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27
10.1177/1524838005283696 TRAUMA, VIOLENCE, & ABUSE / January 2006 Johnson et al. / YOUNG CHILDREN IN INSTITUTIONALCARE YOUNG CHILDREN IN INSTITUTIONAL CARE AT RISK OF HARM REBECCA JOHNSON KEVIN BROWNE CATHERINE HAMILTON-GIACHRITSIS University of Birmingham A recent survey has revealed a large number of young children in institutional care across Europe. Young children placed in institutional care without parents may be at risk of harm. This review considers systematically the research evidence on the impact of institutional care on brain growth, attachment, social behavior, and cog- nitive development. Analytical epidemiological study designs (i.e., including a control/comparison group) show that young children placed in institutional care are at risk of harm in terms of attachment disorder and developmental delays in so- cial, behavioral, and cognitive domains. Delays in physical growth, neural atro- phy, and abnormal brain development have also been implicated. The findings suggest that the lack of a one-to-one relationship with a primary caregiver is a ma- jor cause of harm to children in residential care. Evidence indicates that infants who are placed in institutional care will suffer harm to their development if they are not moved to family-based care by the age of 6 months. The neglect and damage caused by early privation and deprivation is equivalent to violence and policy makers should work to ensure that every child has the opportunity to grow up in a family environment. Key words: young children; residential settings; institutional care; abuse and neglect A RECENT EUROPEAN COMMISSION “Daphne” project surveyed 32 European coun- tries (not including Russian speaking countries) and mapped the number and characteristics of children under the age of 3 years in residential care (Browne et al., 2004). It was reported that there were 23,099 children, of a population of 20.6 million under 3, in institutions for more than 3 months without a parent. This represents 11 children in every 10,000 under 3 years in residential care institutions. There was great variation between different countries for the proportion of children under 3 in institutional care. Four countries had none or less than 1% of children under 3 in institutions, 12 countries had institutionalized between 1 and 10 children per 10,000, seven countries had between 11 and 30 children per 10,000 in institutions and alarmingly, eight countries had between 31 and 60 children per 10,000 in institu- tions. Luxembourg could not provide informa- tion on the rate of children in institutions. A UNICEF survey (2004) of Russian-speaking countries formerly in the USSR (New Independ- ent States) showed that most have 30 or more children per 10,000 in “infant homes” (0-3 34 TRAUMA, VIOLENCE, & ABUSE, Vol. 7, No. 1, January 2006 34-60 DOI: 10.1177/1524838005283696 © 2006 Sage Publications
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10.1177/1524838005283696TRAUMA, VIOLENCE, & ABUSE / January 2006Johnson et al. / YOUNG CHILDREN IN INSTITUTIONALCARE
YOUNG CHILDREN IN INSTITUTIONALCARE AT RISK OF HARM
REBECCA JOHNSONKEVIN BROWNECATHERINE HAMILTON-GIACHRITSISUniversity of Birmingham
Arecent survey has revealed a large number of young children in institutional careacross Europe. Young children placed in institutional care without parents may beat risk of harm. This review considers systematically the research evidence on theimpact of institutional care on brain growth, attachment, social behavior, and cog-nitive development. Analytical epidemiological study designs (i.e., including acontrol/comparison group) show that young children placed in institutional careare at risk of harm in terms of attachment disorder and developmental delays in so-cial, behavioral, and cognitive domains. Delays in physical growth, neural atro-phy, and abnormal brain development have also been implicated. The findingssuggest that the lack of a one-to-one relationship with a primary caregiver is a ma-jor cause of harm to children in residential care. Evidence indicates that infantswho are placed in institutional care will suffer harm to their development if they arenot moved to family-based care by the age of 6 months. The neglect and damagecaused by early privation and deprivation is equivalent to violence and policymakers should work to ensure that every child has the opportunity to grow up in afamily environment.
Key words: young children; residential settings; institutional care; abuse and neglect
A RECENT EUROPEAN COMMISSION“Daphne” project surveyed 32 European coun-tries (not including Russian speaking countries)and mapped the number and characteristics ofchildren under the age of 3 years in residentialcare (Browne et al., 2004). It was reported thatthere were 23,099 children, of a population of20.6 million under 3, in institutions for morethan 3 months without a parent. This represents11 children in every 10,000 under 3 years inresidential care institutions.
There was great variation between differentcountries for the proportion of children under 3
in institutional care. Four countries had none orless than 1% of children under 3 in institutions,12 countries had institutionalized between 1and 10 children per 10,000, seven countries hadbetween 11 and 30 children per 10,000 ininstitutions and alarmingly, eight countries hadbetween 31 and 60 children per 10,000 in institu-tions. Luxembourg could not provide informa-tion on the rate of children in institutions.
A UNICEF survey (2004) of Russian-speakingcountries formerly in the USSR (New Independ-ent States) showed that most have 30 or morechildren per 10,000 in “infant homes” (0-3
34
TRAUMA, VIOLENCE, & ABUSE, Vol. 7, No. 1, January 2006 34-60DOI: 10.1177/1524838005283696© 2006 Sage Publications
years). Comparable data for North America isdifficult to identify. On 30 September 2001,542,000 children (0-18 years) were in public(“foster”) care in the United States and approxi-mately one quarter (130,857) of these are under5 years (U.S. Department of Health and HumanServices, 2003). Furthermore, a report on “ChildWelfare Outcomes 2000” states that across the50 States, a median of 9% (range 1.3 Hawaii to27.2% Arizona) of children under 12 years inpublic (foster) care were placed in residentialchildren’s homes (U.S. Department of Healthand Human Services, 2001). Therefore, it can beestimated for the United States that approxi-mately 11,777 children under 5 years resided inresidential care institutions. Outside the devel-oped world of Europe and North America, theproblem of instititutionalized young children isvast and accurate statistics are unavailable.
The damaging consequences of institutionalcare have been known for many years. The pub-lications of Goldfarb (1945) and Bowlby (1951)were particularly influential and highlighted anumber of emotional, behavioral, and cognitiveimpairments that characterized individualswho had been raised in institutional care. Theseindividuals were reported to be intellectuallyretarded with specific difficulties in languagedevelopment. In addition, they had problemsconcentrating, forming emotional relation-ships, and were often described as attention-seeking. The lack of an attachment with amother figure during infancy was attributed asthe cause of these problems.
The influence of attachment theory (Bowlby,1969) emphasized the negative consequences ofinstitutional care compared to family-basedcare and the importance of a primary caregiverfor normal development. This led to a decline inthe use of institutional care or large children’shomes in some parts of world. In other parts ofworld, child care policy has been less influencedby the writings of Bowlby in terms of meetingthe psychosocial needs of children. Instead, anemphasis has been placed on the physical needsof children and controlling their environment.In such countries this has led to a reliance on in-stitutions rather than the development of substi-tute parenting, such as foster care and adoption(Browne, 2002). Furthermore, in some coun-
tries, advances in child-protection policy andprocedures that can remove parental rightshave sometimes progressed at a faster rate thanthe development of community services tomaintain children’s rights to be supported and/or rehabilitated into their families of origin oroffered alternative family-based care (UnitedNations, 1989). Therefore, children have beenplaced in hospital or residential care institutionsas a place of safety, often on a long-term basis.
In the 1990s, Romanian orphanages attractedthe attention of the media and researchers alikebecause of the devastatingly impoverished con-ditions in which many children were placed(Johnson, 2000). These unfortunate children
Johnson et al. / YOUNG CHILDREN IN INSTITUTIONAL CARE 35
KEY POINTS OF THE RESEARCH REVIEW• There are a significant number of young children
in residential care for more than 3 months with-out a parent in the European region at risk ofharm in terms of attachment disorder, develop-mental delay, and neural atrophy to the develop-ing brain.
• Children in institutional care have limited oppor-tunities to form selective attachments comparedto children in family-based care, especially wherethere are large numbers of children, small num-bers of staff, and a lack of consistent care throughshift work and staff rotation. Even apparently“good” institutional care can have a detrimentaleffect on children’s ability to form relationshipslater in life.
• Analytical epidemiological study designs (i.e.,including a control and/or comparison group)show that many of the problems observed insamples of severely deprived children, such asquasi-autistic behaviors and delays in cognitivedevelopment, show improvement once the childis removed from institutional care and placed in asupportive family environment. However, thequality of the subsequent family environment isan important factor in the outcome of institution-ally reared children.
• Research suggests that children who are movedfrom residential care before the age of 6 monthscan still reach optimal development. The pres-ence of attachment disorder is more common inchildren who have spent more than 6 months ininstitutional care.
