用來描述那些出生時正常健康但不成長，甚至在這種形式的情感忽視之后體重下降的嬰兒的術(shù)語是 "未能成長"。即使在八十年代，當(dāng)勞拉還是個嬰兒的時候，"發(fā)育不良 "也是一種眾所周知的受虐待和被忽視兒童的綜合癥，特別是那些沒有得到足夠的個性化培養(yǎng)和關(guān)注的兒童。這種情況已經(jīng)被記錄了幾個世紀(jì)，最常見的是在孤兒院和其他機(jī)構(gòu)，那里沒有足夠的關(guān)注和照顧。如果不及早解決，它可能是致命的。四十年代的一項研究發(fā)現(xiàn)，在福利院長大的兒童中，有超過三分之一的兒童在兩歲前死亡，這是一個極高的死亡率。在這種情感剝奪中幸存下來的孩子--就像最近的東歐孤兒，我們稍后會見到其中的一個--往往有嚴(yán)重的行為問題，囤積食物，并可能對陌生人過度親近，而難以與那些應(yīng)該與他們最親近的人保持關(guān)系。

當(dāng)弗吉尼亞在她的孩子出生八周后第一次尋求醫(yī)療照顧時，勞拉被正確地診斷為 "發(fā)育不良"，并被送入醫(yī)院進(jìn)行營養(yǎng)穩(wěn)定治療。但是沒有人向弗吉尼亞解釋這一診斷。出院時，她只得到了營養(yǎng)方面的建議，而沒有得到做母親的建議。有人建議進(jìn)行社會工作咨詢，但從來沒有被要求進(jìn)行。醫(yī)療團(tuán)隊忽視了忽視的問題，很大程度上是因為許多醫(yī)生認(rèn)為醫(yī)療問題的 "心理 "或社會方面不如主要的 "生理 "問題有趣和重要。此外，弗吉尼亞似乎并不像一個疏忽的母親。畢竟，一個無情的母親會為她的新生兒尋求早期干預(yù)嗎？

就這樣，勞拉還是沒有長大。幾個月后，弗吉尼亞又帶她到急診室尋求幫助。由于不知道弗吉尼亞的早期依戀關(guān)系中斷的歷史，接下來為她孩子看病的醫(yī)生認(rèn)為勞拉的問題必須與她的胃腸系統(tǒng)有關(guān)，而不是與她的大腦有關(guān)。就這樣，勞拉開始了長達(dá)四年的測試、程序、特殊飲食、手術(shù)和插管喂食的醫(yī)療之旅。弗吉尼亞仍然沒有意識到她的孩子需要被擁抱、搖晃、玩耍和身體上的培養(yǎng)。

嬰兒出生時，壓力反應(yīng)的核心要素已經(jīng)完好無損，并集中在其發(fā)育中的大腦的低級、最原始的部分。當(dāng)嬰兒的大腦從身體內(nèi)部或從她的外部感官得到一些不對勁的信號時，這些信號被記錄為痛苦。如果她需要熱量，這種痛苦可能是 "饑餓"，如果她脫水，可能是 "口渴"，如果她感覺到外部威脅，可能是 "焦慮"。當(dāng)這種痛苦得到緩解時，嬰兒會感到愉悅。這是因為我們的壓力反應(yīng)神經(jīng)生物學(xué)與大腦中的 "快樂/獎勵 "區(qū)域以及代表疼痛、不適和焦慮的其他區(qū)域相互聯(lián)系。減少痛苦和提高我們生存能力的經(jīng)歷往往給我們帶來快樂；增加我們風(fēng)險的經(jīng)歷通常給我們帶來痛苦的感覺。

嬰兒立即發(fā)現(xiàn)哺乳、被抱、被撫摸和被搖晃的感覺是舒緩和愉快的。如果他們受到父母的關(guān)愛，并且有人在他們因饑餓或恐懼而感到緊張時持續(xù)前來，那么被喂養(yǎng)和撫慰的快樂和解脫就會與人類接觸聯(lián)系起來。因此，在正常的童年時期，如上所述，養(yǎng)育性的人際交往與快樂緊密而有力地聯(lián)系起來。正是通過我們對哭泣的嬰兒的數(shù)千次回應(yīng)，我們幫助她建立了健康的能力，從未來的人類聯(lián)系中獲得快樂。

