Orphans

Researchers and social policy makers have long been interested in the developmental impact of institutionalization. Are young children who have experienced extreme deprivation in the first year or two of their lives ever able to overcome such poor developmental beginnings? Children in orphanages have been studied in many parts of the world (e.g., Iran, Lebanon, United States, Greece, Romania, Russia, and Canada). The early work on institutionalization demonstrated that deprivation resulted in developmental insult but made no attempt to establish what it was about deprivation that caused such deficits. Intellectual assessments were often used as outcome measures and social emotional variables were used to explain these outcomes. In the late twentieth century, researchers examined larger samples of orphanage children using standardized developmental assessments and measures of all aspects of development (i.e., physical, intellectual, behavioral, and social-emotional). This entry presents a review of both the early literature and late-twentieth-century research on institutionalized children. In most studies children with orphanage experience are compared to children reared in foster care, adopted children, or children who were home-reared from birth. Typically orphanage children fare less well on most measures than children in these other groups.

Early Literature on Institutionalization

Research interest in the developmental consequences of extreme deprivation in infancy began in the early 1940s and 1950s with the work of researchers such as Rene Spitz (1945a; 1945b), William Goldfarb (1945; 1955), and John Bowlby (1953). Researchers became interested in this topic as a result of the high infant mortality rate in institutions from no known physical cause (Spitz 1945a; 1945b). Rene Spitz coined the term hospitalism to describe the physical and psychological characteristics of infants housed in institutions. He described conditions in the institution as dire. For example, children spent most of their days in cubicles with drab walls wherein sheets often hung over the sides of the infants' cribs, obstructing their view. Spitz suggested that this lack of stimulation explained the rapid deterioration in children's intellectual development. He found a drastic drop in infants' developmental quotients (DQ) over the first few months of life in institutions, and by the end of the second year Spitz reported that infants' DQs had dropped to a low of 45, where an average DQ is 100. Spitz concluded from his study that the damage inflicted on children during their first year of life was irreparable.

William Goldfarb (1955) studied fifteen children who had been reared in an institutions for the first three years of their lives and were subsequently placed in foster care. He compared these children to a group of children who had been in foster care since early infancy. Goldfarb found that the institution group, even in adolescence, were delayed intellectually relative to the foster care group, displayed significantly greater problem behaviors, were socially less mature and appeared emotionally removed in terms of their capacity to form relationships. Goldfarb claimed that early institutional rearing resulted in developmental deficits that were not overcome once children were placed in more stimulating and loving environments. He clearly stated that, given his findings, "babies should be kept out of institutions" (Goldfarb 1947, p. 457).

Clearly, this early work suggested that institutionalized children would be irreparably damaged as a result of such experience. This work has been criticized, however, largely because of methodological limitations (Longstreth 1981; Pinneau 1955). Critics reported that much of this early literature provided scant details regarding not only conditions in orphanages but also the assessments used to evaluate children. The number of children who were tested, the ages at which they were tested, and how often assessments were carried out was often unclear. These limitations made it difficult for later researchers to have strong confidence in the early data on institutionalized children.

Not all early studies, however, predicted such dire outcomes for institutionalized children. In many parts of the world researchers conducted intervention studies attempting to ascertain the kinds of interventions that might prevent poor developmental outcomes. Researchers began demonstrating that many of the cognitive and social deficits among these children were ameliorated after improvements in their environment (Broussard and DeCarie 1971; Dennis 1960; Hunt et al. 1976; see Rosenblith and Sims-Knight 1985 for a review; Skodak and Skeels 1945, 1949). Such interventions included placing infants as houseguests with older children (Skodak and Skeels 1945, 1949), improving child-to-caregiver ratios (Hunt et al. 1976), and early-adoption (Dennis 1973). All of these studies showed that simple changes, even within the orphanage environment (e.g., lowering child-caregiver ratios, providing perceptual stimulation), resulted in increases in children's intelligence quotient (IQ) scores. More importantly, this research showed that the effects of deprivation were not irreparable, although the length of institutionalization could make a difference in developmental outcomes.

Further support for the idea that institutionalized children were not destined for developmental compromise came from the work of Barbara Tizard and her colleagues with children who had spent the first two years of their lives in high-quality institutions in the United Kingdom (Tizard 1977). In these institutions child-to-caregivers ratios were 3:1 and the children experienced adequate social interaction, were taken on outings, and fed well. The caregivers, however, were discouraged from forming intimate relationships with the children. This was the major way in which orphanage children's lives differed from the lives of home-reared children. Tizard first assessed these children at two years of age and compared them to a sample of home-reared children from a working-class background. She found that at this time the institution children's IQs were slightly lower than the IQs of the working class children, and their language was slightly delayed, but their social development was normal. Tizard followed her sample of children up to sixteen years of age and found that the majority of parents claimed their children had developed a deep attachment toward them. These data were in contrast to Goldfarb's earlier work in which he claimed that previously institutionalized children would be unable to form subsequent attachment relationships. As noted previously, however, the children in Tizard's sample had not experienced the extreme deprivation that the children in Gold-farb's sample had. Therefore Tizard's more positive outcomes may be partially the result of less severe deprivation.