• The neglect and damage caused by early priva-tion of parenting is equivalent to violence to ayoung child, as it inhibits optimal developmentand neglects the rights of the child to grow up in afamily.
provided a natural experiment on the effects ofsevere deprivation and provided a unique op-portunity for researchers to investigate whetherthe effects of such conditions can be reversed byplacing these children in the family-based carethey were deprived of in infancy. MichaelRutter and the English and Romanian AdopteesStudy Team at the Institute of Psychiatry in Lon-don (O’Connor et al., 1999, 2000a, 2000b; Rutteret al., 1998, 1999) have followed a large sampleof Romanian children who were adopted intothe United Kingdom after having spent theearly part of their life in such an institution. Sim-ilarly, research in British Columbia and Ontariohas reported on the progress of Romanian or-phans (although these so-called orphans aretypically social orphans rather than true or-phans) subsequently adopted into Canada(Fisher, Ames, Chisholm, & Savoie, 1997;Marcovitch et al., 1997).
The aim of this article is to review the litera-ture in a systematic way to consider the impactof early institutional care on neural develop-ment, attachment, social and/or behavioral de-velopment, and cognitive development. Ascoping exercise revealed that articles coveringthe neurobiological consequences of institu-tional care did not fit the inclusion criteria forthe review. Therefore, this article begins by con-sidering recent theoretical developments in thefield of neurobiology as background informa-tion to add to our understanding of why institu-tional care in the first few years of life isparticularly damaging for development.
NEUROBIOLOGICALCONSEQUENCES
The development ofthe brain in the postnatalperiod is truly stagger-ing; the human infant isborn with some 100-bil-lion neurons and eachneuron forms about15,000 synapses duringthe first few years of life(Balbernie, 2001). By theage of 3 the child hasformed about 1,000 tril-
lion synapses, this corresponds “to a rate of 1.8million new synapses per second between twomonths of gestation and two years after birth!”(Eliot, 2001, p. 27).
The overabundance of synapses and neuronsin the infant’s brain allows the adaptation ofthe brain in response to the environment(neuroplasticity). Synapses that are frequentlyused are reinforced, whereas redundant synap-ses are “pruned.” Thus, early experience deter-mines which neural pathways will become per-manent and which will be eliminated. However,for this process to result in normal brain devel-opment, the infant “must interact with a livingand responsive environment” (Balbernie, 2001).Specifically, a strong case has been proposed forthe maturation of the brain being “embedded inthe attachment relationship between the infantand the primary caregiver” (Schore, 2001a, p. 10).
The human infant is genetically predisposedto respond to a caregiver who will respond to,talk to, and handle them in a sensitive way andintroduce new stimuli in a manner that is safe,predictable, repetitive, gradual, and appropri-ate to the infant’s stage of development (Perry &Pollard, 1998). Thus, a sensitive caregiver and asecure attachment promote brain growth anddevelopment, whilst an impoverished environ-ment has the opposite effect and will suppressbrain development. Neglect and abuse in theearly years of life have the potential to affectsubsequent brain functioning; “neglect leads todeprivation of input needed by the infant brainat times of experience-expectant maturation,while abusive experiences affect brain develop-ment at experience-dependent stages” (Glaser,2000, p. 106).
Although abuse is certainly an issue with re-gard to children in residential care, this occursmore frequently in a family setting (Wolfe, Jaffe,& Jetté, 2003). Neglect, on the other hand, couldbe considered as a feature of typical institu-tional practice; institutional culture is primarilyconcerned with the physical care of childrenand the establishment of routine with little pro-vision for interaction with children (Giese &Dawes, 1999). Among other negative conse-quences, a lack of interaction and deprivation ofinput in the early years has obvious conse-quences for language development. Observa-
36 TRAUMA, VIOLENCE, & ABUSE / January 2006
The human infant isgeneticallypredisposed torespond to acaregiver who willrespond to, talk to,and handle them in asensitive way andintroduce new stimuliin a manner that issafe, predictable,repetitive, gradual,and appropriate tothe infant’s stage ofdevelopment.
tional studies, such as Giese and Dawes (1999)suggest that it is the “regulative” style of staff-child interactions that contributes primarily tolanguage delays seen in some institutionallyraised children. They observed interactionswithin the institutional setting and found thatmost interactions (83%) were highly regulativeand generally commands of a short duration(three seconds on average) that did not encour-age further interactions with the child. Tizard,Cooperman, Joseph, and Tizard (1972) similarlyreported that level of development was relatedto the quality of staff-child interaction.
A child raised in institutional care is typicallydeprived of the supportive, intensive, one-to-one relationship with a primary caregiver that isessential for optimal development. Without acaregiver to “scaffold“ infant learning, there isno process to guide synaptic connections andthe development of neural pathways. Schore(2001b) suggests that neglect leads to excessivepruning, which will result in neural and behav-ioral deficits. The neglect that is intrinsic in mostinstitutional settings is, therefore, damaging tobrain development and can cause regions of thebrain to atrophy (Balbernie, 2001).
Although these questions about critical peri-ods and recovery require more research, com-munication between developmental psycholo-gists and developmental neuroscientists hasbegun to lead to a greater understanding of howneglect and deprivation influence child devel-opment (Nelson et al., 2002). Future research,which takes a multidisciplinary approach (e.g.,Zeanah et al., 2003) offers the best chance foranswering these questions.
What is already clear is that the most sensi-tive period for brain development is the first 3years of life when the brain is in an unparalleledtime of developmental change (Schore, 2001a,2001b). Also, there is strong evidence that hu-man infants are born with a readiness to relate toothers and that engagement with sensitive oth-ers is essential for normal development(Trevarthen & Aitken, 2001). Neglect and abusein the early years of life, therefore, have the po-tential to affect adversely subsequent brainfunctioning (Glaser, 2000). Unfortunately, ne-
glect is typical of institutional practice and theroutine nature of institutional care does not en-courage the development of appropriate socialinteraction, language development, andautonomy (Giese & Dawes, 1999).
METHOD
The methods used for the review followed asystematic approach, with a search strategy andinclusion and/or exclusion criteria based onpopulation, intervention, comparator, and out-come (PICO). The approach, however, did notconsider the execution of the studies and noevaluation of bias or confounding influenceswas conducted.
Search Strategy
A search of published material (EMBASE1996 to 2003; MEDLINE 1996 to 2003; ISI Web ofScience 1998 to 2003; SOSIG 1998 to 2003; Sci-ence Direct 1998 to 2003) was conducted usingthe following terms: children and residentialcare, children and deprivation, children andprivation, early deprivation, early privation,children and orphanages, children andinstitutionalization, or institutionalization. Inaddition, the reference lists of relevant articleswere hand checked, and publications from au-thors known in the field were sought with visitsto experts in Romania. This generated 2,624hits, with research going back as far as 1944identified via reference lists. After taking intoaccount duplicates and inclusion criteria, therewere 27 hits.
Inclusion Criteria
The following PICO was developed for theidentification of studies to be included in thereview:
• Population—children 0-17 years• Intervention—children exposed to residential care
in an institution under the age of 5 years without aprimary caregiver for varying lengths of time
• Comparator—children exposed to family-basedcare with a primary caregiver for varying lengths oftime
Johnson et al. / YOUNG CHILDREN IN INSTITUTIONAL CARE 37
(text continues on page 41)
38
TAB
LE
1:
Su
mm
ary
of
Res
earc
h S
tud
ies
Inve
stig
atin
g A
ttac
hm
ent
in C
hild
ren
Rai
sed
in In
stit
uti
on
al C
are
Stu
dyIn
stitu
tion
Sam
ple
Inst
itutio
nal C
hara
cter
istic
sD
escr
iptio
n of
Stu
dyF
indi
ngs
Gol
dfar
b (1
944)
n=
15
Mal
e-fe
mal
e 1.
1:1
Age
10-
14 y
ears
IT 2
7-47
mon
ths
Not
des
crib
ed (
see
Gol
dfar
b,19
45)
Cap
acity
for
rela
tions
hips
was
mea
sure
d in
adol
esce
nts
who
had
spe
nt th
eir
early
in-
fanc
y in
inst
itutio
nal c
are
but w
ho h
ad s
ub-
sequ
ently
bee
n fo
ster
ed.T
hese
chi
ldre
nw
ere
com
pare
d w
ith a
mat
ched
com
paris
ongr
oup
who
wer
e in
fost
er c
are
and
had
been
in fa
mily
-bas
ed c
are
sinc
e bi
rth.
In c
ompa
rison
to th
e “f
oste
r”gr
oup
the
in-
stitu
tiona
lly r
aise
d ad
oles
cent
s w
ere
emot
iona
lly w
ithdr
awn
in r
elat
ions
hips
and
unpo
pula
r bu
t cra
ving
affe
ctio
n.
Rhe
ingo
ld a
nd B
ayle
y(1
959)
n=
14
Mal
e-fe
mal
e 1:
1A
ge 1
7-22
mon
ths
IT 4
-18
mon
ths
Not
des
crib
ed.
Two
grou
ps o
f chi
ldre
n in
inst
itutio
nal c
are
wer
e co
mpa
red
in a
n ex
perim
enta
l situ
a -tio
n.H
alf t
he c
hild
ren
rece
ived
2 m
onth
s of
care
from
a s
ingl
e ca
regi
ver.
