The boyfriend answered: “Let ’em whine.”
“A re you gonna yell?” the psychologist asked.
“No,” said the boyfriend. “They’ll be scared.”
“Think you can give it a shot?”
“We’ll give it a shot,” the mother promised. It would be nice to have the kids “eating at the table, not hollering and yelling,” she said. “I’m going to school all over again,” she added, a little sadly. Perhaps she meant simply that she had to be taught again, this time how to be a parent. Or perhaps she was reminded of that awful feeling when a teacher disapproved.
Maureen Black’s clinic spends considerable effort on parents’ interactions with their malnourished children. When youngsters fail to eat sufficiently and parents get anxious, angry, and defensive, mealtime becomes associated in the child’s mind with sheer misery. The spiral downward into confrontation can be very steep and fast, as videotapes reveal. On every family’s first appointment, a video camera is set up on a tripod in the room, food is brought in, and the family is left alone to feed the child. “You see an amazing array of behavior,” said Dr. Black. “You have moms smacking their kids, cussing their kids, ignoring their kids, begging their kids, being very nurturing to their kids.” When the tapes are then shown, the staff looks for something to compliment, but many parents are shocked by their own behavior, the psychologist has discovered. “I’ve had people cry when they’ve watched themselves.”
One session recorded a mother destroying what would have been a reasonably successful meal. While her little daughter, “Cathy,” sat at a table that came up to her chin, the mother sat eating pizza and giving commands: “Eat your food. Eat your food.” Cathy reached for a piece of pizza, began to eat quite well, then dropped a small piece. “No!” her mother scolded. “Makes a mess! Eat your food!” But Cathy was eating, with an empty spoon in her right hand, pizza in the other. She got no praise, only reprimands. When she reached for a carton of chocolate milk meant to be saved until after the food, her mother snapped: “No! Eat! Eat!” So she reached for another piece of pizza, without having finished her first one, and her mother yelled, “No! Eat that! Eat that!”
In fact, Cathy had been eating quietly and happily, but the repeated scolding was finally too much, and now she burst into tears. The mother tried to save the day by handing her daughter two more pieces of pizza, but it was too late. The abrasiveness had rubbed the mealtime raw, and Cathy was in a state. All the mother could say was, “Cathy, hush! Hush! Hush!” Cathy ran off camera, her mother followed, there was the sound of a slap, and then a little girl’s scream. The mother yelled: “Cathy! Stop that crying and hush!”
In a later session, the mother took a different tack and withdrew. Cathy spooned macaroni and cheese, blew on it, then ate it mostly with her left hand while holding the spoon in her right. Very little macaroni actually went into her mouth, and the spoon was hard for her to handle. Empty, it became more of a toy than a utensil; she licked it, then bit it. Her mother had nothing to say but, “Eat your food!” Cathy again piled a lot on the spoon, too much for her mouth, so she picked a piece of macaroni off with her left hand, and the rest fell back into the bowl. The struggling little girl could have been helped had her mother noticed what was happening. Instead, the mother sat watching but not seeing, apparently. Finally, when Cathy reached for the carton of chocolate milk, her mother came to her assistance by putting a straw in it.
Another mother on camera, labeled by the clinic as “authoritarian,” spoke to her toddler in an ugly voice as she jabbed a spoon at him. “Eat your food! Now eat it! Eat your food, eat it!” She handed the child the spoon; he just played with it. She snatched it away roughly. The boy squirmed off the chair. She seized both his wrists and yanked him, arms above his head, back onto the chair. She smacked his hand, and he cried. Then she tried to force a spoonful of food into his mouth, which sent him into a blood-curdling wail.
“You’re gonna eat whether you like it or not!” the mother said harshly. She slapped his cheek and tried again and again to force the spoon into his mouth. Every time, he turned his head away, so she grabbed his head with one hand, twisted it around, and tried to push food in with the other. The boy wriggled out of the chair once more and crawled under the table. His mother jerked him up by his arm, and he wailed. She wiped his face roughly.
