【书籍连载】登天之梯：一个儿童心理咨询师的诊疗笔记 中英翻译 第四章

用来描述那些出生时正常健康但不成长，甚至在这种形式的情感忽视之后体重下降的婴儿的术语是 "未能成长"。即使在八十年代，当劳拉还是个婴儿的时候，"发育不良 "也是一种众所周知的受虐待和被忽视儿童的综合症，特别是那些没有得到足够的个性化培养和关注的儿童。这种情况已经被记录了几个世纪，最常见的是在孤儿院和其他机构，那里没有足够的关注和照顾。如果不及早解决，它可能是致命的。四十年代的一项研究发现，在福利院长大的儿童中，有超过三分之一的儿童在两岁前死亡，这是一个极高的死亡率。在这种情感剥夺中幸存下来的孩子--就像最近的东欧孤儿，我们稍后会见到其中的一个--往往有严重的行为问题，囤积食物，并可能对陌生人过度亲近，而难以与那些应该与他们最亲近的人保持关系。

当弗吉尼亚在她的孩子出生八周后第一次寻求医疗照顾时，劳拉被正确地诊断为 "发育不良"，并被送入医院进行营养稳定治疗。但是没有人向弗吉尼亚解释这一诊断。出院时，她只得到了营养方面的建议，而没有得到做母亲的建议。有人建议进行社会工作咨询，但从来没有被要求进行。医疗团队忽视了忽视的问题，很大程度上是因为许多医生认为医疗问题的 "心理 "或社会方面不如主要的 "生理 "问题有趣和重要。此外，弗吉尼亚似乎并不像一个疏忽的母亲。毕竟，一个无情的母亲会为她的新生儿寻求早期干预吗？

就这样，劳拉还是没有长大。几个月后，弗吉尼亚又带她到急诊室寻求帮助。由于不知道弗吉尼亚的早期依恋关系中断的历史，接下来为她孩子看病的医生认为劳拉的问题必须与她的胃肠系统有关，而不是与她的大脑有关。就这样，劳拉开始了长达四年的测试、程序、特殊饮食、手术和插管喂食的医疗之旅。弗吉尼亚仍然没有意识到她的孩子需要被拥抱、摇晃、玩耍和身体上的培养。

婴儿出生时，压力反应的核心要素已经完好无损，并集中在其发育中的大脑的低级、最原始的部分。当婴儿的大脑从身体内部或从她的外部感官得到一些不对劲的信号时，这些信号被记录为痛苦。如果她需要热量，这种痛苦可能是 "饥饿"，如果她脱水，可能是 "口渴"，如果她感觉到外部威胁，可能是 "焦虑"。当这种痛苦得到缓解时，婴儿会感到愉悦。这是因为我们的压力反应神经生物学与大脑中的 "快乐/奖励 "区域以及代表疼痛、不适和焦虑的其他区域相互联系。减少痛苦和提高我们生存能力的经历往往给我们带来快乐；增加我们风险的经历通常给我们带来痛苦的感觉。

婴儿立即发现哺乳、被抱、被抚摸和被摇晃的感觉是舒缓和愉快的。如果他们受到父母的关爱，并且有人在他们因饥饿或恐惧而感到紧张时持续前来，那么被喂养和抚慰的快乐和解脱就会与人类接触联系起来。因此，在正常的童年时期，如上所述，养育性的人际交往与快乐紧密而有力地联系起来。正是通过我们对哭泣的婴儿的数千次回应，我们帮助她建立了健康的能力，从未来的人类联系中获得快乐。

因为大脑的关系和快乐中介神经系统都与我们的压力反应系统有关，与亲人的互动是我们主要的压力调节机制。起初，婴儿必须依赖他们周围的人，不仅是为了缓解他们的饥饿感，也是为了安抚因无法获得食物和其他方式照顾自己而产生的焦虑和恐惧。从他们的照顾者那里，他们学会了如何对这些感觉和需求做出反应。如果他们的父母在他们饥饿时给他们喂食，在他们受惊时安抚他们，并对他们的情绪和身体需求做出一般的反应，他们最终建立了婴儿安抚和安慰自己的能力，这种技能在他们以后面对生活中的普通起伏时非常有用。