The
com
pari -
son
grou
p w
as c
ompl
etel
y re
ared
und
er in
-st
itutio
nal r
outin
e.T
he s
ocia
l res
pons
ive -
ness
of t
he c
hild
ren
was
test
ed a
fter
the
expe
rimen
tal p
hase
and
18
mon
ths
late
r.T
he s
ocia
l res
pons
iven
ess
of c
hild
ren
sub-
sequ
ently
ado
pted
or
rest
ored
was
als
oco
mpa
red.
Afte
r th
e 2
mon
ths
of h
avin
g a
sing
le c
are -
give
r, th
e ex
perim
enta
l gro
up w
as r
ated
as m
ore
soci
ally
res
pons
ive.
How
ever
,th
is w
as n
ot m
aint
aine
d 18
mon
ths
late
r.A
dopt
ed c
hild
ren
gave
mor
e po
sitiv
e re
-sp
onse
s th
an r
esto
red
child
ren
did
but
this
diff
eren
ce w
as n
ot s
igni
fican
t.T
hech
ildre
n st
ill in
inst
itutio
nal c
are
wer
efr
iend
lier
to s
tran
gers
than
chi
ldre
n w
hoha
d be
en m
oved
from
inst
itutio
nal t
ofa
mily
-bas
ed c
are.
Tiz
ard
and
Jose
ph(1
970)
n=
30
Mal
e-fe
mal
e 1:
1A
ge 2
yea
rsIT
4-2
4 m
onth
s
Sta
ff to
chi
ld r
atio
1:3
but
hig
hst
aff t
urno
ver.
Boo
ks, t
oys,
pla
yfa
cilit
ies.
Mix
ed a
ge g
roup
s.H
ome
visi
ts a
nd o
utin
gs.P
er-
sona
l rel
atio
nshi
ps d
isco
urag
ed.
Goo
d st
anda
rd o
f phy
sica
l car
e.
Res
pons
e to
str
ange
rs a
nd to
sep
arat
ion
was
mea
sure
d in
a s
ampl
e of
chi
ldre
nra
ised
in a
UK
res
iden
tial n
urse
ry.A
sam
ple
of “
wor
king
-cla
ss”c
hild
ren
was
use
d as
aco
ntro
l gro
up.
The
chi
ldre
n ra
ised
at h
ome
wer
e si
gnifi
-ca
ntly
mor
e fr
iend
ly to
a s
tran
ger
than
the
resi
dent
ial n
urse
ry c
hild
ren.
Whe
n le
ftal
one
with
a s
tran
ger,
the
resi
dent
ial
nurs
ery
child
ren
wer
e m
ore
likel
y to
run
out o
f the
roo
m;n
one
of th
e ho
me
chil-
dren
did
this
.
Wol
kind
(19
74)
n=
92
Mal
e-fe
mal
e 1.
7:1
Age
5-1
2 ye
ars
IT 6
mon
ths-
6 ye
ars
Not
des
crib
ed.C
hild
ren’
s ho
me
inth
e U
nite
d K
ingd
om.
A p
sych
iatr
ic s
tudy
of c
hild
ren
who
wer
elo
ng-s
tay
resi
dent
s in
a U
K in
stitu
tion
was
carr
ied
out.
Sym
ptom
s of
chi
ldre
n w
how
ere
adm
itted
bef
ore
the
age
of 2
yea
rsw
as c
ompa
red
with
thos
e of
chi
ldre
n ad
mit-
ted
afte
r th
is a
ge.
The
re w
ere
diffe
renc
es b
etw
een
the
two
grou
ps fo
r di
sinh
ibiti
on;t
he c
hild
ren
ad-
mitt
ed b
efor
e th
e ag
e of
2 y
ears
wer
e“o
verf
riend
ly.”
Tiz
ard
and
Ree
s (1
975)
n=
26
Mal
e-fe
mal
e 2.
3:1
Age
4 a
nd a
hal
f yea
rsIT
24-
48 m
onth
s
Sta
ff to
chi
ld r
atio
1:3
but
hig
hst
aff t
urno
ver.
Boo
ks, t
oys,
pla
yfa
cilit
ies.
Mix
ed a
ge g
roup
s.H
ome
visi
ts a
nd o
utin
gs.P
er-
sona
l rel
atio
nshi
ps d
isco
urag
ed.
Goo
d st
anda
rd o
f phy
sica
l car
e.
Affe
ctio
nal b
onds
wer
e as
sess
ed in
a s
am-
ple
of c
hild
ren
rais
ed in
a U
K r
esid
entia
lnu
rser
y w
as m
easu
red.
Chi
ldre
n w
ere
ei-
ther
stil
l in
nurs
ery,
ado
pted
, or
rest
ored
toth
eir
natu
ral p
aren
ts.A
sam
ple
of “
wor
king
-cl
ass”
child
ren
was
use
d as
a c
ontr
ol g
roup
.
The
chi
ldre
n st
ill in
nur
sery
car
e w
ere
de-
scrib
ed b
y st
aff a
s sh
allo
w, e
mot
iona
llyde
tach
ed, a
nd w
ere
thou
ght n
ot to
car
ede
eply
abo
ut a
nyon
e.T
he a
dopt
ed c
hil-
dren
wer
e th
ough
t by
thei
r ad
opte
d m
oth-
ers
to b
e de
eply
atta
ched
to th
em.
39
Tiz
ard
and
Hod
ges
(197
8)n
= 5
1M
ale-
fem
ale
1.8:
1A
ge 8
yea
rsIT
24-
48 m
onth
s
Sam
e as
abo
ve.
Atta
chm
ent b
ehav
ior
and
pare
nt r
atin
gs o
f atta
ch-
men
t in
a sa
mpl
e of
chi
ldre
n ra
ised
in a
UK
res
i -de
ntia
l nur
sery
wer
e m
easu
red.
Som
e ch
ildre
nw
ere
still
in th
e nu
rser
y bu
t mos
t had
bee
nad
opte
d or
res
tore
d to
thei
r na
tura
l par
ents
.Asa
mpl
e of
“w
orki
ng-c
lass
”chi
ldre
n w
as u
sed
as a
cont
rol g
roup
.
Com
pare
d to
the
cont
rol g
roup
, the
ex-
inst
itutio
nal c
hild
ren
wer
e m
ore
ofte
nra
ted
as o
ver-
frie
ndly
.84%
of t
hem
othe
rs o
f ado
pted
chi
ldre
n be
lieve
dth
eir
child
to b
e at
tach
ed (
50%
of r
e -st
ored
mot
hers
).T
he e
nviro
nmen
t of
the
rest
ored
chi
ldre
n is
des
crib
ed a
sm
uch
less
favo
rabl
e as
that
exp
eri -
ence
d by
the
adop
ted
child
ren.
Hod
ges
and
Tiz
ard
(198
9a)
n=
42
Mal
e-fe
mal
e 2:
1A
ge 1
6 ye
ars
IT 2
4-48
mon
ths
Sam
e as
abo
ve.
The
fam
ily r
elat
ions
hips
of e
x-in
stitu
tiona
l ado
les -
cent
s ra
ised
unt
il at
leas
t the
age
of 2
in a
UK
res
i -de
ntia
l nur
sery
was
mea
sure
d at
16
year
s.T
head
just
men
t of t
he c
hild
ren
who
had
sub
sequ
ently
been
ado
pted
and
res
tore
d w
as c
ompa
red
and
also
with
a c
ontr
ol g
roup
of a
dole
scen
ts.
Clo
se a
ttach
men
ts w
ere
muc
h m
ore
likel
y am
ong
the
adop
ted
child
ren
and
thei
r ad
optiv
e pa
rent
s th
an b
etw
een
the
rest
ored
chi
ldre
n an
d th
eir
natu
ral
pare
nts.
Mar
covi
tch
et a
l.(1
997)
n=
56
Mal
e-fe
mal
e 1:
1.1
Age
3-5
yea
rsIT
0-<
6 m
onth
s, 6
-48
mon
ths
Sev
erel
y de
priv
ed e
nviro
n -m
ent.
Nut
ritio
nal a
nd p
sy-
chol
ogic
al p
rivat
ion.
Har
shph
ysic
al c
ondi
tions
.
Atta
chm
ent s
tatu
s w
as m
easu
red
in a
sam
ple
ofR
oman
ian
orph
ans
who
had
sub
sequ
ently
bee
nad
opte
d in
Can
ada.
The
out
com
e fo
r ch
ildre
n w
hoha
d sp
ent l
ess
than
6 m
onth
s in
an
orph
anag
ew
as c
ompa
red
with
that
of c
hild
ren
who
had
spe
ntlo
nger
than
6 m
onth
s in
an
inst
itutio
n.A
con
trol
sam
ple
from
ano
ther
stu
dy o
f hea
lthy
4-ye
ar-o
lds
was
use
d as
a c
ompa
rison
for
the
atta
chm
ent
mea
sure
.
