually a human signal of either aggression or romantic interest, depending on the situation. He wanted to know exactly how long to look, but of course, I couldn’t tell him because of how dependent such things are on nonverbal cues and context. I tried telling him to wait three seconds, but this resulted in him counting out loud and made matters worse. As we practiced I rapidly discovered that we use more social cues than I had ever realized, and I had no idea how to teach them.
For example, when Connor looked away after initiating eye contact, he would turn his whole face, rather than simply moving his eyes. Or, he’d look up afterwards, his eye rolling unintentionally signaling boredom or sarcasm. It was like trying to teach someone from outer space to make human conversation. Eventually, however, he got to the point where he could socially engage, even though he still often seemed a bit robotic.
Each step was complicated. Trying to teach him to shake hands properly, for example, resulted in alternately limp fish approaches and too firm grips. Because he didn’t read other people’s cues very well, he often wasn’t aware that he’d said something that hurt someone’s feelings, or perplexed them, or seemed frighteningly odd. He was a nice young man: when he came in, he would always say hi to the secretaries and attempt to engage them in conversation. But something about the interaction would be off, often his wording and tone of voice would be odd and he wouldn’t notice the awkward silences. Once someone asked him where he lived, and he responded, “I just moved,” and left it at that. From his tone and short reply the other person figured that he didn’t want to talk. He would seem brusque or weird; Connor didn’t understand that he needed to put the person at ease by providing more information. Conversations have a rhythm to them, but Connor didn’t yet know how to play along.
At one point, too, I tried to address his fashion sense, which was another source of trouble with his peers. Style is partly a reflection of social skills; to be fashionable you have to observe others and read cues about “what’s in” and “what’s out,” and then discover how to copy them in a way that suits you. The signals are subtle and a person’s choices, in order to be successful, must reflect both individuality and appropriate conformity. Among adolescents, ignoring these signals can be socially disastrous—and Connor was clueless.
He’d wear his shirt buttoned all the way up to the neck, for example. One day, I suggested not buttoning the top button. He looked at me like I was crazy and asked, “What do you mean?”
I responded, “Well, you don’t always have to button it.”
“But there’s a button there,” he said, uncomprehending.
So I took a pair of scissors and cut it off. Jane was not pleased, calling me up to say, “Since when are scissors part of a normal therapeutic intervention?” But as he continued to improve, Jane calmed back down. Connor even made friends with another boy in our treatment program, a teenager who had also suffered neglect and who was at a similar level of emotional development. They’d been in the music and movement class together. When the other boy was frustrated about not being able to keep time, Connor had told him that he’d been just as bad at first, and then urged him to stick with it. They bonded even further over, of all things, Pokémon cards. At the time they were popular with elementary school-age children, but this was the emotional level of these boys’ development, even though they were high school sophomores.
They tried to share their obsession with their peers, but the other teens, of course, made fun of them.
Connor had one final out-of-control incident, incidentally, which was a result of the Pokémon obsession. He was defending his friend from some other adolescents who were teasing him about the cards, trying to tear them up. Jane, of course, panicked when she heard about it. She’d thought I shouldn’t encourage the boys in their Pokémon games, fearing just such an incident. I did speak with both of them about when and where to flash their Pokémon cards, but I thought it was better to allow the connection between these two to flourish since it was giving both boys an opportunity to practice their social skills. I didn’t think they’d be able to go from preschool to high-school socialization without elementary-school- like experiences (such as Pokémon) as intermediate steps, as awkward as I knew they’d be. We explained the situation to the school and Connor and his friend continued to enjoy Pokémon, but with a bit more discretion.
Connor went on to graduate high school and college without further outbursts. He continued his “sequential” development with just a bit of help from our clinical team; we saw him on breaks from school. He continued to socially mature. I knew the treatment had been a success when Connor—now a computer programmer— sent me an email with the header: “Next lesson: Girls!”