我们都见过蹒跚学步的孩子在擦伤膝盖后看向妈妈：如果她没有担心的表情，孩子就不会哭；但如果宝宝看到妈妈关心的表情，就会开始大声哀嚎。这只是照顾者和孩子之间发生的复杂舞蹈的最明显的例子，这种舞蹈教给孩子情绪的自我调节。当然，有些孩子可能在遗传上对压力和刺激更敏感或更不敏感，但遗传上的优势或弱点在孩子最初的关系中被放大或钝化了。对我们大多数人来说，包括成年人，仅仅是熟悉的人的存在，亲人的声音，或看到他们的身影接近，实际上就可以调节压力反应神经系统的活动，关闭压力荷尔蒙的泛滥，并减少我们的痛苦感。只要握住亲人的手就是强大的减压药。

大脑中还有一类神经细胞被称为 "镜像 "神经元，它们与他人的行为同步反应。这种相互调节的能力提供了依恋的另一个基础。例如，当一个婴儿微笑时，他母亲大脑中的镜像神经元通常会做出一系列反应，这些反应与妈妈自己微笑时出现的模式几乎相同。这种镜像通常会导致母亲用自己的微笑来回应。不难看出，随着母亲和孩子的同步化和相互加强，两组镜像神经元都反射出对方的喜悦和联系感，移情和回应关系的能力会在此产生。

然而，如果婴儿的微笑被忽视，如果她被反复留下独自哭泣，如果她没有被喂养，或被粗暴地喂养而没有温柔，或没有被拥抱，人类接触和安全、可预测性和快乐之间的积极关联可能不会发展。如果像弗吉尼亚的情况那样，她开始与一个人建立联系，但当她对自己的特殊气味、节奏和微笑感到舒适时就被抛弃，一旦她适应了新的照顾者，又被抛弃，这些联想可能永远不会形成。没有足够的重复发生来巩固这种联系；人是不能互换的。爱的代价是失去的痛苦，从婴儿期开始。婴儿和他的第一个主要照顾者之间的依恋不是微不足道的：婴儿对他的照顾者的爱与最深的浪漫联系一样深刻。事实上，正是这种主要依恋的模板记忆，将使婴儿在成年后拥有健康的亲密关系。

作为一个婴儿，弗吉尼亚从来没有机会真正了解她是被爱的；一旦她习惯了一个照顾者，她就会被赶到另一个照顾者那里。在她的生活中没有一个或两个持续的照顾者，她从来没有经历过一个孩子需要的特殊关系重复，以将人类接触与快乐联系起来。她没有发展出基本的神经生物学能力来同情她自己的孩子对身体爱的需求。然而，由于她确实生活在一个稳定的、充满爱的家庭中，当时她大脑的高级认知区域正处于最活跃的发展阶段，她能够学习到作为父母 "应该 "做什么。但是，她仍然没有情感基础，使这些养育行为感到自然。

因此，当劳拉出生时，弗吉尼亚知道她应该 "爱 "她的孩子。但她并没有像大多数人那样感受到这种爱，因此她没有通过身体接触来表达这种爱。

对劳拉来说，这种刺激的缺乏是毁灭性的。她的身体以荷尔蒙失调的方式作出反应，阻碍了正常的生长，尽管她得到的营养非常充足。这个问题类似于在其他哺乳动物中被称为 "矮子综合症 "的情况。在一窝老鼠中，甚至在小狗和小猫中，如果没有外部干预，最小、最弱的动物往往在出生后的几周内死亡。矮小动物没有力量刺激母亲的乳头以产生足够的乳汁（在许多物种中，每个婴儿都喜欢并只吸吮一个特定的乳头），也没有力量从母亲那里引出足够的梳理行为。母亲忽视了这个小家伙的身体，不象对其他小家伙那样舔他或给他梳理。这反过来又进一步限制了他的成长。没有这种梳理，他自身的生长激素就会关闭，所以即使他以某种方式得到足够的食物，他仍然不能正常生长。这种机制，对小动物来说相当残酷，把资源导向那些最能利用它们的动物。母亲为了保护自己的资源，会优先喂养健康的动物，因为它们有最好的机会存活下来，并将自己的基因传递下去。