The
ado
ptee
s w
ere
very
diff
eren
t to
the
cont
rol s
ampl
e.T
he r
ate
of s
ecur
e at
-ta
chm
ent w
as s
igni
fican
tly lo
wer
for
the
adop
tees
(30
% v
s.42
%).
Thi
s di
f-fe
renc
e m
ay b
e gr
eate
r as
ther
e m
ayha
ve b
een
“fal
se s
ecur
es”a
mon
g th
ead
opte
es.A
void
ant a
ttach
men
t, w
hich
was
the
mos
t com
mon
form
of i
nse-
cure
atta
chm
ent i
n th
e co
ntro
l gro
up,
was
abs
ent a
mon
g th
e ad
opte
es, w
how
ere
ambi
vale
nt o
r di
sorg
aniz
ed in
thei
r at
tach
men
t.
Chi
shol
m (
1998
)n
= 4
6M
ale-
fem
ale
1:1.
2A
ge 5
3-55
mon
ths
IT 8
-53
mon
ths
Sta
ff to
chi
ld r
atio
1:1
0-20
.S
ever
ely
depr
ived
env
i-ro
nmen
t.N
utrit
iona
l and
psyc
holo
gica
l priv
atio
n.H
arsh
phy
sica
l con
ditio
ns.
Atta
chm
ent a
nd in
disc
rimin
ate
frie
ndlin
ess
wer
eas
sess
ed a
t 30
mon
ths
and
54 m
onth
s in
a s
am-
ple
of R
oman
ian
orph
ans
(RO
) w
ho h
ad s
ubse
-qu
ently
bee
n ad
opte
d in
Can
ada.
The
se c
hild
ren
wer
e co
mpa
red
with
a m
atch
ed g
roup
of C
anad
ian
born
(C
B)
child
ren
(non
adop
ted)
and
a g
roup
of
Rom
ania
n ch
ildre
n w
ho h
ad b
een
adop
ted
befo
re4
mon
ths
(EA
).
RO
chi
ldre
n di
d no
t diff
er fr
om C
B a
ndE
A o
n at
tach
men
t sec
urity
(pa
rent
alre
port
) bu
t the
y di
d di
spla
y m
ore
inse
-cu
re a
ttach
men
t pat
tern
s th
an th
eot
her
two
grou
ps.R
O c
hild
ren
wer
esi
gnifi
cant
ly m
ore
likel
y to
sho
w in
dis-
crim
inat
ely
frie
ndly
beh
avio
r th
an th
eC
B a
nd E
A c
hild
ren;
the
latte
r tw
ogr
oups
did
not
sho
w a
ny s
igni
fican
tdi
ffere
nces
.
(con
tinu
ed)
40
O’C
onno
r et
al.
(199
9)n
= 1
11M
ale-
fem
ale
1:1.
2A
ge 4
yea
rsIT
< 6
mon
ths,
6-<
24m
onth
s
Sev
erel
y de
priv
ed e
nviro
n -m
ent.
Nut
ritio
nal a
nd p
sy-
chol
ogic
al p
rivat
ion.
Har
shph
ysic
al c
ondi
tions
.
Atta
chm
ent d
isor
der
(dis
inhi
bite
d be
havi
or, e
.g.,
wou
ld r
eadi
ly g
o of
f with
a s
tran
ger)
and
beh
av-
iora
l and
em
otio
nal p
robl
ems
wer
e m
easu
red
in a
sam
ple
of R
oman
ian
orph
ans
(RO
) w
ho h
ad s
ub-
sequ
ently
bee
n ad
opte
d in
the
Uni
ted
Kin
gdom
.D
urat
ion
of d
epriv
atio
n w
as c
ompa
red
with
out
-co
me.
A g
roup
of U
K-a
dopt
ed c
hild
ren
not e
x -po
sed
to d
epriv
atio
n w
as u
sed
as a
com
paris
ongr
oup.
A s
tron
g re
latio
nshi
p w
as fo
und
be-
twee
n du
ratio
n of
dep
rivat
ion
and
at-
tach
men
t dis
orde
r be
havi
ors,
but
70%
of th
e ch
ildre
n ex
pose
d to
mor
e th
an2
year
s of
dep
rivat
ion
did
not e
xhib
itse
vere
atta
chm
ent d
isor
der
whe
reas
som
e ch
ildre
n on
ly d
epriv
ed in
the
early
mon
ths
did.
RO
sho
wed
mor
e at
-ta
chm
ent d
isor
der
than
the
UK
com
-pa
rison
gro
up.
Sm
yke,
Dum
itres
cu, a
ndZ
eana
h (2
002)
n=
32
Mal
e-fe
mal
e ra
tio n
otst
ated
Age
4-6
8 m
onth
sIT
4-6
8 m
onth
s
Sta
ff to
chi
ld r
atio
1:10
.M
ultip
le c
areg
iver
s.C
hil -
dren
spe
nd m
ost o
f day
in o
ne la
rge
room
or
outs
ide.
Inhi
bite
d an
d di
sinh
ibite
d at
tach
men
t dis
orde
r w
asin
vest
igat
ed w
ere
mea
sure
d in
chi
ldre
n in
“st
an-
dard
”Rom
ania
n in
stitu
tiona
l car
e, in
chi
ldre
n re
-ce
ivin
g “p
ilot”
care
(m
ore
cons
iste
ncy
of c
are-
give
rs)
and
a co
ntro
l gro
up o
f chi
ldre
n in
day
car
ebu
t who
had
nev
er b
een
plac
ed in
an
inst
itutio
n.
Inhi
bite
d an
d di
sinh
ibite
d at
tach
men
tbe
havi
ors
wer
e ob
serv
ed s
igni
fican
tlym
ore
in th
e ch
ildre
n in
sta
ndar
d ca
reco
mpa
red
to th
e ot
her
two
grou
ps.
The
pilo
t gro
up d
ispl
ayed
mor
edi
sinh
ibite
d be
havi
or th
an th
e co
ntro
lgr
oup
thou
gh th
e di
ffere
nces
wer
e no
tsi
gnifi
cant
.
O’C
onno
r et
al.
(200
0a)
n=
165
Mal
e-fe
mal
e 1:
1.2
Age
6 y
ears
IT <
6 m
onth
s, 6
-< 2
4m
onth
s, 2
4-42
mon
ths
Sam
e as
abo
ve.
Atta
chm
ent d
isor
der
(dis
inhi
bite
d be
havi
or, e
.g.,
wou
ld r
eadi
ly g
o of
f with
a s
tran
ger)
and
beh
av-
iora
l and
em
otio
nal p
robl
ems
wer
e m
easu
red
in a
sam
ple
of R
oman
ian
orph
ans
(RO
) w
ho h
ad s
ub-
sequ
ently
bee
n ad
opte
d in
the
Uni
ted
Kin
gdom
.D
urat
ion
of d
epriv
atio
n w
as c
ompa
red
with
out
-co
me.
A g
roup
of U
K-a
dopt
ed c
hild
ren
not e
x-po
sed
to d
epriv
atio
n w
as u
sed
as a
com
paris
ongr
oup.
Atta
chm
ent d
isor
der
corr
elat
ed w
ithat
tent
iona
l and
con
duct
pro
blem
s bu
tap
pear
s to
be
a di
stin
ct s
et o
f beh
av-
iors
.A s
tron
g re
latio
nshi
p w
as fo
und
betw
een
dura
tion
of d
epriv
atio
n an
dat
tach
men
t dis
orde
r be
havi
ors,
but
70%
of t
he c
hild
ren
expo
sed
to m
ore
than
2 y
ears
of d
epriv
atio
n di
d no
t ex-
hibi
t sev
ere
atta
chm
ent d
isor
der
whe
re a
s so
me
child
ren
only
dep
rived
in th
e ea
rly m
onth
s di
d.R
O s
how
edm
ore
atta
chm
ent d
isor
der
than
the
UK
com
paris
on g
roup
.
NO
TE
:nre
fers
to th
e in
stitu
tiona
l sam
ple
subj
ects
onl
y;th
e st
udie
s ha
d a
sim
ilar
num
ber
of c
ompa
rison
or
cont
rol s
ubje
cts.
IT =
ran
ge o
f tim
e sp
ent i
n in
stitu
tiona
l car
e.
TAB
LE
1(c
on
tinu
ed)
Stu
dyIn
stitu
tion
Sam
ple
Inst
itutio
nal C
hara
cter
istic
sD
escr
iptio
n of
Stu
dyF
indi
ngs
• Outcome—child to primary caregiver attachmentpatterns, social and behavioural development, cog-nitive development
Studies were only selected where there wasevidence of a control or comparison group-study design. Attachment (12 studies), socialand/or behavioral (17 studies), and cognitive(13 studies) domains were addressed sepa-rately. Thus, some studies that researched morethan one domain are included in more than onetable.