CONNOR IS STILL SOCIALLY AWKWARD and may always be “geeky.” However, even though he suffered almost exactly the same kind of neglect during a similar developmental period as Leon did, he never showed anything like the other teen’s malicious, sociopathic behavior. He became a victim of bullies, not a bully himself; while he was an outsider, he was not someone filled with hate. His behavior was bizarre and his tantrums appeared threatening, but he didn’t attack other children or steal from them or enjoy hurting people. His rages were prompted by his own frustration and anxiety, not by a desire for vengeance or a sadistic wish to make others feel as bad as he did.
Was it treatment—from us and all of the other clinicians before us—that made the difference? Was it important that his family pushed for intervention when he was young? Did it matter that we were able to intervene early in Connor’s adolescence? Probably.
But did any of that truly count in keeping him from becoming a raging sociopath like Leon? It is, of course, impossible to know.
However, in our work with children like these two very different boys who experienced severe early neglect, we have found a number of factors that clearly do play a role in which path they follow, and we try to address as many of them as possible in our treatment.
A number of genetically influenced factors matter.
Temperament, which is affected by genetics and intrauterine environment (influenced by maternal heart rate, nutrition, hormone levels, and drugs) is one. As noted previously, children whose stress response systems are naturally better regulated from birth are easier babies, so their parents are less likely to get frustrated with them and abuse or neglect them.
Intelligence is another critical factor, one that is often poorly understood. Intelligence is basically faster information processing: a person requires fewer repetitions of an experience to make an association. This property of intelligence appears to be largely genetically determined. Being able to learn with fewer repetitions means that brighter children can, in essence, do more with less.
Hypothetically, for example, if it takes a normal child 800 repetitions of having his mother feed him when he is hungry in order for him to learn that she will come and help modulate his distress, it might take only 400 repetitions for a “smarter” child to make the connection.
While this doesn’t mean that smart children need less affection, it does suggest that if they are deprived, brighter kids may be better equipped to cope. Needing fewer repetitions to build an association may allow smarter kids to more quickly connect people with love and pleasure, even when they don’t receive what is usually the bare minimum of stimulation required to cement those links. This quality might also allow them to benefit more from brief experiences of loving attention outside the family, which can often help severely abused and neglected children recognize that the way it is at home is not necessarily the way it is everywhere, a realization that can offer them much-needed hope.
Intelligence may also help protect young people in other ways from developing the kind of rage and sociopathy we saw in Leon.
For one, it allows them to be more creative when making decisions, giving them more options and decreasing the likelihood they’ll make bad choices. This also helps them avoid a defeatist attitude, thinking “there’s nothing else I can do.” Being able to envision alternate scenarios may also help increase impulse control. If you can think of a better future, you may be more likely to plan for it. And being better able to project yourself into the future may also improve your ability to empathize with others. If you’re planning for consequences, in some sense, you are empathizing with your “future self.” Imagining yourself in another setting is not a far leap from imagining the perspective of others— in other words, empathizing. However, intelligence alone is probably not enough to keep a child on the right track. Leon, for example, tested above average in some areas. But it does seem to help.Another factor is the timing of the trauma: the earlier it starts, the more difficult it is to treat and the greater the damage is likely to be.
Justin had nearly a year of loving and nurturing care before he was placed in that dog cage. That affection built the basics of so many important functions—including empathy—into his brain and, I believe, greatly aided his later recovery.
But perhaps the most important factor in determining how these children fare is the social environment in which the child is raised.
When Maria and Alan lived among their extended families, other relatives were able to make up for Maria’s limitations, and Frank had a normal, happy childhood. Leon’s neglect occurred only when Maria no longer had a supportive social network to help her cope with parenting. In Connor’s case, while his parents had more financial resources, they were stymied by a lack of information about child development. Better knowledge would have allowed them to recognize his problems much sooner.
In the last fifteen years numerous nonprofit organizations and government agencies have focused on the importance of education about appropriate parenting and early childhood development, and on just how much critical brain development goes on in the first few years of life. From Hillary Clinton’s “It Takes a Village” to Rob Reiner’s “I Am Your Child” Foundation to the Zero to Three organization and the United Way’s “Success by Six,” millions of dollars have been spent to educate the public about the needs of young children.
The hope of these efforts—some of which I have been involved with—is to make this kind of neglect far less likely to occur due to ignorance. I believe they have had a significant impact. However, the age segregation in our society, the lack of integration of these key concepts into public education and the limited experience many people have with young children before they have their own still puts far too many parents and their children at risk. Currently, there’s little we can do to change a child’s genes, temperament or brain processing speed, but we can make a difference in their caregiving and social environment. Many of the traumatized children I’ve worked with who have made progress report having had contact with at least one supportive adult: a teacher who took a special interest in them, a neighbor, an aunt, even a school bus driver. In Justin’s case, his grandmother’s early kindness and love allowed his brain to develop a latent capacity for affection that unfurled when he was removed from his later deprived situation.
Even the smallest gesture can sometimes make the difference to a child whose brain is hungry for affection.
Our work using the neurosequential approach with adolescents like Connor also suggests that therapy can mitigate the damage done by early neglect. Affectionate touch, appropriate to the developmental age at which the harm was done, can be given through massage therapy, and then repeated at home in order to strengthen the desired associations. Rhythm-keeping can be taught through music and movement classes, which can not only help a dysregulated brainstem to improve its control over important motor activities like walking, but also, we think, strengthen its role in stress response system regulation. Socialization can be improved by starting with teaching simpler, rule-based, one-on-one relationships and then moving to more complex peer group challenges.

I believe if Leon’s maternal neglect had been discovered earlier, there is a good chance that he would not have turned out the way he did. It took a long chain of deprivation of developmentally necessary stimuli and poor responses to Leon’s needs and bad choices by Leon himself for him to become a vicious killer. At any one of these crossroads, particularly those at the beginning of his life, a change in direction could potentially have led to a completely different outcome. If we had been able to treat him as a young adolescent, like Connor, or, better still, during the elementary school years, like Justin, I think his future could have been altered.
Had someone intervened when he was still a toddler he would have become a completely different person, far more like his brother than the predatory young man I met in the prison cell.
Because trauma—including that caused by neglect, whether deliberate or inadvertent—causes an overload of the stress response systems, which is marked by a loss of control, treatment for traumatized children must start by creating an atmosphere of safety. This is done most easily and effectively in the context of a predictable, respectful relationship. From this nurturing “home base,” maltreated children can begin to create a sense of competence and mastery. To recover they must feel safe and in control. Consequently, the last thing you want to do is force treatment on these children or use any kind of coercive tactics.

Reference: From Chapter 6 from the book "The Boy Who Was Raised as a Dog" by Bruce Perry

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