被诊断为 "发育不良 "的婴儿，通常被发现生长激素水平降低，这解释了劳拉无法增加体重。没有释放这些激素所需的物理刺激，劳拉的身体将她的食物视为废物。她不需要通过清洗或运动来避免发胖：缺乏身体刺激已经使她的身体编程这样做。没有爱，孩子就真的不会成长。劳拉并不是厌食症；就像一窝小狗中的瘦小者一样，她只是没有得到身体的滋养，她的身体需要知道她是 "被需要的"，而且她可以安全地成长。

当我第一次来到休斯顿时，我认识了一位养母，她经常带孩子来我们诊所。P.*妈妈是一个热情好客的人，她不拘泥于仪式，总是说出自己的想法，她似乎凭直觉知道她收留的那些受虐待和经常受到创伤的孩子需要什么。

当我考虑如何帮助弗吉尼亚州帮助劳拉时，我回想了我从P妈妈那里学到的东西。我建立了一个教学诊所，那里有十几位精神病学家、心理学家、儿科和精神病学住院医生、医科学生以及其他工作人员和受训者。这是一个教学诊所，部分目的是让受训者观察高级临床医生和 "专家 "的临床工作。我是在对P妈妈的一个寄养儿童进行初步评估访问的反馈部分被介绍给她的。

P妈妈是一个高大、有力的女人。她的行动充满了自信和力量。她穿着一件颜色鲜艳的大木棉，脖子上还围着一条围巾。她是来咨询罗伯特的情况的，罗伯特是她寄养的一个七岁的孩子。在我们访问的三年前，这个男孩被从他母亲的监护下带走。罗伯特的母亲是一名妓女，她在儿子的一生中一直沉迷于可卡因和酒精。她忽视并殴打他；这个男孩还看到她被顾客和皮条客殴打，自己也被她的伙伴恐吓和虐待。

自从被从家里带走后，罗伯特曾在六个寄养家庭和三个庇护所中生活。他曾三次因行为失控而住院治疗。他被诊断为十几种疾病，包括注意力缺陷多动症（ADHD）、对抗性缺陷障碍（ODD）、双相情感障碍、精神分裂症和各种学习障碍。他通常是一个充满爱心和亲和力的孩子，但他有偶发的 "暴怒 "和攻击性，使同龄人、老师和养父母感到害怕，以至于他们拒绝他，并在他暴怒后将他从任何环境中带走。P妈妈把他带到了我们这里，因为他的不专心和攻击性又一次让他在学校惹上了麻烦，学校要求我们做些什么。他让我想起了许多我在芝加哥住院治疗中心工作过的男孩。

当我开始谈话时，我试图与P妈妈接触，让她感到舒适。我知道，如果人们感到平静，他们可以更有效地 "听 "和处理信息。我想让她感到安全和尊重。现在回想起来，我在她眼里一定是非常傲慢的。我太自信了；我认为我知道她的寄养孩子发生了什么事，隐含的信息是："我了解这个孩子，而你不了解。" 她轻蔑地看着我，脸上没有笑容，双手合十。我滔滔不绝地解释了压力反应的生物学原理，以及如何解释这个男孩的攻击性和过度警觉的症状，很可能让人听不懂。我还没有学会如何清楚地解释创伤对孩子的影响。

"她问："那么你能做些什么来帮助我的孩子呢？她的语言让我震惊：为什么她把这个七岁的孩子称为婴儿？我不知道该怎么理解。

我建议使用克罗尼丁，这是我在中心对桑迪和孩子们使用的药物。她平静而坚定地打断了我的话："你不能对我的孩子使用药物"。

我试图解释，我们对药物治疗相当保守，但她不听。"没有医生会给我的孩子下药，"她说。这时，坐在我旁边的儿童精神病学研究员，也就是罗伯特的主要临床医生，开始焦躁不安。这很令人尴尬。大人物副主席兼精神病学主任先生正在自讨没趣。我在疏远这位母亲，却毫无进展。我再次试图解释压力反应系统的生物学原理，但她打断了我。