For each domain, a table summarizes thefindings from a number of studies that have in-vestigated the consequences for children raisedin institutional care during their early yearscompared to a control or comparison sample. Inthe text, some of these studies are described inmore detail, focusing in particular on longitudi-nal studies with matched control groups.
CONSEQUENCES FOR ATTACHMENT
A summary of studies that have investigatedrelationships and attachment in children raisedin institutional care is provided in Table 1. Nineof these studies report specifically on indiscrim-inate friendliness, overfriendliness, and/ordisinhibited behavior. Eight of these nine stud-ies report that children raised in institutionalcare exhibited these features of a disordered at-tachment more than controls or children whowere admitted to institutional care after the ageof two years (Wolkind, 1974).
Tizard and Rees (1975) investigatedaffectional bonds in a sample of UK childrenwho had spent their early years in a residentialnursery. Although the conditions in the nurserywere good, there was a high turnover of staffand the staff group was discouraged from hav-ing close relationships with the children. At agefour, the staff reported that the children were“not deeply attached to anyone.” For the insti-tutional children who had been adopted by theage of 4, a third of them were reported asoverfriendly to strangers by their adoptive par-ents. Similarly, at age 8, ex-institutional childrenwere more often described as overfriendly incomparison to other children (Tizard & Rees,1975). The overfriendliness had attenuated by
the age of 16, although the ex-institutional teen-agers were still more oriented toward adultattention and approval. At age 16, the ex-insti-tutional children (children adopted and chil-dren restored to their natural family) showedmore problems with peer relationships and re-lationships with adults outside the family com-pared to other teenagers. In terms of family rela-tionships, only children restored to their naturalfamily were more likely to have difficulties andpoor family relationships. The adopted childrendid not differ in their family relationships fromother teenagers. Thus, institutional care with alack of secure attachments in the early years hadnot resulted in an inability to form close rela-tionships. However, the formation of subse-quent attachments does not occur automaticallyby placing the child in a family setting. The criti-cal factor appeared to be whether “the parentwanted the child and was able to put a lot intothe relationship” (Hodges & Tizard, 1989a).
Later research has sought to investigate rela-tionships in institutionally raised childrenwithin the framework of attachment theory. Forexample, Marcovitch et al. (1997) investigatedchild-parent attachment in a sample of childrenwho had been adopted from Romanian institu-tions into Canada and who had experienced“poor” conditions of institutional care. The chil-dren had been deprived of basic physical, emo-tional, and nutritional needs. The opportunityfor these children to form any sort of relation-ship with a caregiver was extremely limited.Marcovitch et al. (1997) assessed attachment inthese children with the strange situation test(Ainsworth, Blehar, Waters, & Wall, 1978) usingthe classification scheme developed by Cassidy,Marvin, and Attachment Working Group of theMacArthur Network on the Transition from In-fancy to Early Childhood (1987, 1992) for usewith preschoolers. The rate of secure attach-ment in the adoptee group was significantlylower than in the comparison group (30% vs.42%). However, the actual difference may bemuch greater as the previously institutional-ized children may have been incorrectly catego-rized as secure. The coding system used for as-sessing attachment was based on parent-childreunion and did not consider response tostrangers. However, the indiscriminate friendli-
Johnson et al. / YOUNG CHILDREN IN INSTITUTIONAL CARE 41
ness toward strangers seen in these children isincompatible with secure attachment status.This pattern of behavior suggests a disorganiza-tion of the attachment-behavioral system andmight suggest the presence of a disinhibited-at-tachment disorder (O’Connor et al., 1999). Chil-dren described as having a disinhibited-attach-ment disorder show indiscriminately friendlybehavior toward strangers and approach peo-
ple with whom they donot have a close relation-ship when distressed. Ithas been suggested thatthis represents a “disor-ganization” of the attach-ment system, which is adifferent and perhapsmore serious problemthan “insecure” attach-ment (O’Connor et al.,1999).
O’Connor et al. (1999)investigated attachment-disorder behaviors intheir sample of Romanianorphans who had beenadopted in the United
Kingdom. They found that the duration of thedeprivation experienced by their sample of 4-year-old Romanian orphans was positively as-sociated with attachment disorder behaviors(e.g., lack of checking with parents, clear indica-tion that child would readily go off with astranger). They also point out, however, that notall children who had experienced prolongeddeprivation display these behaviors.
Smyke, Dumitrescu, and Zeanah (2002) inves-tigated inhibited and disinhibited-attachmentdisorder in three groups of Romanian children.The first group received standard institutionalcare, which involved more than 20 differentstaff members caring for a large group of chil-dren in rotating shifts. The second group of chil-dren was in the same institution but receivedcare on a “pilot unit.” In the pilot unit, a smallerpool of staff was used so that instead of 20 in-consistent caregivers there were 4 consistentcarers. Children in the pilot unit were alsohoused in smaller groups (10 to 12 rather than30 to 35 in the standard unit), so that each group
had one main consistent caregiver. The thirdgroup was a control group of children who wereattending day care but who had never beenplaced in an institution. The group receiving thestandard institutional care had significantlyhigher scores for the signs of both inhibited anddisinhibited attachment disorders than theother two groups did. There were no significantdifferences between the pilot care group and thecontrol group for inhibited behaviors but therewere some significant differences for measuresof indiscriminate behavior; the pilot group hadhigher scores and exhibited more indiscrimi-nate behavior.
In terms of attachment, even apparently“good” institutional care can have a detrimentaleffect on children’s ability to form relationshipslater in life. The lack of a warm and continuousrelationship with a sensitive caregiver can pro-duce children who are desperate for adult at-tention and affection. Superficially, the behav-ior of these children can seem “normal,” andsome earlier classifications of attachmentmight label them as secure rather than disorga-nized and/or disorientated (Carlson, Cicchetti,Barnett, & Braunwald, 1989; Zeanah, 2000).However, their lack of discrimination is indica-tive of an attachment disorder (Carlson et al.,1989; Zeanah, 2000). The presence of attachmentdisorder is more common in children who havespent more than 6 months in institutional care(O’Connor et al., 1999, 2000a). However, thispattern is not an inevitable consequence of earlydeprivation and there are mediating factors thatcan ameliorate negative effects, such as the childbeing a particular favorite of a residential careworker and as a result receiving sensitive caregiving. Nevertheless, children in institutionalcare clearly have limited opportunities to formselective attachments compared to children infamily-based care, especially where there arelarge numbers of children, small numbers ofstaff, and a lack of consistent care through shiftwork and staff rotation.
CONSEQUENCES FOR SOCIAL ANDBEHAVIORAL DEVELOPMENT
Research investigating the development ofchildren who have been raised in institutions
42 TRAUMA, VIOLENCE, & ABUSE / January 2006
(text continues on page 48)
In terms ofattachment, evenapparently “good”institutional care canhave a detrimentaleffect on children’sability to formrelationships later inlife. The lack of awarm and continuousrelationship with asensitive caregivercan produce childrenwho are desperatefor adult attentionand affection.
43
TAB
LE
2:
Su
mm
ary
of
Res
earc
h S
tud
ies
Inve
stig
atin
g t
he
So
cial
an
d B
ehav
iora
l Dev
elo
pm
ent
of
Ch
ildre
n R
aise
d in
Inst
itu
tio
nal
Car
e
Stu
dyIn
stitu
tion
Sam
ple
Inst
itutio
nal C
hara
cter
istic
sD
escr
iptio
n of
Stu
dyF
indi
ngs
Gol
dfar
b (1
944)
n=
15
Mal
e-fe
mal
e 1.
1:1
Age
10-
14 y
ears
IT 2
7-47
mon
ths
Not
des
crib
ed (
see
Gol
dfar
b,19
45).
Per
sona
lity,
pro
blem
beh
avio
r, an
d so
cial
mat
urity
wer
e m
easu
red
in a
dole
scen
tsw
ho h
ad s
pent
thei
r ea
rly in
fanc
y in
inst
itu-
tiona
l car
e bu
t who
had
sub
sequ
ently
bee
nfo
ster
ed.T
hese
chi
ldre
n w
ere
com
pare
dw
ith a
mat
ched
com
paris
on g
roup
who
wer
e in
fost
er c
are
and
had
been
in fa
mily
-ba
sed
care
sin
ce b
irth
.
In c
ompa
rison
to th
e “f
oste
r”gr
oup,
the
in-
stitu
tiona
lly r
aise
d ad
oles
cent
s w
ere
“ap -
preh
ensi
ve,”
“apa
thet
ic,”
rest
less
and
hy -
pera
ctiv
e, a
nd le
ss s
ocia
lly m
atur
e.
Gol
dfar
b (1
945)
n=
15
Mal
e-fe
mal
e 1.
