The Boy Who Was Raised as a Dog (20 page)

I was the first medical professional Arthur had told about his childrearing practices because, unfortunately for Justin, I was the first to ask.

After interviewing Arthur, reading Justin's charts and observing his behavior, I realized that it was possible that some of the boy's problems were not due to a complete absence of potential. Maybe he didn't speak because he had rarely been spoken to. Maybe, unlike a normal child who hears some three million words by age three, he'd been exposed to far fewer. Maybe he didn't stand and walk because no one had coaxed him with her hand out to steady and encourage him. Maybe he didn't know how to eat with utensils because he had never held any in his hands. I decided to approach Justin with the hope that his deficits were indeed due to lack of appropriate stimulation, essentially a lack of opportunity and not lack of capacity.

The nursing staff watched as I walked carefully toward his crib. “He's gonna start throwing,” one of them said cynically. I tried to move in slow motion. I wanted him to watch me. I figured that the novelty of my measured pace in contrast to the typical hurried motion in the PICU would catch his attention. I did not look at him. I knew eye contact might be threatening, just as it is for many animals. I pulled the curtains surrounding his crib partially closed so that all he could see was me or the nurses' station. That way he would be less distracted by the children in the adjacent beds.

I tried to imagine the world from his perspective. He was still ill, his pneumonia only partially resolved. He looked terrified and confused; he had no understanding of this new, chaotic realm in which he'd been placed. At least his home in the dog kennel had been familiar; he'd known the dogs around him and knew what to expect from them. Also, I was sure he was hungry, since he had thrown away most of his food over the last three days. As I got close, he sneered, scrambled around the small space of his crib and gave out one of his screeches.

I stood still. Then I slowly started to take off my white coat, letting it slip to the floor. He stared at me. I slowly undid my tie and pulled it off. I rolled up the sleeves of my shirt. With each action I took one small step closer. I did not speak as I moved. I tried to be as nonthreatening as possible: no quick movements, no eye contact, trying to speak in a low, melodic, rhythmic tone, almost like a lullaby. I approached him as one would a terrified baby or a frightened animal.

“My name is Dr. Perry, Justin. You don't know what is happening here, do you? I will try to help you, Justin. See, I am just taking off my white coat. That's OK, right? Now let me come a bit closer. Far enough? OK. Let's see what might work here. Mmm. I will take off my tie. Ties are not familiar to you, I'll bet. Let me do that
.
”

He stopped moving around the crib. I could hear his breathing: a rapid wheezy grunt. He had to be starving. I noticed a muffin on a lunch tray, far out of his reach but still within his view. I moved toward it. He grunted louder and faster. I took the muffin broke a small piece off, and slowly put it in my mouth and chewed deliberately, trying to indicate pleasure and satisfaction.

“Mmm, so good, Justin. Do you want some?” I kept talking and reached my arm out. I was getting closer. In fact, I was close enough now for him to reach my outstretched hand and the food. I stood still, keeping up my banter and holding the muffin out to him. It seemed like hours, but within thirty seconds he tentatively reached out of the crib. He stopped halfway to the muffin and pulled his arm back in. He seemed to be holding his breath. And then, suddenly, he grabbed at the muffin
and pulled it into the crib. He scooted over to the furthest corner and watched me. I stood in the same place, smiled, and tried to bring some light into my voice, “Good, Justin. That is your muffin. It's OK. It's good.”

He started to eat. I waved goodbye and walked slowly back to the nurses station.

“Well. Just wait a minute he'll be screaming and throwing things again,” said one of the nurses, who seemed almost disappointed that he hadn't displayed his “bad” behavior for me. “I expect so,” I said on my way out.

From what I'd learned so far about the effects of neglect on the brain, I knew that the only way to find out whether Justin had unexpressed potential, or had no capacity for further development, was to see if his neural systems could be shaped by patterned, repetitive experience in a safe and predictable environment. But I hadn't yet learned the best way to structure this experience.

I did know that the first thing I needed to do was decrease the chaos and sensory overload surrounding Justin. We moved him to one of the PICU “private” rooms. Then we minimized the number of staff interacting with him. We began physical, occupational and speech/language therapy. We had one of our psychiatric staffers spend time with him every day. And I made daily visits as well.

The improvement was remarkably rapid. Each succeeding day was better for Justin. Every day he appeared to feel safer. He stopped throwing food and smearing feces. He started to smile. He showed clear signs of recognition and comprehension of verbal commands. We realized he had received some social stimulation and affection from the dogs he'd lived with; dogs are incredibly social animals and have a sophisticated social hierarchy in their packs. At times he responded to unfamiliar people much like a scared dogs will: tentatively approaching, backing off and then moving forward again.

As the days went by he began to be affectionate with me and several other staff members. He even started to show signs of a sense of humor. For example, he knew that “throwing poop” made the staff crazy. So
once, when someone gave him a candy bar, he let the chocolate melt into his hands and raised his arm as though he were about to throw it. The people around him moved back. And then he broke into a big, hearty laugh. It was this primitive sense of humor—which demonstrated that he understood the effects of his actions on others and connected with them—that rapidly gave me hope about his capacity for change.

At first, however, my colleagues thought I was wasting hospital resources by asking that physical therapists try to help him stand, to improve his large and fine motor strength and control. But within a week Justin was sitting in a chair and standing with assistance. By three weeks he had taken his first steps. Then an occupational therapist came to help him with fine motor control and fundamentals of self-care: dressing himself, using a spoon, brushing his teeth. Although many children who suffer this kind of deprivation develop a highly tuned sense of smell and often try to sniff and lick their food and people, Justin's sniffing was particularly pronounced and may have had to do with his life among the dogs. He had to be taught that this isn't always appropriate.

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.