"她尖锐地说道："向学校解释你刚才告诉我的事情。"我的孩子不需要药物。他需要的是人们对他的爱和善意。那所学校和所有那些老师都不理解他。"

"好吧，我们可以和学校谈。" 我退缩了。

然后我就投降了。"P妈妈，你怎么帮助他？" 我问道，我很好奇为什么她没有因为他的 "暴怒 "而导致他被以前的寄养家庭和学校开除的问题。

"我只是抱着他，摇晃他。我只是爱他。晚上，当他惊醒并在房子里徘徊时，我只是把他放在我身边的床上，揉揉他的背，唱几句，他就睡着了。" 那位老兄现在偷看我，显然很担心：七岁的孩子不应该和他们的照顾者睡在床上。但我很感兴趣，继续听着。

"当他白天不高兴时，什么东西似乎能让他平静下来？" 我问道。

"同样的事情。我只是把所有东西都放下，抱着他，在椅子上摇晃。不需要太长的时间，可怜的东西。"

她说这话时，我想起了罗伯特记录中的一个反复出现的模式。在每一份记录中，包括最近一次从学校转来的记录，愤怒的工作人员对这个男孩的不服从和不成熟的 "婴儿式 "行为感到沮丧，并抱怨他的需要和粘人。我问P妈妈："那么，当他有这样的行为时，你就不会感到沮丧和愤怒吗？"

"当婴儿大吵大闹时，你会对婴儿生气吗？"她问。"不，那是婴儿的事。婴儿尽其所能，如果他们捣乱，如果他们哭泣，如果他们向我们吐痰，我们总是原谅他们。"

"那罗伯特是你的宝贝？"

"他们都是我的宝贝。只是罗伯特已经当了七年的婴儿。"

我们结束了会议，并预约了一周后的另一次会议。我答应会给学校打电话。当我和罗伯特走到诊所大厅时，P妈妈看着我。我开玩笑说，罗伯特需要回来教我们更多。这时，她终于笑了。

多年来，P妈妈继续把她的寄养儿童带到我们的诊所。我们也继续向她学习。P妈妈早在我们之前就发现，许多遭受虐待和忽视的年轻受害者需要身体上的刺激，比如被摇晃和轻柔地抱着，这些安慰似乎适合于更小的孩子。她知道，你与这些孩子的互动不是基于他们的年龄，而是基于他们的需要，基于他们在发展的 "敏感期 "可能错过的东西。几乎所有送到她那里的孩子都非常需要被拥抱和抚摸。每当我的工作人员看到她在候诊室里抱着这些孩子并摇晃时，他们都会担心她会把他们婴儿化。

但我渐渐明白了，为什么她那压倒性的亲和力和身体上的养育方式，最初我担心会让大孩子感到窒息，但这往往正是医生应该做的。这些孩子从来没有得到过反复的、有模式的身体养育，而这些养育需要发展一个良好的、有反应的压力反应系统。他们从未了解到他们是被爱和安全的；他们没有安全探索世界和无畏成长所需的内部安全感。他们渴望抚摸，而P妈妈给了他们抚摸的机会。

现在，当我与劳拉和她的母亲坐在一起时，我知道他们都可以受益，不仅可以从P妈妈的育儿智慧中受益，还可以从她自己难以置信的母性和亲和力中受益。我回到护士站，找出她的电话号码，然后打电话。我问她是否愿意让一位母亲和她的孩子搬来和她一起住，这样弗吉尼亚就可以学习如何抚养劳拉。她立即同意了。幸运的是，这两个家庭都参与了一个私人资助的项目，使我们能够支付这种照顾，而寄养系统通常太不灵活，不允许这样。