5:1
Age
43
mon
ths
IT 4
-32
mon
ths
Not
des
crib
ed in
det
ail “
Adu
lt-ch
ild r
atio
is v
ery
low
so
that
ther
e is
a m
inim
um o
f adu
lt st
im-
ulat
ion,
”“th
e ch
ild’s
act
iviti
es a
reco
mpl
etel
y re
gula
ted
...H
e is
not e
ncou
rage
d to
par
ticip
ate
inth
e fo
rmul
atio
n of
his
ow
n da
y to
day
prog
ram
.”
The
beh
avio
r an
d so
cial
mat
urity
of c
hild
ren
rais
ed in
inst
itutio
nal c
are
in th
e U
nite
dK
ingd
om w
as te
sted
at 3
yea
rs.T
he c
hil -
dren
wer
e th
en p
lace
d in
fost
er h
omes
,an
d a
follo
w-u
p te
st c
ondu
cted
9 m
onth
saf
ter
the
first
test
.The
se c
hild
ren
wer
eco
mpa
red
with
a m
atch
ed c
ompa
rison
grou
p w
ho w
ere
in fo
ster
car
e an
d ha
dbe
en in
fam
ily-b
ased
car
e si
nce
birt
h.
At t
he fi
rst t
estin
g th
e in
stitu
tiona
lly r
eare
dch
ildre
n an
d th
e fo
ster
car
e ch
ildre
n ha
dsi
mila
r sc
ores
for
soci
al m
atur
ity.A
t the
seco
nd te
st a
fter
the
inst
itutio
n ch
ildre
nha
d al
so b
een
fost
ered
, how
ever
, the
scor
es o
f the
inst
itutio
n gr
oup
impr
oved
.T
his
is in
terp
rete
d as
a tr
aum
a fo
llow
ing
sepa
ratio
n fr
om th
e fa
mili
ar in
stitu
tiona
len
viro
nmen
t.In
the
beha
vior
rat
ings
, the
fost
er c
are
child
ren
wer
e ra
ted
as m
ore
fa-
vora
ble
than
the
inst
itutio
n gr
oup,
but
at
the
seco
nd te
st th
ere
wer
e no
diff
eren
ces.
Wol
kind
and
Rut
ter
(197
3)n
= 7
8M
ale-
fem
ale
20:1
Age
10-
11 y
ears
IT a
t lea
st o
ne w
eek
Not
des
crib
ed.V
arie
ty o
f UK
res
i-de
ntia
l ins
titut
ions
.A
pop
ulat
ion
sam
ple
of 1
0- to
11-
year
-old
child
ren
in tw
o Lo
ndon
bor
ough
s w
assc
reen
ed u
sing
teac
her
mea
sure
s of
be-
havi
oral
pro
blem
s.A
ran
dom
sam
ple
of th
e“d
evia
nt”c
hild
ren
was
inve
stig
ated
furt
her
in c
ompa
rison
to a
con
trol
gro
up o
f “no
n-de
vian
t”ch
ildre
n.In
form
atio
n w
as c
olle
cted
abou
t any
per
iods
of p
aren
tal s
epar
atio
n(e
.g.,
plac
emen
t with
fost
er p
aren
ts o
r in
ach
ildre
n’s
hom
e).
Chi
ldre
n ex
perie
ncin
g sh
ort-
term
inst
itu-
tiona
l car
e w
ere
foun
d to
be
at r
isk
for
anti-
soci
al d
isor
der;
a si
gnifi
cant
ly la
rger
num
-be
r of
chi
ldre
n in
the
devi
ant g
roup
had
been
“in
car
e”th
an in
the
rand
omly
se-
lect
ed c
ontr
ol g
roup
.The
vas
t maj
ority
of
the
devi
ant g
roup
was
mal
e.P
erio
ds in
care
wer
e ty
pica
lly v
ery
brie
f, an
d in
stitu
-tio
nal c
are
is r
ejec
ted
by th
e au
thor
s as
lead
ing
to th
e pr
oble
ms
seen
in th
ese
chil-
dren
.Fam
ily d
isco
rd is
sug
gest
ed a
s a
mor
e lik
ely
expl
anat
ion,
and
it is
sug
gest
edth
at b
oys
are
mor
e su
scep
tible
to th
is ty
peof
str
ess.
Wol
kind
(19
74)
n=
92
Mal
e-fe
mal
e 1.
7:1
Age
5-1
2 ye
ars
IT 6
mon
ths-
6 ye
ars
Not
des
crib
ed.C
hild
ren’
s ho
me
inth
e U
nite
d K
ingd
om.
A p
sych
iatr
ic s
tudy
of c
hild
ren
who
wer
elo
ng-s
tay
resi
dent
s in
a U
K in
stitu
tion
was
carr
ied
out.
Sym
ptom
s of
chi
ldre
n w
how
ere
adm
itted
bef
ore
the
age
of 2
yea
rsw
as c
ompa
red
with
thos
e of
chi
ldre
n ad
-m
itted
afte
r th
is a
ge.
The
re w
as n
o di
ffere
nce
betw
een
child
ren
adm
itted
bef
ore
the
age
of 2
and
chi
ldre
nad
mitt
ed a
fter
this
age
for
“affe
ctio
nles
sps
ycho
path
y”(e
.g.,
antis
ocia
l dis
orde
r).I
tis
sug
gest
ed th
at th
is c
ondi
tion
is p
rimar
ilyth
e re
sult
of fa
mily
fact
ors.
(con
tinu
ed)
44
Tiz
ard
and
Ree
s(1
975)
n=
26
Mal
e-fe
mal
e 2.
3:1
Age
4 a
nd a
hal
f yea
rsIT
24-
48 m
onth
s
Sta
ff to
chi
ld r
atio
1:3
but
hig
hst
aff t
urno
ver.
Boo
ks, t
oys,
pla
yfa
cilit
ies.
Mix
ed a
ge g
roup
s.H
ome
visi
ts a
nd o
utin
gs.P
er-
sona
l rel
atio
nshi
ps d
isco
urag
ed.
Goo
d st
anda
rd o
f phy
sica
l car
e.
Beh
avio
r pr
oble
ms
wer
e m
easu
red
in a
sam
ple
of c
hild
ren
rais
ed in
a U
K r
esid
en-
tial n
urse
ry.C
hild
ren
wer
e ei
ther
stil
l in
nurs
ery,
ado
pted
, or
rest
ored
to th
eir
natu
-ra
l par
ents
.A s
ampl
e of
“w
orki
ng-c
lass
”ch
ildre
n w
as u
sed
as a
con
trol
gro
up.
The
res
iden
tial n
urse
ry c
hild
ren
and
the
cont
rol g
roup
sho
wed
diff
eren
t pat
tern
s of
beha
vior
pro
blem
s.N
urse
ry g
roup
:poo
rco
ncen
trat
ion,
pee
r pr
oble
ms,
tem
per
tan -
trum
s, a
nd c
lingi
ng.T
he “
wor
st”p
robl
emsc
ores
wer
e fr
om c
hild
ren
with
an
irreg
ular
or b
roke
n pa
rent
con
tact
.The
low
est
scor
es w
ere
from
the
adop
ted
child
ren.
Res
tore
d ch
ildre
n w
ere
rate
d as
the
mos
tat
tent
ion-
seek
ing.
Tiz
ard
and
Hod
ges
(197
8)n
= 5
1M
ale-
fem
ale
1.8:
1A
ge 8
yea
rsIT
24-
48 m
onth
s
Sam
e as
abo
ve.
Beh
avio
r pr
oble
ms
wer
e m
easu
red
in a
sam
ple
of c
hild
ren
rais
ed in
a U
K r
esid
en-
tial n
urse
ry.S
ome
child
ren
wer
e st
ill in
the
nurs
ery
but m
ost h
ad b
een
adop
ted
or r
e-st
ored
to th
eir
natu
ral p
aren
ts.A
sam
ple
of“w
orki
ng-c
lass
”chi
ldre
n w
as u
sed
as a
cont
rol g
roup
.
Com
pare
d to
the
cont
rol g
roup
the
ex-
inst
itutio
nal c
hild
ren
wer
e m
ore
ofte
n ra
ted
as a
ttent
ion
seek
ing,
in a
dditi
on th
e re
-st
ored
chi
ldre
n ha
d a
varie
ty o
f ner
vous
habi
ts.E
x-in
stitu
tiona
l chi
ldre
n w
ere
mor
elik
ely
to b
e de
scrib
ed b
y te
ache
rs a
s di
s-ob
edie
nt, r
estle
ss, a
nd p
oor
at p
eer
rela
-tio
ns th
an th
e co
ntro
l chi
ldre
n.O
f the
re-
stor
ed c
hild
ren,
66%
had
bee
n re
ferr
ed to
a C
hild
Gui
danc
e C
linic
com
pare
d to
12%
of a
dopt
ed c
hild
ren.
Hod
ges
and
Tiz
ard
(198
9a)
n=
42
Mal
e-fe
mal
e 2:
1A
ge 1
6 ye
ars
IT 2
4-48
mon
ths
Sam
e as
abo
ve.