因為大腦的關(guān)系和快樂中介神經(jīng)系統(tǒng)都與我們的壓力反應(yīng)系統(tǒng)有關(guān)，與親人的互動是我們主要的壓力調(diào)節(jié)機(jī)制。起初，嬰兒必須依賴他們周圍的人，不僅是為了緩解他們的饑餓感，也是為了安撫因無法獲得食物和其他方式照顧自己而產(chǎn)生的焦慮和恐懼。從他們的照顧者那里，他們學(xué)會了如何對這些感覺和需求做出反應(yīng)。如果他們的父母在他們饑餓時給他們喂食，在他們受驚時安撫他們，并對他們的情緒和身體需求做出一般的反應(yīng)，他們最終建立了嬰兒安撫和安慰自己的能力，這種技能在他們以后面對生活中的普通起伏時非常有用。

我們都見過蹣跚學(xué)步的孩子在擦傷膝蓋后看向媽媽：如果她沒有擔(dān)心的表情，孩子就不會哭；但如果寶寶看到媽媽關(guān)心的表情，就會開始大聲哀嚎。這只是照顧者和孩子之間發(fā)生的復(fù)雜舞蹈的最明顯的例子，這種舞蹈教給孩子情緒的自我調(diào)節(jié)。當(dāng)然，有些孩子可能在遺傳上對壓力和刺激更敏感或更不敏感，但遺傳上的優(yōu)勢或弱點在孩子最初的關(guān)系中被放大或鈍化了。對我們大多數(shù)人來說，包括成年人，僅僅是熟悉的人的存在，親人的聲音，或看到他們的身影接近，實際上就可以調(diào)節(jié)壓力反應(yīng)神經(jīng)系統(tǒng)的活動，關(guān)閉壓力荷爾蒙的泛濫，并減少我們的痛苦感。只要握住親人的手就是強(qiáng)大的減壓藥。

大腦中還有一類神經(jīng)細(xì)胞被稱為 "鏡像 "神經(jīng)元，它們與他人的行為同步反應(yīng)。這種相互調(diào)節(jié)的能力提供了依戀的另一個基礎(chǔ)。例如，當(dāng)一個嬰兒微笑時，他母親大腦中的鏡像神經(jīng)元通常會做出一系列反應(yīng)，這些反應(yīng)與媽媽自己微笑時出現(xiàn)的模式幾乎相同。這種鏡像通常會導(dǎo)致母親用自己的微笑來回應(yīng)。不難看出，隨著母親和孩子的同步化和相互加強(qiáng)，兩組鏡像神經(jīng)元都反射出對方的喜悅和聯(lián)系感，移情和回應(yīng)關(guān)系的能力會在此產(chǎn)生。

然而，如果嬰兒的微笑被忽視，如果她被反復(fù)留下獨自哭泣，如果她沒有被喂養(yǎng)，或被粗暴地喂養(yǎng)而沒有溫柔，或沒有被擁抱，人類接觸和安全、可預(yù)測性和快樂之間的積極關(guān)聯(lián)可能不會發(fā)展。如果像弗吉尼亞的情況那樣，她開始與一個人建立聯(lián)系，但當(dāng)她對自己的特殊氣味、節(jié)奏和微笑感到舒適時就被拋棄，一旦她適應(yīng)了新的照顧者，又被拋棄，這些聯(lián)想可能永遠(yuǎn)不會形成。沒有足夠的重復(fù)發(fā)生來鞏固這種聯(lián)系；人是不能互換的。愛的代價是失去的痛苦，從嬰兒期開始。嬰兒和他的第一個主要照顧者之間的依戀不是微不足道的：嬰兒對他的照顧者的愛與最深的浪漫聯(lián)系一樣深刻。事實上，正是這種主要依戀的模板記憶，將使嬰兒在成年后擁有健康的親密關(guān)系。

作為一個嬰兒，弗吉尼亞從來沒有機(jī)會真正了解她是被愛的；一旦她習(xí)慣了一個照顧者，她就會被趕到另一個照顧者那里。在她的生活中沒有一個或兩個持續(xù)的照顧者，她從來沒有經(jīng)歷過一個孩子需要的特殊關(guān)系重復(fù)，以將人類接觸與快樂聯(lián)系起來。她沒有發(fā)展出基本的神經(jīng)生物學(xué)能力來同情她自己的孩子對身體愛的需求。然而，由于她確實生活在一個穩(wěn)定的、充滿愛的家庭中，當(dāng)時她大腦的高級認(rèn)知區(qū)域正處于最活躍的發(fā)展階段，她能夠?qū)W習(xí)到作為父母 "應(yīng)該 "做什么。但是，她仍然沒有情感基礎(chǔ)，使這些養(yǎng)育行為感到自然。