现在，我必须说服弗吉尼亚和我的同事。当我回到她等待的房间时，弗吉尼亚似乎很焦虑。我的精神病学同事给了她一篇我写的论文，内容是关于我们对受虐待儿童的临床工作。弗吉尼亚认为我认为她是一个不称职的父母。我还没来得及说话，她就说："如果这能让我的孩子好起来，请带走她。弗吉尼亚确实爱她的孩子--以至于她愿意让她离开，如果那是让她康复的条件。

我解释了我想做的事情，我想让她和P妈妈一起生活。她也马上同意了，说她会做任何事情来帮助劳拉。

然而，我的儿科同事仍然非常担心劳拉的营养需求。她的体重过轻，他们担心如果没有医疗支持，她会摄取不到足够的热量。毕竟，她目前是通过管道进食的。我告诉其他医生，我们将严格监控她的饮食，以确保她获得足够的卡路里，事实证明，我们这样做是件好事。这样我们就可以记录她的显著进步。在与P妈妈在一起的第一个月里，劳拉消耗的卡路里数量与她在医院的前一个月完全相同，在此期间，她的体重勉强维持在26磅。然而，在P妈妈的养育环境中，劳拉在一个月内增加了10磅，从26磅增加到36磅！她的体重在一个月内增加了35%。她的体重增加了35%，而之前的卡路里数量还不足以防止体重下降，因为她现在得到了大脑所需的身体培养，释放出生长所需的适当激素。

通过观察Mama P.和接受Mama对她周围所有人的身体爱抚，弗吉尼亚开始了解劳拉需要什么，以及如何为她提供这些。在Mama P.之前，吃饭都是机械式的，或者充满了冲突：各种医生和医院不断变化的饮食指示和建议，都是为了帮助劳拉，这让劳拉的吃饭经历更加混乱空洞。此外，由于弗吉尼亚对她孩子的需求缺乏了解，她会从亲和到强硬和惩罚，再到干脆无视她的女儿。由于没有养育孩子通常给母亲和孩子带来的回报，弗吉尼亚特别容易产生挫败感。养育孩子是困难的。如果没有神经生物学上的能力来感受养育孩子的乐趣，刺激和烦恼就会特别大。

P.妈妈的幽默感、她的温暖和她的拥抱让弗吉尼亚得到了一些她所错过的母爱。通过观察P妈妈对其他孩子和劳拉的反应，弗吉尼亚开始捕捉到劳拉的暗示。现在她可以更好地了解劳拉什么时候饿了，什么时候想玩，什么时候需要小睡。这个四岁的孩子似乎还停留在 "可怕的两岁 "的挑衅阶段，但现在她开始在情感上和身体上都成熟起来。随着劳拉的成长，母亲和女儿之间在吃饭时的紧张关系结束了。弗吉尼亚放松了警惕，能够以更大的耐心和一致性来管教她。

弗吉尼亚和劳拉与P妈妈一起生活了大约一年。之后，这两个女人仍然是亲密无间的朋友，弗吉尼亚搬到了妈妈的附近，这样她就可以保持密切联系。劳拉成了一个聪明的小女孩，与她的母亲相似，她倾向于在情感上保持距离，但有一个强大的道德指南针；她们都有强烈的积极价值观。当弗吉尼亚有了第二个孩子后，她从一开始就知道如何适当地照顾他，他没有出现成长问题。弗吉尼亚上了大学，她的两个孩子都在学校里表现良好。他们有朋友，有一个投入的教会社区，当然，还有就在街边的P妈妈。

然而，劳拉和弗吉尼亚都仍然带着早期童年的伤痕。如果你偷偷地观察这对母女，你可能会发现她的面部表情空洞，甚至是悲伤。一旦她意识到你的存在，她就会摆出她的社交角色，对你做出适当的回应，但如果你密切注意你的 "直觉"，你会感觉到你们之间的互动有些尴尬或不自然。两人都能模仿许多正常的社会互动线索，但都不觉得自己被自然地牵引着去社交，去自发地微笑或表达温暖的滋养性身体行为，如拥抱。

尽管我们在某种程度上都在为他人 "表演"，但对于那些早期被忽视的人来说，面具很容易脱落。在 "更高 "的认知水平上，母亲和女儿都是非常好的人。她们已经学会使用道德规则和强大的信仰系统来驯服她们的恐惧和欲望。但是在她们大脑的关系和社会交流系统中，也就是与他人的情感联系的源头，存在着她们早期童年时被破坏的养育的影子。我们的发展经历的性质和时间塑造了我们。就像那些在生命后期学习外语的人一样，弗吉尼亚和劳拉永远不会说不带口音的爱的语言。

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“And Robert is your baby?”