The Baltimore clinic saw the boy for years. He was the sixth child of a single mother who had dropped out of school after ninth grade, received welfare, and was obviously overwhelmed. His medical file recorded a loss of weight beginning at six months, and he remained at only the fifth per-centile of weight through age eight. Testing showed his cognitive abilities below normal; in second grade, his math and reading were about a year behind.
The damage that malnutrition does to brain development and physical health is stealthy, because it precedes the retarded growth that usually sounds the alarm. “For a child to actually not be growing, you have to have many, many, many episodes of missed meals,” said Debbie Frank. “But the health and behavioral effects of hunger, of involuntary lack of access to food, show up, it turns out, before the growth effects.” Or even without growth effects. Even with enough protein and calories to maintain body size, a child can suffer from the absence of “micronutrients that are reflected in food quality like iron and zinc, for example, that can affect your immune function, your learning, and all sorts of stuff,” she noted.
The hollow sensation of hunger alone interferes with childhood learning. As anyone who has been without adequate food for more than a couple of days can attest, it narrows the focus of attention. Lethargic, light-headed, then intensely obsessive, the hungry person filters out the irrelevant. I experienced this myself when the navy sent me to a survival school run by the marines. After a few days scavenging for food in the woods, I began to slow down and think about little else—not politics, not literature, not even the interesting idiosyncrasies of my survival-class teammates. The only thing about them that mattered was whether they were facilitating or impeding my ability to acquire food. I certainly had no interest in reading a book. Teachers see it in their classrooms, where ill-fed children cannot concentrate. At Dunbar High School in Washington, D.C., an English teacher kept a supply of granola bars so he could toss them to hungry students. “Learning is discretionary,” said Dr. Frank, “after you’re well-fed, warm, secure.”
The syndrome is not easily broken. “Malnutrition impairs certain very important parts of your immune system,” the doctor explained. “Besides making your barrier—things like your mucous membranes and your skin—more penetrable, it also interferes with what’s called your cellmediated immunity, which is the immunity that fights viruses … and also your secretory … immunoglobulin that lines your respiratory tract and your GI tract.… And the way the story works is as follows: When anybody’s kid in any kind of family gets sick—a little kid—they lose weight. They feel yucky they throw up, they have diarrhea, they have fever, and fever raises your metabolic rate and you use more calories. And anybody’s kid from a perfectly ordinary childhood illness—you know, ear infection, prevailing stomach crud, whatever’s going around—can lose a pound or two. But in my house or your house, when the kid gets over the prevailing crud or the ear infection or whatever, they get very hungry and they eat extra. You feed them second and third helpings on everything. Within a few days they’re back to baseline, and their immune function’s also back to baseline.
“In the families we serve, once the kid gets any kind of a deficit (and it doesn’t have to be from a rare illness, just from normal childhood, whatever’s going around) … there isn’t anything extra.” This happens especially toward the end of the month when the food money runs out, or during vacations when there are no school lunches. “So that the deficit gets established and doesn’t get repleted. And then the baby—or the child or anybody—is more susceptible to the next infection, which then drives him still further down. What generally kills malnourished kids in the Thir
d World … is infections. Things like measles are absolutely lethal in malnourished kids.”
The incidence of malnutrition in the United States is difficult to measure. The Census Bureau conducts an annual telephone survey of “food insecurity” for the Department of Agriculture, but it depends on subjective self-reporting and misses families who are too poor to have phones. Dr. Frank thinks it understates the problem. Extrapolating from a sample of 50,000 families, the study found 5.4 percent, or 6.4 million of the country’s households, with at least one member who had been hungry at some point during the year 2010. They were part of a larger population of 17.2 million households (14.5 percent of the country’s total) who were deemed “food insecure” because they reported themselves as having been uncertain that they could afford enough to eat.1 Surveying food’s insufficient quantity, rather than its quality, may leave uncounted a larger number of families who would not label themselves “food insecure” but have children lacking nutrients vital to healthy brain development. The worsening problem of obesity illustrates the point that a lot of the wrong food is not helpful.