The
soc
ial r
elat
ions
hips
of e
x-in
stitu
tiona
lad
oles
cent
s ra
ised
unt
il at
leas
t the
age
of
2 in
a U
K r
esid
entia
l nur
sery
was
mea
-su
red
at 1
6 ye
ars.
The
adj
ustm
ent o
f the
child
ren
who
had
sub
sequ
ently
bee
nad
opte
d an
d re
stor
ed w
as c
ompa
red
and
also
with
a c
ontr
ol g
roup
of a
dole
scen
ts.
Bot
h gr
oups
of e
x-in
stitu
tiona
l chi
ldre
n ha
dm
ore
diffi
culti
es w
ith p
eers
and
had
few
ercl
ose
rela
tions
hips
with
pee
rs th
an th
eco
ntro
l gro
up.
Hod
ges
and
Tiz
ard
(198
9b)
n=
42
Mal
e-fe
mal
e 2:
1A
ge 1
6 ye
ars
IT 2
4-48
mon
ths
Sam
e as
abo
ve.
The
beh
avio
ral a
djus
tmen
t of e
x-in
stitu
tiona
l ado
lesc
ents
rai
sed
until
at
leas
t the
age
of 2
in a
UK
res
iden
tial
nurs
ery
was
mea
sure
d at
16
year
s.T
head
just
men
t of t
he c
hild
ren
who
had
sub
se-
quen
tly b
een
adop
ted
and
rest
ored
was
com
pare
d an
d al
so w
ith a
con
trol
gro
up o
fad
oles
cent
s.
At 1
6 ye
ars,
the
ex-in
stitu
tiona
l ado
lesc
ents
still
sho
wed
pro
blem
s at
sch
ool a
ccor
ding
to te
ache
r ra
tings
.The
se c
hild
ren
tend
edto
be
mor
e re
stle
ss a
nd d
istr
actib
le, q
uar-
rels
ome
with
pee
rs, a
nd r
esen
tful i
f cor
-re
cted
by
adul
ts c
ompa
red
to c
ontr
ols.
Ado
pted
chi
ldre
n ha
d be
gun
to d
ispl
aysi
gns
of a
nxie
ty.R
esto
red
child
ren
tend
edto
be
mor
e an
tisoc
ial o
r ap
athe
tic.O
vera
ll,th
e re
stor
ed c
hild
ren
show
ed m
ore
prob
-le
ms
than
the
adop
ted
child
ren,
and
pro
b-le
ms
obse
rved
in th
is g
roup
at a
ge 8
had
not i
mpr
oved
.
TAB
LE
2(c
on
tinu
ed)
Stu
dyIn
stitu
tion
Sam
ple
Inst
itutio
nal C
hara
cter
istic
sD
escr
iptio
n of
Stu
dyF
indi
ngs
45
Kal
er a
nd F
reem
an(1
994)
n=
25
Mal
e-fe
mal
e 1.
5:1
Age
23-
50 m
onth
sIT
1-4
7 m
onth
s
Des
crib
ed a
s re
pres
enta
tive
exam
ple
of a
Rom
ania
nor
phan
age
The
soc
ial d
evel
opm
enta
l sta
tus
of R
oma -
nian
orp
hans
was
com
pare
d w
ith a
gro
upof
Rom
ania
n ki
nder
gart
en c
hild
ren.
The
chi
ldre
n fr
om th
e or
phan
age
wer
e de
-la
yed
on a
ll m
easu
res:
adap
tive
beha
vior
,so
cial
com
mun
icat
ion,
vis
ual s
elf-
reco
gni -
tion,
soc
ial r
efer
enci
ng, l
evel
of p
lay,
and
leve
l of i
nter
actio
n.T
he g
reat
est s
tren
gth
in th
e or
phan
age
child
ren
was
in th
eir
peer
soci
al in
tera
ctio
n bu
t the
ir be
havi
or s
ug-
gest
ed th
ey w
ere
rela
ting
to o
ne a
noth
erin
disc
rimin
atel
y.
Slo
utsk
y (1
997)
n=
52
Mal
e-fe
mal
e 1:
1A
ge 7
0-88
mon
ths
IT 2
7-70
mon
ths
Sta
ff to
chi
ld r
atio
1:8
-10.
Bas
icbu
t ade
quat
e fa
cilit
ies
(toy
s,bo
oks)
.No
pers
onal
pos
ses -
sion
s.P
erso
nal r
elat
ions
hips
dis
-co
urag
ed.G
ood
stan
dard
of
phys
ical
car
e.
Em
path
y an
d co
nfor
mity
wer
e m
easu
red
inch
ildre
n pl
aced
in a
Rus
sian
orp
hana
ge.
The
se c
hild
ren
wer
e co
mpa
red
with
agr
oup
of R
ussi
an k
inde
rgar
ten
child
ren.
The
chi
ldre
n ra
ised
in th
e or
phan
age
had
alo
wer
leve
l of e
mpa
thy
but a
hig
her
leve
l of
conf
orm
ity th
an th
e ki
nder
gart
en c
hild
ren.
Thi
s ef
fect
was
gre
ater
the
long
er th
e ch
il -dr
en h
ad b
een
in th
e in
stitu
tion.
Fis
her
et a
l.(1
997
n=
46
Mal
e-fe
mal
e 1:
1.3
Age
18-
76 m
onth
sIT
8-5
3 m
onth
s
Sev
erel
y de
priv
ed e
nviro
nmen
t.N
utrit
iona
l and
psy
chol
ogic
al p
ri-
vatio
n.H
arsh
phy
sica
lco
nditi
ons.
Beh
avio
r pr
oble
ms
wer
e m
easu
red
in a
sam
ple
of R
oman
ian
orph
ans
(RO
) w
hoha
d su
bseq
uent
ly b
een
adop
ted
in C
an-
ada.
The
se c
hild
ren
wer
e co
mpa
red
with
am
atch
ed g
roup
of C
anad
ian-
born
(C
B)
child
ren
(non
-ado
pted
) an
d a
mat
ched
grou
p of
Rom
ania
n ch
ildre
n (R
C)
who
had
been
ado
pted
in C
anad
a bu
t had
nev
erbe
en in
stitu
tiona
lized
.
The
RO
chi
ldre
n ha
d hi
gher
tota
l pro
blem
scor
es th
an th
e C
B a
nd R
C c
ompa
rison
grou
ps.T
he R
O c
hild
ren
also
had
sig
nifi-
cant
ly h
ighe
r “in
tern
aliz
ing”
scor
es (
e.g.
,de
pres
sion
, soc
ial w
ithdr
awal
) bu
t not
“ext
erna
lizin
g”sc
ores
(e.
g., a
ggre
ssio
n,hy
pera
ctiv
ity)
than
the
othe
r tw
o gr
oups
.65
% o
f RO
had
an
eatin
g pr
oble
m (
over
-ea
ting,
pro
blem
with
sol
id fo
ods)
, 44%
had
a sl
eepi
ng p
robl
em (
did
not s
igna
l wak
e-up
), 8
4% d
ispl
ayed
ste
reot
yped
beh
avio
rs.
The
se p
robl
ems
wer
e no
t typ
ical
in th
e C
Ban
d R
C g
roup
s.M
ore
sibl
ing
prob
lem
sw
ere
repo
rted
in th
e R
O c
hild
ren
and
the
RO
and
RC
chi
ldre
n ha
d m
ore
peer
pro
b-le
ms
than
the
CB
gro
up.I
mpr
ovem
ents
wer
e ob
serv
ed fo
r ea
ting
prob
lem
s an
dst
ereo
type
d be
havi
ors,
the
leas
t im
prov
e-m
ents
wer
e ob
serv
ed fo
r si
blin
g an
d pe
erpr
oble
ms.
Mar
covi
tch
et a
l.(1
997)
n=
56
Mal
e-fe
mal
e 1:
1.1
Age
3-5
yea
rsIT
< 6
-mon
ths,
6-4
8 m
onth
s
Sam
e as
abo
ve.
Beh
avio
r pr
oble
ms
wer
e m
easu
red
in a
sam
ple
of R
oman
ian
orph
ans
who
had
subs
eque
ntly
bee
n ad
opte
d in
Can
ada.
The
out
com
e fo
r ch
ildre
n w
ho h
ad s
pent
less
than
6 m
onth
s in
an
orph
anag
e w
asco
mpa
red
with
that
of c
hild
ren
who
had
spen
t lon
ger
than
6 m
onth
s in
an
inst
itutio
n.
Bot
h gr
oups
of c
hild
ren
scor
ed in
the
nor-
mal
ran
ge o
n m
easu
re o
f beh
avio
r pr
ob-
lem
s bu
t chi
ldre
n w
ho h
ad s
pent
long
erth
an 6
mon
ths
in th
e or
phan
age
cons
is-
tent
ly s
core
d hi
gher
than
chi
ldre
n in
inst
itu-
tiona
l car
e fo
r le
ss th
an 6
mon
ths.