因此，當(dāng)勞拉出生時，弗吉尼亞知道她應(yīng)該 "愛 "她的孩子。但她并沒有像大多數(shù)人那樣感受到這種愛，因此她沒有通過身體接觸來表達(dá)這種愛。

對勞拉來說，這種刺激的缺乏是毀滅性的。她的身體以荷爾蒙失調(diào)的方式作出反應(yīng)，阻礙了正常的生長，盡管她得到的營養(yǎng)非常充足。這個問題類似于在其他哺乳動物中被稱為 "矮子綜合癥 "的情況。在一窩老鼠中，甚至在小狗和小貓中，如果沒有外部干預(yù)，最小、最弱的動物往往在出生后的幾周內(nèi)死亡。矮小動物沒有力量刺激母親的乳頭以產(chǎn)生足夠的乳汁（在許多物種中，每個嬰兒都喜歡并只吸吮一個特定的乳頭），也沒有力量從母親那里引出足夠的梳理行為。母親忽視了這個小家伙的身體，不象對其他小家伙那樣舔他或給他梳理。這反過來又進(jìn)一步限制了他的成長。沒有這種梳理，他自身的生長激素就會關(guān)閉，所以即使他以某種方式得到足夠的食物，他仍然不能正常生長。這種機(jī)制，對小動物來說相當(dāng)殘酷，把資源導(dǎo)向那些最能利用它們的動物。母親為了保護(hù)自己的資源，會優(yōu)先喂養(yǎng)健康的動物，因為它們有最好的機(jī)會存活下來，并將自己的基因傳遞下去。

被診斷為 "發(fā)育不良 "的嬰兒，通常被發(fā)現(xiàn)生長激素水平降低，這解釋了勞拉無法增加體重。沒有釋放這些激素所需的物理刺激，勞拉的身體將她的食物視為廢物。她不需要通過清洗或運動來避免發(fā)胖：缺乏身體刺激已經(jīng)使她的身體編程這樣做。沒有愛，孩子就真的不會成長。勞拉并不是厭食癥；就像一窩小狗中的瘦小者一樣，她只是沒有得到身體的滋養(yǎng)，她的身體需要知道她是 "被需要的"，而且她可以安全地成長。

當(dāng)我第一次來到休斯頓時，我認(rèn)識了一位養(yǎng)母，她經(jīng)常帶孩子來我們診所。P.*媽媽是一個熱情好客的人，她不拘泥于儀式，總是說出自己的想法，她似乎憑直覺知道她收留的那些受虐待和經(jīng)常受到創(chuàng)傷的孩子需要什么。

當(dāng)我考慮如何幫助弗吉尼亞州幫助勞拉時，我回想了我從P媽媽那里學(xué)到的東西。我建立了一個教學(xué)診所，那里有十幾位精神病學(xué)家、心理學(xué)家、兒科和精神病學(xué)住院醫(yī)生、醫(yī)科學(xué)生以及其他工作人員和受訓(xùn)者。這是一個教學(xué)診所，部分目的是讓受訓(xùn)者觀察高級臨床醫(yī)生和 "專家 "的臨床工作。我是在對P媽媽的一個寄養(yǎng)兒童進(jìn)行初步評估訪問的反饋部分被介紹給她的。

P媽媽是一個高大、有力的女人。她的行動充滿了自信和力量。她穿著一件顏色鮮艷的大木棉，脖子上還圍著一條圍巾。她是來咨詢羅伯特的情況的，羅伯特是她寄養(yǎng)的一個七歲的孩子。在我們訪問的三年前，這個男孩被從他母親的監(jiān)護(hù)下帶走。羅伯特的母親是一名妓女，她在兒子的一生中一直沉迷于可卡因和酒精。她忽視并毆打他；這個男孩還看到她被顧客和皮條客毆打，自己也被她的伙伴恐嚇和虐待。