As scientific understanding of the brain has progressed in recent decades, so has the chronicle of damage done by malnutrition. Inadequate iron is a critical example. Sobering studies have found that children who suffer from severe iron deficiency in infancy don’t catch up in brain function, even once the iron deficiency is eliminated. In adolescence, they still score lower “in arithmetic achievement and written expression, motor functioning, and some specific cognitive processes such as spatial memory and selective recall;” teachers also see them displaying “more anxiety or depression, social problems, and attention problems,” according to a lengthy National Academy of Sciences report, From Neurons to Neighborhoods, which compiles research on child development. Iron is necessary in many features of brain development, including growth of the brain in size and the creation of the myelin sheath (the fatty, insulating envelope around nerve fibers), which facilitates the transmission of impulses among neurons, the brain’s impulse-conducting cells. The most sensitive periods of brain growth come during the last trimester of pregnancy and the first two years after birth, so the timing of nutritional deficiency can determine what mental capabilities are damaged. Insufficient nutrition even earlier, during the second trimester, can reduce the creation of neurons. Malnutrition in the third trimester retards their maturation and inhibits the production of branched cells called glia.2
Premature birth can be a “biological insult” to the brain, with disproportional impact on black and poor mothers and children. Some scientists see a genetic link with prematurity. Others note that racial disparities in maternal health—including inferior medical care, nutritional deficits, and untreated vaginal infections—seem primarily responsible for a higher incidence of prematurity among black than white women, and a consequent rate of infant mortality among blacks that is 2.4 times that of whites.3While advances in neonatal intensive care have increased the survival rate of premature underweight infants, other severe results can impose lifetime handicaps, including blindness, deafness, and cognitive impairment. Among the dangers faced by such babies are brain hemorrhages, inadequate glucose in the blood, and the denial of certain intrauterine nutrients and acids crucial for brain growth.4 “Infants born at very low birth weight appear to account for approximately one-third of children with cerebral palsy and 10 percent of those with mental retardation,” write Drs. Barry Zuckerman and Robert Kahn.5 Even minor brain hemorrhages that do not cause retardation place children “at higher risk of minor handicaps (e.g., behavior problems, attention problems, memory deficits),” From Neurons to Neighborhoods reports. “Emerging data strongly suggest that the human brain continues to develop in a unique way in utero until the end of gestation and that early termination of pregnancy disrupts that development with subsequent behavioral consequences.” Some researchers have found that toddlers who were premature babies “cannot be assumed to have caught up with their full-term counterparts in all aspects of cognitive development.”6
My Sunday school teacher, who was also a professor of philosophy, once pointed to a lamp and asked the class what we thought that lamp was least capable of doing. We came up with a few obvious answers: walk, talk, change its own light bulb. But he was looking for something else. There was no way, he told us, that the lamp could ever understand how it worked. He let us ponder that for a moment, and then continued: Nor could we human beings understand how we worked, not entirely. The mind and all its wonders were beyond our thorough comprehension, he said, and would probably be so forever.
That was more than forty years ago, long before the high-tech instruments that now observe the brain with magnetic resonance imaging (MRI) and positron emission tomography (PET). Using those tools and many others, mushrooming neurobiological and behavioral research has made significant discoveries by testing humans and experimenting on the brains of monkeys and mice. My Sunday school teacher would still be mostly right: The human brain remains a vast frontier, largely uncharted. But the newfound knowledge has also created a new discussion, one with solemn implications for the poor. The difficult conditions in which lower-income people live, their vulnerability to disease and stress, are now seen as affecting the brain itself. Many scientists and other researchers from various disciplines no longer recognize rigid boundaries between biology and experience, and between the genetic and the environmental. The dichotomies are mostly gone, replaced by a holistic concept of mental and emotional development guided by the interaction between “nature and nurture,” in the words of Jack Shonkoff, a pediatrician and dean of the Heller School for Social Policy and Management at Brandeis. “You’ve had behavioral scientists talk about what a powerful determinant experience is, environment is, on outcomes,” he said. “Now what you have is molecular biologists saying: No gene operates independently of the influence of the environment…. that if it’s the genes, it’s not immutable. It’s a predisposition. It has to then interact with the environment.”