Later Deprivation Studies

It was not until late 1989 and early 1990 that researchers once again could address the impact of extreme deprivation on young children, when the Ceausescu regime in Romania was overthrown. At this time the outside world became aware of thousands of children who had been housed in Romanian state-run orphanages. The conditions in Romanian orphanages were similar to or worse than the conditions described by Goldfarb (Ames 1990; Groze and Ileana 1996). Children spent from twenty to twenty-four hours a day in their cribs, with little visual or auditory stimulation (Ames 1990, 1997), and child-to-caregiver ratios ranged from 10:1 for infants to as high as 20:1 for children over three years of age (Chisholm et al. 1995). Therefore researchers were once again permitted the opportunity to evaluate the developmental impact of extreme deprivation. Sandra Kaler and Betty Jo Freeman (1994) examined the cognitive and social-emotional developmental status of children within an orphanage in Romania and found that the majority of orphanage children were severely delayed.

Since the early 1990s three major studies have examined the developmental outcomes of children who had spent their first year or two of life in a Romanian orphanage and were subsequently adopted. Two studies in Canada (Ames 1997; Marcovitch et al. 1997) and one in the United Kingdom (Rutter et al. 1998) have followed these children postadoption. These studies represent an improvement on the earlier literature given they have used large samples of children, comparison groups, and standardized measures that evaluate several aspects of children's development. We now know more about the impact of institutionalization on children's physical, intellectual, behavioral, and social-emotional development.

Intellectual Development

Elinor Ames and her colleagues (Morison, Ames, and Chisholm 1995) examined children's development, eleven months postadoption, assessing delays in four areas: fine motor, gross motor, personal-social, and language. They found that when their parents first met them the vast majority of adoptees were delayed in all four areas of development. Eleven months postadoption, however, adoptees displayed clear developmental catch-up in that now only close to half the adoptees showed delays in each area of development. This is consistent with the work of Michael Rutter and his colleagues in the United Kingdom (Rutter et al. 1998).

In both of these studies of Romanian adoptees intellectual development was also examined (Morison and Ellwood 2000; Rutter et al. 1998). In Ames's sample, when the adopted children had been in their adoptive homes for approximately three years, orphanage children had significantly lower IQs than both Canadian-born and earlyadopted children (Morison and Ellwood 2000). This was particularly the case for children who were adopted after two years of age. Therefore, the longer that children had been institutionalized the more likely such institutionalization had an impact on intellectual development. It is important to note, however, that there was wide variability in IQ scores within each group of children, with some orphanage children scoring in the superior range for IQ (Ames 1997).

Rutter and his colleagues compared Romanian adoptees' intellectual development to a group of within-country adoptees (Rutter et al. 1998). Rutter and his colleagues (1998) found that by the age of four, the Romanian adoptees who had been adopted before six months of age did not differ in terms of IQ from the sample of within-country adoptees. For those children adopted after six months of age, their mean IQ scores were only slightly below 100 but they did score significantly lower than either the within-country adoptees or the early-adopted Romanian children.

These findings are consistent with findings from a study comparing orphanage and home-reared children in Russia. Vladimir Sloutsky (1997) assessed differences in IQ scores between six- and seven-year-old children reared in an orphanage with home-reared children and found that the orphanage children scored significantly lower in IQ than home-reared children.

Behavior Problems

Behavior problems have also been examined in recent studies of institutionalized children. These studies have found that orphanage children display rather unique behavior problems when compared with either home-reared nonadopted children or within country-adoptees.

Ames and her colleagues attribute most of the behavior problems of orphanage children to their orphanage experience given that early-adopted children who were adopted before two months of age did not appear different from Canadian-born children in any problem area (Ames 1997; Fisher et al. 1997). The most troublesome problems for adoptive parents were in the areas of eating, sleeping, stereotyped behavior, and sibling and peer relationships. Eleven months postadoption, one-third of orphanage children in their sample would not eat solid food or ate too much, both behaviors that were likely the result of orphanage experience. Although orphanage children did not differ from Canadian-born children in the number of sleeping problems they had, the kind of sleeping problems that adoptive parents experienced with their orphanage children differed. The sleeping problem of most concern to adoptive parents was the fact that children would not signal when they were awake, another behavior that was likely the result of institutionalization.