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

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

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

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

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

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

I explained what I wanted to do instead, that I wanted her to live with Mama P. She, too, assented right away, saying she would do anything to help Laura.

My pediatric colleagues, however, were still extremely concerned about Laura’s nutritional needs. She was so underweight that they were afraid that she would not take in enough calories without medical support. After all, she was currently being fed through a tube. I told the other doctors that we would strictly monitor her diet to be sure she was getting enough calories, and it turned out to be a good thing that we did. We could then document her remarkable progress. For the first month with Mama P., Laura consumed the exact same number of calories she had in the prior month in the hospital, during which her weight had barely been maintained at twenty-six pounds. In Mama P’s nurturing environment, however, Laura gained ten pounds in one month, growing from twenty-six to thirty-six pounds! Her weight increased by 35 percent on the same number of calories that had previously not been enough to prevent weight loss, because she was now receiving the physical nurturing her brain needed to release the appropriate hormones required for growth.

By observing Mama P. and by receiving the physical affection Mama showered on everyone around her, Virginia began to learn what Laura needed and how to provide it for her. Before Mama P., meals had been robotic or filled with conflict: the constantly changing dietary instructions and advice given by various doctors and hospitals who were trying to help just added to the confused hollow experience of eating for Laura. Also, because of Virginia’s lack of understanding of her child’s needs, she’d swing from being affectionate to being tough and punitive to simply ignoring her daughter. Without the rewards that nurturing normally provides both mother and child, Virginia had been especially prone to frustration. Parenting is difficult. Without the neurobiological capacity to feel the joys of parenting, irritations and annoyances loom especially large.

Mama P.’s sense of humor, her warmth, and her hugs allowed Virginia to get some of the mothering she’d missed. And by watching how Mama P. responded to her other children and to Laura, Virginia began to pick up on Laura’s cues. Now she could better read when Laura was hungry, when she wanted to play, when she needed a nap. The four-year-old had seemed stuck in the defiant stage of the “terrible twos,” but now she began to mature, both emotionally and physically. As Laura grew, the tension between mother and daughter during mealtimes ended. Virginia relaxed and was able to discipline with more patience and consistency.

Virginia and Laura lived with Mama P. for about a year. Afterwards, the two women remained tight friends, and Virginia moved into Mama’s neighborhood so that she could remain in close touch. Laura became a bright little girl, similar to her mother in that she tended to be emotionally distant, but with a powerful moral compass; they both had strong positive values. When Virginia had a second child, she knew how to care for him appropriately, right from the start, and he suffered no growth problems. Virginia went on to college and both of her children are doing well in school. They have friends, an invested church community and, of course, Mama P. just down the street.

Both Laura and Virginia still bear scars from their early childhoods, however. If you were to secretly observe either mother or daughter, you might find her facial expression vacant, or even sad. Once she became aware of your presence, she would put on her social persona and respond appropriately to you, but if you paid close attention to your “gut” you would sense something awkward or unnatural in your interactions. Both can mimic many of the normal social interactive cues, but neither feels naturally pulled to be social, to spontaneously smile or to express warm nurturing physical behaviors such as a hug.

Though we all “perform” for others to some extent, the mask slips easily for those who have suffered early neglect. On a “higher” more cognitive level both mother and daughter are very good people. They have learned to use moral rules and a strong belief system to tame their fears and desires. But in the relational and social communication systems of their brain, the source of emotional connections to others, there are shadows of the disrupted nurturing of their early childhoods. The nature and timing of our developmental experiences shape us. Like people who learn a foreign language late in life, Virginia and Laura will never speak the language of love without an accent.