In this view, the elements of life are tied in an intricate web. No matter how unrelated they seem from one another, none can be dramatically altered without tugging on strands across a distance. Eating and learning, housing and health, a mother’s early nurturing and a child’s later brain function are connected. Advancing research into the science of children’s intellectual and behavioral growth is mapping this web, sometimes with the microscopic detail of laboratory work, sometimes with the bold strokes of systematic observation. Many findings are accompanied by cautionary notes. Because humans cannot ethically be subjected to experimentation involving trauma or deprivation, “a lot of what we say we’ve learned from brain research comes from nonhuman animal studies—rodents and primates,” Dr. Shonkoff noted. “We can infer, but we can’t say that’s the same thing as studying [human] brain development. Human brains are different from rat brains and even rhesus monkeys.”
Nevertheless, the biological development of the human brain is now understood partly as a function of early learning experiences. The number of synapses (junctions across which nerve impulses pass) increases from about 50 trillion at birth to a peak of one quadrillion at age three, then is halved by age fifteen. Such “pruning” is part of a natural process that some scientists call “use it or lose it.” Crudely put, it may mean that tasks or functions not performed are deemed unnecessary, and the brain adapts accordingly. In the first couple of years, for example, the brain can recognize any sound in any language; after exposure to a particular language for a few years, the brain loses the ability to perceive sounds that are not heard and used. “Thus, the child’s experience, like a sculptor carving a complex statue from a large block of stone, shapes the child’s brain,” write Drs. Zuckerman and Kahn. “But such ‘plasticity’ of the neural networks does not last forever.”7 It is not a perfect metaphor because the brain is not carved in stone, of course, and its capacities continue developing well past adolescence. But early interactions can teach lifetime lessons.
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Take a two-month-old infant who cries at 3 a.m. Drs. Zuckerman and Kahn offer two scenarios. John’s mother picks him up, “cradles him next to her body, then talks to him about being hungry. John nurses for about a half-hour, pausing occasionally to gaze up into the eyes of his mother, who responds by speaking softly to her son … puts John in the crib, kisses him, and covers him as he slowly begins to drift off to sleep.” The baby “is learning about cause and effect,” the doctors note, “that the adults in his life are trustworthy and can be counted on to help him if he is frustrated or in need.”
Another two-month-old, Sean, gets different treatment. His mother “has just fallen asleep after a fight with her husband. She has difficulty getting out of bed and shouts, ‘Just a minute, just a minute. I’m coming.’ … She lifts him up abruptly and puts him to her breast. She stares fixedly ahead, going over the recent fight with her husband.… Sean responds to his mother’s tension by squirming restlessly, stiffening, and finally arching and drawing back from her nipple to cry. The mother responds, ‘You don’t want to eat, fine, don’t eat.’ She puts her somewhat hungry baby back into the crib and goes back to bed yelling, ‘Shut up, just shut up.’ ” What Sean is learning, Drs. Zuckerman and Kahn observe, is that “to be handled and held can be uncomfortable and distressing, and that being hungry and crying only leads to a harsh tone, rough handling, and partially met needs. He is learning to be wary and distrustful of others. Even learning about cause and effect is tainted for Sean because of the negative affect. John, by contrast, may develop a love of learning because the brain circuitry connects cause and effect to pleasure.”8
There is reciprocity here: The mother is also learning that her baby is not cuddly and malleable, and she becomes less warm as a result; child behavior and parenting styles influence each other. Children with a sense of “secure attachment” induce better parenting, according to research summarized by the study From Neurons to Neighborhoods: “The children, in effect, are more receptive to the parent’s instruction, guidance, and teaching, which then reinforces the parent’s sensitive parenting and, in all likelihood, further binds their secure attachment.”9 Maternal depression can be part of the same cycle: The mother doesn’t nurture, the child doesn’t respond, and that worsens the mother’s depression. “Depressed mothers have been shown to display less spontaneity, more unhappy affect, fewer vocalizations, and diminished physical contact with their four-month-olds,” write Dr. Steven Parker and colleagues in a 1988 paper. “These infants already manifest fewer vocalizations and happy expressions toward their mothers.”10 Children’s cognitive outcomes can also be affected, according to some studies, one of which found reduced reading skills among eight-year-olds who were three when their mothers suffered from depression.11
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