自從被從家里帶走后，羅伯特曾在六個寄養(yǎng)家庭和三個庇護(hù)所中生活。他曾三次因行為失控而住院治療。他被診斷為十幾種疾病，包括注意力缺陷多動癥（ADHD）、對抗性缺陷障礙（ODD）、雙相情感障礙、精神分裂癥和各種學(xué)習(xí)障礙。他通常是一個充滿愛心和親和力的孩子，但他有偶發(fā)的 "暴怒 "和攻擊性，使同齡人、老師和養(yǎng)父母感到害怕，以至于他們拒絕他，并在他暴怒后將他從任何環(huán)境中帶走。P媽媽把他帶到了我們這里，因為他的不專心和攻擊性又一次讓他在學(xué)校惹上了麻煩，學(xué)校要求我們做些什么。他讓我想起了許多我在芝加哥住院治療中心工作過的男孩。

當(dāng)我開始談話時，我試圖與P媽媽接觸，讓她感到舒適。我知道，如果人們感到平靜，他們可以更有效地 "聽 "和處理信息。我想讓她感到安全和尊重。現(xiàn)在回想起來，我在她眼里一定是非常傲慢的。我太自信了；我認(rèn)為我知道她的寄養(yǎng)孩子發(fā)生了什么事，隱含的信息是："我了解這個孩子，而你不了解。" 她輕蔑地看著我，臉上沒有笑容，雙手合十。我滔滔不絕地解釋了壓力反應(yīng)的生物學(xué)原理，以及如何解釋這個男孩的攻擊性和過度警覺的癥狀，很可能讓人聽不懂。我還沒有學(xué)會如何清楚地解釋創(chuàng)傷對孩子的影響。

"她問："那么你能做些什么來幫助我的孩子呢？她的語言讓我震驚：為什么她把這個七歲的孩子稱為嬰兒？我不知道該怎么理解。

我建議使用克羅尼丁，這是我在中心對桑迪和孩子們使用的藥物。她平靜而堅定地打斷了我的話："你不能對我的孩子使用藥物"。

我試圖解釋，我們對藥物治療相當(dāng)保守，但她不聽。"沒有醫(yī)生會給我的孩子下藥，"她說。這時，坐在我旁邊的兒童精神病學(xué)研究員，也就是羅伯特的主要臨床醫(yī)生，開始焦躁不安。這很令人尷尬。大人物副主席兼精神病學(xué)主任先生正在自討沒趣。我在疏遠(yuǎn)這位母親，卻毫無進(jìn)展。我再次試圖解釋壓力反應(yīng)系統(tǒng)的生物學(xué)原理，但她打斷了我。

"她尖銳地說道："向?qū)W校解釋你剛才告訴我的事情。"我的孩子不需要藥物。他需要的是人們對他的愛和善意。那所學(xué)校和所有那些老師都不理解他。"

"好吧，我們可以和學(xué)校談。" 我退縮了。

然后我就投降了。"P媽媽，你怎么幫助他？" 我問道，我很好奇為什么她沒有因為他的 "暴怒 "而導(dǎo)致他被以前的寄養(yǎng)家庭和學(xué)校開除的問題。

"我只是抱著他，搖晃他。我只是愛他。晚上，當(dāng)他驚醒并在房子里徘徊時，我只是把他放在我身邊的床上，揉揉他的背，唱幾句，他就睡著了。" 那位老兄現(xiàn)在偷看我，顯然很擔(dān)心：七歲的孩子不應(yīng)該和他們的照顧者睡在床上。但我很感興趣，繼續(xù)聽著。

"當(dāng)他白天不高興時，什么東西似乎能讓他平靜下來？" 我問道。

"同樣的事情。我只是把所有東西都放下，抱著他，在椅子上搖晃。不需要太長的時間，可憐的東西。"

她說這話時，我想起了羅伯特記錄中的一個反復(fù)出現(xiàn)的模式。在每一份記錄中，包括最近一次從學(xué)校轉(zhuǎn)來的記錄，憤怒的工作人員對這個男孩的不服從和不成熟的 "嬰兒式 "行為感到沮喪，并抱怨他的需要和粘人。我問P媽媽："那么，當(dāng)他有這樣的行為時，你就不會感到沮喪和憤怒嗎？"