Stereotyped behavior concerned adoptive parents. The majority of orphanage children (84%) displayed stereotyped behavior, mostly in the form of rocking. Three years after adoption adoptive parents reported improvements in all behavior areas. At this time orphanage children did not look different from Canadian-born and early-adopted children in eating problems, sleeping problems, or sibling problems. However, they still displayed more stereotyped behavior than children in the other two groups, although this behavior had improved as well from Time 1 to Time 2. Clearly these recent results suggest that much of the difficulties linked to orphanage experience are over-come when children's environments improve.

Children's behavior problems were also examined using the Child Behavior Checklist (CBCL), a standardized behavior problem questionnaire developed by Thomas Achenbach, Craig Edelbrook, and Catherine Howell (1987). Romanian orphanage children scored significantly higher on the CBCL than did Canadian-born or early-adopted children, and a large percentage of orphanage children scored above the clinical cut-off for the CBCL (Fisher et al. 1997). This finding is consistent with work in a Greek residential group care facility with nine-year-old children (Vorria et al. 1998). In comparing residential group care children to children reared in two-parent families Panyiota Vorria and colleagues (1998) found that the group care children were more inattentive, passive, and participated less in group activities at school than did their family-reared peers. In general, institution-reared children typically display more behavior problems than home-reared children.

Social-Emotional Development

For many reasons indiscriminate friendliness is a behavior that is particularly relevant to any study of institutionalized children. References to indiscriminately friendly behavior are evident in the early literature on the social development of institutionalized children who were later fostered or adopted (Goldfarb 1955; Provence and Lipton 1962). Tizard (1977) characterized indiscriminate friendliness as behavior that was affectionate and friendly toward all adults (including strangers) without the fear or caution characteristic of normal children. In these cases a child's behavior toward other adults could not be discriminated from his or her behavior toward caregivers.

Studies of institutionalized children have also examined indiscriminate friendliness. In Ames's study parents were asked five questions assessing (a) whether their child wandered without distress; (b) whether their child was willing to go home with a stranger; (c) how friendly their child was with new adults; (d) whether their child was ever shy; and (e) what their child typically did upon meeting new adults. These researchers found that orphanage children displayed significantly more indiscriminate friendliness than both early-adopted and Canadian-born children, and orphanage children were just as indiscriminate three years postadoption as they were initially (Chisholm 1998). Similarly, Thomas O'Connor, Michael Rutter, and their colleagues in the United Kingdom (2000) found that indiscriminate friendliness was associated with length of deprivation in their sample of Romanian adoptees.

Attachment

Indiscriminate friendliness is particularly relevant to the study of attachment because some researchers have suggested that indiscriminately friendly behavior may be indicative of nonattachment, a term used to describe an attachment disorder that results from an infant not having had the opportunity to form an attachment relationship (Lieberman and Pawl 1988) or a reactive attachment disorder. (Zeanah 1996). A. F. Lieberman and J. H. Pawl (1988) have used the term nonattachment to describe an attachment disorder that results from an infant not having had the opportunity to form an attachment relationship. This is precisely the situation of children reared in institutions, so researchers have focused on linking this behavior to children's attachment. Kim Chisholm (1998) found that the more extreme indiscriminate behaviors (i.e., wandering without distress and being willing to go home with a stranger) were associated with insecure attachment in Ames's sample.

The question of whether orphanage children are able to form attachment relationships with their adoptive families has been of concern to both researchers and adoptive parents. Researchers have examined attachment using standard separation reunion procedures and validated coding systems.

Chisholm (1998), using Ames's sample of Romanian adoptees, found that one-third of orphanage children were securely attached to their adoptive parent, one-third were insecurely attached to their parent but in a way that is not uncommon in normative samples of children, and one-third of orphanage children displayed atypical insecure attachment patterns. Some researchers have suggested that such atypical patterns may be indicative of future psychopathology (Carlson and Sroufe 1995; Crittenden 1988a). Although all of the orphanage children formed attachments, significantly more of them displayed insecure attachment patterns than children in both the Canadian-born and early-adopted groups. This is consistent with other research on a sample of Romanian adoptees living in the Toronto area (Handley-Derry et al. 1995) and the UK sample of Romanian adoptees (Marvin and O'Connor 2000).

