Ruth and Peter, a couple I know well, tried for several years, without success, to have a child. Ruth's doctor finally prescribed a fertility drug, which stimulated the release of two ova from Ruth's ovaries. As a result, fraternal twins&151;Jeannie and Jason&151;were born.
Ruth and Peter already had one child, Rosanne, age 6 when Jeannie and Jason arrived. The twins' birth took place in London, during the year that Peter worked for a foreign branch of his American employer. Ruth and Peter were grateful for Great Britain's government-sponsored health insurance, which covered Jeannie and Jason's birth and the family's health care. Rosanne had been born in the United States, just after Ruth and Peter graduated from college and before they found their first jobs. Without health insurance, medical bills for Rosanne's birth piled up, adding to the financial burden the couple faced. The British insurance was especially fortuitous, since Jeannie and Jason's birth was difficult, and Jason had a serious medical condition.
Jason (left) and Jeannie. Notice the surgical scar on Jason's head, where the fontanel was opened when he was 3 months old.
Eight months into her pregnancy, Ruth experienced periodic contractions, and her cervix began to dilate. The doctor hospitalized her, confining her to bed rest in an effort to postpone the birth and grant the twins an extra measure of prenatal growth. A week later, Ruth went into labor; Jeannie and Jason arrived 3 weeks before their due date. At 5 pounds 6 ounces, Jeannie was the larger of the twins, entering the outside world with a lusty and assertive cry. Jason, at 5 pounds 1 ounce, appeared more vulnerable. He slept more and fed poorly. During the first few days, Jason lost more weight than Jeannie; by the end of the first week, he weighed only 4 pounds 8 ounces. While Jeannie went home with Ruth, Jason remained in the hospital. Besides giving Jason a chance to put on weight, the pediatrician wanted to evaluate the condition of his skull. The largest fontanel (gap, or "soft spot"), located on top of Jason's head, was fused at birth, impeding the ability of his skull bones to expand with brain growth during the first few years of life.
At 2 weeks of age, when Jason joined the family at home, life was chaotic. Because Peter had to be at work all day, he could assist with child care only in the evenings and on weekends. Ruth was fatigued from the birth, and it seemed that a baby was always awake, requiring attention. Ruth and Peter had to divide time between the twins, and neither got as much stimulation as the average single infant. Extended family members were thousands of miles away across the Atlantic Ocean. Ruth and Peter had no one they could depend on to relieve the constant pressures of caregiving&151;and to help them find time for Rosanne as well.
Overwhelmed by the needs of their three children, Ruth and Peter left the infants in their cribs for long periods&151;sometimes 4 or 5 hours at a time. Jason lay quietly, seemingly content but understimulated; his motor skills and playful, exploratory behaviors emerged slowly. At age 3 months, he underwent head surgery to open the fused fontanel. Although the operation went well, a recovery period of several weeks delayed Jason's development further.
As Jeannie and Jason grew larger and stronger, their distinct personalities became evident. Jason was a placid baby who rarely cried. Jeannie, in contrast, was feisty and willful. When Ruth and Peter put her down for naps to get some relief from her never-ending demands, she screamed angrily. At age 6 months, she rocked on all fours and banged her head rhythmically against the side of the hard wooden crib. Worried that she would injure herself, Ruth asked the pediatrician about Jeannie's strange behavior.
"She needs to be held, cuddled, and rocked more. Then she won't feel such a need to stimulate herself," Dr. Franzen explained. But Jeannie was wiry and energetic, and Ruth and Peter found her hard to cuddle. Every diaper change was an ordeal as she squirmed and cried at the top of her lungs, refusing to submit. Peter had to hold Jeannie's arms and legs while Ruth worked quickly to remove the soiled diaper and exchange it for a clean one. Jeannie's irritable style meant that her parents granted her more attention than they did Jason&151;one reason that Jeannie developed somewhat more quickly.
At the end of each day, Ruth and Peter fell into bed exhausted, only to be woken several times by Jeannie and Jason. Both parents were on "a short string" emotionally. Ruth was stressed by unrelenting baby care, lack of social supports, and absence of outlets for her professional talents. When Peter came home each evening, he found her sullen and depressed. Ruth tried to remind herself: "In a few months, they'll be a bit older; things will get easier."
When Jeannie and Jason were 10 months old, the family boarded a plane for the United States. Their return&151;to the city where Peter's parents lived&151;did provide much-needed assistance with child rearing. Once a week, Peter's mother looked after the babies; on two additional days, Ruth took them to a family day care home, where a kind, patient woman provided a loving and stimulating environment. These arrangements permitted Ruth to return to part-time teaching&151;an opportunity that eased the family's financial worries while granting Ruth gratifying career involvement. Gradually, Ruth and Peter felt less need to put the babies in their cribs for long naps. Rosanne frequently amused them and helped with their feedings. Jeannie stopped her head banging, and Jason seemed more alert and interested in his surroundings. The family appeared happier in all respects.
Throughout toddlerhood and the preschool years, both twins&151;Jason, especially&151;lagged behind in development. They walked, talked, dressed themselves, rode a tricycle, cut with scissors, and recognized letters of the alphabet later than most of their agemates. When Ruth and Peter sat down one day to discuss the twins' progress, Peter commented, "Their development is more precarious than that of many other children. We have to give them extra encouragement and support." Although Jeannie's emotional tirades became less frequent, they surfaced from time to time, and her physical strength made quieting her a real challenge. Jason remained reticent and inactive; he often did not evoke the stimulation and involvement at home and school that he needed to develop at his best.
By elementary-school age, parental warmth, patience, and firmness led Jeannie to channel her physical strength and emotional volatility productively. She excelled at gymnastics and immersed herself in school projects, becoming a first-rate student. Jason gained in competence as well. His teachers noticed his artistic talent and praised him for his strengths. Still, he had difficulty with reading and writing in the first few years of grade school and did not develop as rapidly as his twin sister.