"當(dāng)嬰兒大吵大鬧時，你會對嬰兒生氣嗎？"她問。"不，那是嬰兒的事。嬰兒盡其所能，如果他們搗亂，如果他們哭泣，如果他們向我們吐痰，我們總是原諒他們。"

"那羅伯特是你的寶貝？"

"他們都是我的寶貝。只是羅伯特已經(jīng)當(dāng)了七年的嬰兒。"

我們結(jié)束了會議，并預(yù)約了一周后的另一次會議。我答應(yīng)會給學(xué)校打電話。當(dāng)我和羅伯特走到診所大廳時，P媽媽看著我。我開玩笑說，羅伯特需要回來教我們更多。這時，她終于笑了。

多年來，P媽媽繼續(xù)把她的寄養(yǎng)兒童帶到我們的診所。我們也繼續(xù)向她學(xué)習(xí)。P媽媽早在我們之前就發(fā)現(xiàn)，許多遭受虐待和忽視的年輕受害者需要身體上的刺激，比如被搖晃和輕柔地抱著，這些安慰似乎適合于更小的孩子。她知道，你與這些孩子的互動不是基于他們的年齡，而是基于他們的需要，基于他們在發(fā)展的 "敏感期 "可能錯過的東西。幾乎所有送到她那里的孩子都非常需要被擁抱和撫摸。每當(dāng)我的工作人員看到她在候診室里抱著這些孩子并搖晃時，他們都會擔(dān)心她會把他們嬰兒化。

但我漸漸明白了，為什么她那壓倒性的親和力和身體上的養(yǎng)育方式，最初我擔(dān)心會讓大孩子感到窒息，但這往往正是醫(yī)生應(yīng)該做的。這些孩子從來沒有得到過反復(fù)的、有模式的身體養(yǎng)育，而這些養(yǎng)育需要發(fā)展一個良好的、有反應(yīng)的壓力反應(yīng)系統(tǒng)。他們從未了解到他們是被愛和安全的；他們沒有安全探索世界和無畏成長所需的內(nèi)部安全感。他們渴望撫摸，而P媽媽給了他們撫摸的機(jī)會。

現(xiàn)在，當(dāng)我與勞拉和她的母親坐在一起時，我知道他們都可以受益，不僅可以從P媽媽的育兒智慧中受益，還可以從她自己難以置信的母性和親和力中受益。我回到護(hù)士站，找出她的電話號碼，然后打電話。我問她是否愿意讓一位母親和她的孩子搬來和她一起住，這樣弗吉尼亞就可以學(xué)習(xí)如何撫養(yǎng)勞拉。她立即同意了。幸運的是，這兩個家庭都參與了一個私人資助的項目，使我們能夠支付這種照顧，而寄養(yǎng)系統(tǒng)通常太不靈活，不允許這樣。

現(xiàn)在，我必須說服弗吉尼亞和我的同事。當(dāng)我回到她等待的房間時，弗吉尼亞似乎很焦慮。我的精神病學(xué)同事給了她一篇我寫的論文，內(nèi)容是關(guān)于我們對受虐待兒童的臨床工作。弗吉尼亞認(rèn)為我認(rèn)為她是一個不稱職的父母。我還沒來得及說話，她就說："如果這能讓我的孩子好起來，請帶走她。弗吉尼亞確實愛她的孩子--以至于她愿意讓她離開，如果那是讓她康復(fù)的條件。

我解釋了我想做的事情，我想讓她和P媽媽一起生活。她也馬上同意了，說她會做任何事情來幫助勞拉。

然而，我的兒科同事仍然非常擔(dān)心勞拉的營養(yǎng)需求。她的體重過輕，他們擔(dān)心如果沒有醫(yī)療支持，她會攝取不到足夠的熱量。畢竟，她目前是通過管道進(jìn)食的。我告訴其他醫(yī)生，我們將嚴(yán)格監(jiān)控她的飲食，以確保她獲得足夠的卡路里，事實證明，我們這樣做是件好事。這樣我們就可以記錄她的顯著進(jìn)步。在與P媽媽在一起的第一個月里，勞拉消耗的卡路里數(shù)量與她在醫(yī)院的前一個月完全相同，在此期間，她的體重勉強(qiáng)維持在26磅。然而，在P媽媽的養(yǎng)育環(huán)境中，勞拉在一個月內(nèi)增加了10磅，從26磅增加到36磅！她的體重在一個月內(nèi)增加了35%。她的體重增加了35%，而之前的卡路里數(shù)量還不足以防止體重下降，因為她現(xiàn)在得到了大腦所需的身體培養(yǎng)，釋放出生長所需的適當(dāng)激素。