These findings taken together contradict claims in the early literature on institutionalized children (Goldfarb 1955; Spitz 1945), showing that orphanage children in all three of these studies were able to form attachment relationships with their adoptive parents. It is important to note, however, that these recent findings further suggest that when the attachment process does go wrong in previously institutionalized children, it may go very wrong. In Chisholm's study (1998) significantly more orphanage children than Canadian-born or earlyadopted children displayed atypical attachment patterns, which some researchers have suggested are risk factors in the development of psychopathology (Carlson and Sroufe 1995; Crittenden 1988).

Summary

How does one attempt to summarize the recent literature on institutionalized children? Most of the studies show, perhaps unsurprisingly, that children who have spent an extended period of time in orphanage display deficits in all areas of development when compared to any other group (i.e., early-adopted, within-country adopted, and/or home-reared children). Although this sounds like the same pessimistic picture that both Goldfarb and Spitz painted, when one examines the data beyond mere group differences, a different picture emerges. Ames (1997) extended the work with her sample by going beyond group differences and examining the data within her orphanage group. As reported earlier, orphanage children in Ames's sample displayed significantly more behavior problems, they had significantly lower IQs, more social problems, and they displayed significantly more insecure attachment patterns, particularly more atypical or extreme attachment patterns than children in the other groups. On each of these measures, however, there was substantial within-group variation. Not all of the orphanage children were experiencing all of these problems. This raises a risk and resiliency question. Why do some children recover from such extreme deprivation seemingly unscathed, whereas other children carry scars into their futures? Ames examined the correlates that were associated with particular problems, and whether it was the same orphanage children experiencing each of these problems. She defined four areas of serious problems: having an IQ of eight-five or lower, having an atypical insecure attachment pattern, having severe behavior problems, or continued presence of stereotyped behavior.

Ames then grouped her sample in terms of the number of serious problems and compared her groups in this way. She found only one earlyadopted child had as many as three serious problems, and none of her Canadian-born group had three serious problems, but 30 percent of the orphanage group had three or four of these serious problems. This third of the orphanage group accounted for 68 percent of all the individual serious problems that orphanage children had. Ames then reanalyzed all of the data excluding those orphanage children with three or four serious problems from the analyses. She found there were no longer group differences on behavior problems as assessed by the CBCL or insecure attachment patterns. Nevertheless, orphanage children still had significantly lower IQs than Canadian-born children.

This is a more positive picture than earlier work on institutionalization and speaks to the strength in young children of overcoming tremendous adversity. Fully two-thirds of orphanage children were doing well given their poor start. One-third of the children, even three years postadoption, were doing poorly.

Ames then examined factors that were associated with a child having three or more serious problems. She considered characteristics of the institution, child characteristics, and family characteristics. Although length of time in the orphanage was associated with more problems, no characteristics of the institution or the child were associated with a child having serious problems.

There were, however, family characteristics that were associated with children having more problems. One factor that seemed to predict whether a child would have serious problems was the number of Romanian children adopted. Families who adopted two children had more serious problems than families who only adopted one child. A number of other family characteristics were associated with children having serious problems and all of these appear to be tapping the resources available to a family. The higher the family income, the older the mother, and the higher the socioeconomic status (SES) of the family, the fewer problems they were experiencing with their child. A final—rather surprising—correlate of children who were experiencing many problems involved the parent who had traveled to Romania to adopt a child. Children who were selected by the father alone experienced more problems postadoption than children who had been selected by either the mother alone or both parents. Ames (1997) suggested that the parent who is going to be the parent providing most of the day-to-day caregiving should have been the parent to travel to Romania.

These correlates seem to suggest that resiliency is not something within a child. It develops as a result of the particular interactions a child experiences with his or her environment. Therefore, institutionalization represents a risk factor that initially sets a child on a less than optimal developmental pathway. Where a child ends up developmentally, however, will depend on what happens after the initial trauma.

Children's experience in orphanages clearly constitutes a risk factor for their optimal development. Given an optimal postorphanage environment with few stressors, however, orphanage children appear to do well and overcome early adversity. Institutionalization appears to contribute to less than optimal development only when coupled with other stressors (for example, low SES, high parenting stress). This is consistent with the suggestion that one risk factor in isolation does not lead to an increased probability for psychopathology. It is the combination of several risk factors working together that substantially increases the likelihood of future difficulty (Belsky, Rosenberger, and Crnic 1995; Rutter 1985).

Clearly, children who experience institutionalization and are subsequently adopted generally arrive in their adoptive homes in poor condition. Parents are dealing simultaneously with an array of problem areas, which requires an exceptionally high level of commitment from parents. The fact that many parents are successful in promoting optimal developmental outcomes in their children is truly a laudable achievement.

See also:Adoption; Children's Rights; Failure to Thrive; Foster Parenting

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KIM MACLEAN