I walked unnoticed through the din to the nurses’ station and studied the board to find the boy I’d been asked to see. Then, I heard him. A loud, odd shriek made me turn immediately to find a bony little child in a loose diaper sitting in a cage. Justin’s crib had iron bars and a plywood panel wired to the top of it. It looked like a dog cage, which I was about to discover was terribly ironic.

The little boy rocked back and forth, whimpering a primitive self-soothing lullaby. He was filthy with his own feces, there was food all over his face and his diaper was heavy, soaked with urine. He was being treated for severe pneumonia, but he resisted all procedures and had to be held down to draw blood. He tore out his IVs, he yelled and screamed at staff and he threw his food. The closest this hospital had to a psychiatric unit was the PICU (where the ratio of staff to patients was very high), so Justin had been transferred. There, they had jury-rigged his crib/cage arrangement. And once placed in the cage, the boy began to throw feces and anything else he could get his hands on. That’s when they called psychiatry.

Over the years I had learned that it is not a good idea to take a child by surprise. Unpredictability and the unknown make everyone feel anxious and therefore less able to process information accurately. Also, and importantly for clinical evaluation, the more anxious someone is the harder it is for him to accurately recall and describe his feelings, thoughts and history. But most critically, when a child is anxious it is much more difficult to form a positive relationship, the true vehicle for all therapeutic change.

When I saw Justin I knew this case was going to be different. I needed to know more about him before I could approach him. I took his chart, went back to the nurses’ station and read his old records, occasionally glancing over to watch him rock with his knees up by his chin, his arms around his legs. He was humming or moaning to himself, and every few minutes he would let out a loud angry-sounding shriek. The PICU staff had become used to this; no one even glanced his way anymore.

During her illness, her live-in boyfriend, Arthur,* babysat for Justin. Baby Justin’s behavior became difficult, surely a result of losing both his mother and his grandmother in such a short time. Arthur, still grieving himself, didn’t know what to do with a crying, tantruming young child, and being in his late sixties, he wasn’t physically or mentally prepared for such a challenge. He called Child Protective Services (CPS), seeking a permanent placement for the boy who, after all, was not even a relative. CPS apparently felt the boy was safe and asked if Arthur would keep Justin while they found alternate placement. He agreed. Arthur was a passive man, in general, and patient. He assumed that CPS would get around to finding a new home for Justin. But CPS is a reactive, crisis-focused agency and, with no one putting pressure on it to do so, it didn’t act.

Arthur was not malicious, but he was ignorant about the needs of children. He made a living as a dog breeder and, sadly, applied that knowledge to the care of the baby. He began keeping Justin in a dog cage. He made sure the baby was fed and changed, but he rarely spoke to him, played with him, or did any of the other normal things parents do to nurture their children. Justin lived in that cage for five years, spending most of his days with only dogs as his companions.

As I read through Justin’s chart I began to imagine his life as it unfolded. At the age of two, Justin had been given a diagnosis of “static encephalopathy,” meaning that he had severe brain damage of unknown origin that was unlikely to improve. He had been taken to the doctor because he was severely developmentally delayed: he was unable to walk or say even a few words by the time most children are actively exploring toddlers who have begun to speak in sentences. Tragically, when Arthur had brought Justin in for medical check-ups, no one inquired about his living situation. And no one took a good developmental history. The boy had been tested for various physical ailments, and his brain had been scanned, revealing atrophy (shrinkage) of the cerebral cortex and enlargement of the fluid-filled ventricles in the center of the brain. In fact, his brain looked like that of someone with advanced Alzheimer’s disease; his head circumference was so small that he was below the second percentile for children his age.

Whether because of this medical pessimism or because of his irregular care, Justin was never provided any speech therapy, physical therapy, or occupational therapy, and no in-home social services were offered to his elderly caregiver. Left to his own devices Arthur made caregiving decisions that fit his understanding of child rearing. He’d never had children of his own and had been a loner for most of his life. He was very limited himself, probably with mild mental retardation. He raised Justin as he raised his other animals: giving him food, shelter, discipline and episodic direct compassion. Arthur wasn’t intentionally cruel: he’d take both Justin and the dogs out of their cages daily for regular play and affection. But he didn’t understand that Justin acted like an animal because he’d been treated as one, and so when the boy “didn’t obey,” back into the cage he went. Most of the time, Justin was simply neglected.

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.

“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.

“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 dog will: tentatively approaching, backing off, and then moving forward again.

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.

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.

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’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.

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.

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.

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.

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.

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.

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.

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.

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.

“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.

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.

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.

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.

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 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!”

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.

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.

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.

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.

The next chapter illustrates some of the harm coercive methods can cause.