通過觀察Mama P.和接受Mama對她周圍所有人的身體愛撫，弗吉尼亞開始了解勞拉需要什么，以及如何為她提供這些。在Mama P.之前，吃飯都是機(jī)械式的，或者充滿了沖突：各種醫(yī)生和醫(yī)院不斷變化的飲食指示和建議，都是為了幫助勞拉，這讓勞拉的吃飯經(jīng)歷更加混亂空洞。此外，由于弗吉尼亞對她孩子的需求缺乏了解，她會從親和到強(qiáng)硬和懲罰，再到干脆無視她的女兒。由于沒有養(yǎng)育孩子通常給母親和孩子帶來的回報，弗吉尼亞特別容易產(chǎn)生挫敗感。養(yǎng)育孩子是困難的。如果沒有神經(jīng)生物學(xué)上的能力來感受養(yǎng)育孩子的樂趣，刺激和煩惱就會特別大。

P.媽媽的幽默感、她的溫暖和她的擁抱讓弗吉尼亞得到了一些她所錯過的母愛。通過觀察P媽媽對其他孩子和勞拉的反應(yīng)，弗吉尼亞開始捕捉到勞拉的暗示?，F(xiàn)在她可以更好地了解勞拉什么時候餓了，什么時候想玩，什么時候需要小睡。這個四歲的孩子似乎還停留在 "可怕的兩歲 "的挑釁階段，但現(xiàn)在她開始在情感上和身體上都成熟起來。隨著勞拉的成長，母親和女兒之間在吃飯時的緊張關(guān)系結(jié)束了。弗吉尼亞放松了警惕，能夠以更大的耐心和一致性來管教她。

弗吉尼亞和勞拉與P媽媽一起生活了大約一年。之后，這兩個女人仍然是親密無間的朋友，弗吉尼亞搬到了媽媽的附近，這樣她就可以保持密切聯(lián)系。勞拉成了一個聰明的小女孩，與她的母親相似，她傾向于在情感上保持距離，但有一個強(qiáng)大的道德指南針；她們都有強(qiáng)烈的積極價值觀。當(dāng)弗吉尼亞有了第二個孩子后，她從一開始就知道如何適當(dāng)?shù)卣疹櫵麤]有出現(xiàn)成長問題。弗吉尼亞上了大學(xué)，她的兩個孩子都在學(xué)校里表現(xiàn)良好。他們有朋友，有一個投入的教會社區(qū)，當(dāng)然，還有就在街邊的P媽媽。

然而，勞拉和弗吉尼亞都仍然帶著早期童年的傷痕。如果你偷偷地觀察這對母女，你可能會發(fā)現(xiàn)她的面部表情空洞，甚至是悲傷。一旦她意識到你的存在，她就會擺出她的社交角色，對你做出適當(dāng)?shù)幕貞?yīng)，但如果你密切注意你的 "直覺"，你會感覺到你們之間的互動有些尷尬或不自然。兩人都能模仿許多正常的社會互動線索，但都不覺得自己被自然地牽引著去社交，去自發(fā)地微笑或表達(dá)溫暖的滋養(yǎng)性身體行為，如擁抱。

盡管我們在某種程度上都在為他人 "表演"，但對于那些早期被忽視的人來說，面具很容易脫落。在 "更高 "的認(rèn)知水平上，母親和女兒都是非常好的人。她們已經(jīng)學(xué)會使用道德規(guī)則和強(qiáng)大的信仰系統(tǒng)來馴服她們的恐懼和欲望。但是在她們大腦的關(guān)系和社會交流系統(tǒng)中，也就是與他人的情感聯(lián)系的源頭，存在著她們早期童年時被破壞的養(yǎng)育的影子。我們的發(fā)展經(jīng)歷的性質(zhì)和時間塑造了我們。就像那些在生命后期學(xué)習(xí)外語的人一樣，弗吉尼亞和勞拉永遠(yuǎn)不會說不帶口音的愛的語言。

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 “l(fā)ove” 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.