(con
tinu
ed)
46
Vor
ria, R
utte
r, P
ickl
es,
Wol
kind
, and
Hob
sbau
m (
1998
)
n=
41
Mal
e-fe
mal
e 1:
1A
ge 9
-11
year
sIT
2-7
yea
rs
Sta
bilit
y of
car
e-gi
ving
sta
ff bu
tlo
w c
areg
iver
-chi
ld r
atio
.Car
e-gi
ving
“no
n-pe
rson
aliz
ed.”
Goo
dst
anda
rd o
f phy
sica
l car
e.
The
soc
ial a
nd b
ehav
iora
l adj
ustm
ent o
fG
reek
chi
ldre
n in
long
-ter
m r
esid
entia
lca
re w
as in
vest
igat
ed.A
lthou
gh th
e ch
il-dr
en w
ere
in lo
ng-t
erm
car
e, m
ost h
adsp
ent t
he fi
rst 2
yea
rs o
f life
with
thei
r fa
m-
ily.T
he o
utco
me
of th
ese
child
ren
was
com
pare
d w
ith a
mat
ched
con
trol
gro
up o
fG
reek
chi
ldre
n ra
ised
in tw
o-pa
rent
fam
ilies
.
The
res
iden
tial c
are
grou
p w
as m
ore
inat
-te
ntiv
e, le
ss p
artic
ipat
ory
and
mor
edi
stra
ctib
le a
t sch
ool t
han
the
cont
rol
grou
p.O
n pa
rent
and
teac
her
ratin
gs, t
hein
stitu
tiona
l chi
ldre
n sh
owed
mor
e ov
eral
ldi
stur
banc
e, h
ad le
ss h
arm
onio
us p
eer
re-
latio
ns a
nd w
ere
mor
e at
tent
ion-
seek
ing
with
teac
hers
.Boy
s sh
owed
poo
r ta
sk in
-vo
lvem
ent,
mor
e em
otio
nal d
iffic
ultie
s,co
nduc
t pro
blem
s, a
nd h
yper
activ
ity th
anco
ntro
ls.G
irls
show
ed p
oor
task
invo
lve-
men
t and
mor
e em
otio
nal d
iffic
ultie
s th
anco
ntra
sts.
Kre
ppne
r et
al.
(199
9)n
= 1
04M
ale-
fem
ale
2.3:
1A
ge 4
yea
rsIT
< 6
mon
ths,
6-<
24m
onth
s
Sev
erel
y de
priv
ed e
nviro
nmen
t.N
utrit
iona
l and
psy
chol
ogic
al p
ri-
vatio
n.H
arsh
phy
sica
lco
nditi
ons.
The
pre
tend
and
soc
ial r
ole
play
of a
sam
-pl
e of
Rom
ania
n or
phan
s (R
O)
who
had
subs
eque
ntly
bee
n ad
opte
d in
the
Uni
ted
Kin
gdom
was
inve
stig
ated
.A g
roup
of U
Kad
opte
es w
ere
also
obs
erve
d as
a c
om-
paris
on g
roup
.
The
UK
ado
ptee
s w
ere
muc
h m
ore
likel
y to
enga
ge in
inte
ract
ive
role
-pla
y, p
rete
ndpl
ay, r
efer
to o
ther
s’m
enta
l sta
tes
and
show
mor
e sh
ared
enj
oym
ent t
han
the
RO
.T
he d
iffer
ence
s co
uld
not b
e ex
plai
ned
byco
gniti
ve d
evel
opm
ent a
nd v
erba
l abi
lity.
The
re w
ere
no d
iffer
ence
s be
twee
n ea
rlier
or la
ter
plac
ed R
O, t
houg
h th
ere
was
atr
end
for
the
late
pla
ced
child
ren
to e
ngag
ein
less
pre
tend
and
rol
e-pl
ay.
Rut
ter
et a
l.(1
999)
n=
111
Mal
e-fe
mal
e 2.
3:1
Age
6 y
ears
IT 6
-24
mon
ths
Sev
erel
y de
priv
ed e
nviro
nmen
t.N
utrit
iona
l and
psy
chol
ogic
alpr
ivat
ion.
Poo
r ph
ysic
alco
nditi
ons.
The
pre
senc
e of
beh
avio
rs a
ssoc
iate
d w
ithau
tism
wer
e in
vest
igat
ed a
sam
ple
of R
o-m
ania
n or
phan
s (R
O)
who
had
sub
se-
quen
tly b
een
adop
ted
in th
e U
nite
d K
ing
-do
m.A
gro
up o
f UK
ado
ptee
s w
ere
also
obse
rved
as
a co
mpa
rison
gro
up.
“Aut
istic
”beh
avio
rs w
ere
obse
rved
in 1
2%of
the
RO
chi
ldre
n at
age
4;h
owev
er, t
heim
prov
emen
t see
n at
age
6, t
he e
qual
-sex
ratio
, and
the
norm
al h
ead
circ
umfe
renc
esu
gges
ted
that
thes
e ca
ses
diffe
red
to “
or-
dina
ry”a
utis
m.
TAB
LE
2(c
on
tinu
ed)
Stu
dyIn
stitu
tion
Sam
ple
Inst
itutio
nal C
hara
cter
istic
sD
escr
iptio
n of
Stu
dyF
indi
ngs
47
Bec
kett
et a
l.(2
002)
n=
144
Mal
e-fe
mal
e 1:
1.2
Age
6 y
ears
IT <
6 m
onth
s, 6
-<12
mon
ths,
12-
<24
mon
ths,
24-4
3 m
onth
s
Sam
e as
abo
ve.
A n
umbe
r of
beh
avio
r pa
ttern
s w
ere
inve
sti -
gate
d in
a s
ampl
e of
Rom
ania
n or
phan
sw
ho h
ad s
ubse
quen
tly b
een
adop
ted
inth
e U
nite
d K
ingd
om.D
urat
ion
of d
epriv
a -tio
n w
as c
ompa
red
with
out
com
e.T
he b
e -ha
vior
s m
easu
red
incl
uded
roc
king
, sel
f-in
-ju
ry, u
nusu
al s
enso
ry in
tere
sts,
and
eat
ing
prob
lem
s (d
iffic
ulty
with
sol
id fo
ods)
.
At a
dopt
ion,
47%
eng
aged
in r
ocki
ng b
e -ha
vior
, 18%
stil
l did
this
at a
ge 6
.At e
ntry
into
the
Uni
ted
Kin
gdom
, 24%
sel
f-in
jure
d;13
% s
till s
elf-
inju
red
at a
ge 6
.Sel
f-in
jury
was
ofte
n a
resp
onse
to b
eing
told
off.
All
the
abov
e w
ere
mor
e lik
ely
in c
hild
ren
who
had
been
in in
stitu
tions
for
a lo
nger
per
iod
of ti
me.
At p
lace
men
t, 11
% h
ad u
nusu
alse
nsor
y in
tere
sts,
and
som
e ch
ildre
n be
-ga
n di
spla
y af
ter
adop
tion
(too
imm
atur
e at
entr
y).P
robl
ems
with
che
win
g an
d sw
al-
low
ing
solid
food
s w
ere
mor
e lik
ely
in c
hil -
dren
who
had
rem
aine
d in
inst
itutio
nal
care
for
a ye
ar o
r lo
nger
.
Har
den
(200
2)n
= 3
5M
ale-
fem
ale
1.5:
1A
ge 9
-30
mon
ths
IT 9
-27
mon
ths
Sta
ff to
chi
ld r
atio
1:2
(bu
t diff
er-
ent w
eeke
nd s
taff)
.Wel
lpr
ovis
ione
d.C
areg
iver
-chi
ld in
-te
ract
ion
enco
urag
ed.G
ood
stan
dard
of p
hysi
cal c
are.
Ada
ptiv
e be
havi
or a
nd b
ehav
ior
prob
lem
sw
ere
mea
sure
d in
a s
ampl
e of
infa
nts
and
todd
lers
in U
.S.c
ongr
egat
e ca
re s
ettin
gs.
The
se c
hild
ren
wer
e co
mpa
red
with
agr
oup
of U
.S.c
hild
ren
fost
ered
in fa
mili
es.
The
chi
ldre
n ra
ised
in c
ongr
egat
e ca
refa
red
wor
se th
at th
e ch
ildre
n fo
ster
ed in
fam
ilies
on
mea
sure
s of
com
mun
icat
ion
and
soci
aliz
atio
n.T
here
wer
e no
diff
er-
ence
s in
rep
orte
d an
d ob
serv
ed b
ehav
ior
prob
lem
s.
NO
TE
:nre
fers
to th
e in
stitu
tiona
l sam
ple
subj
ects
onl
y;th
e st
udie
s ha
d a
sim
ilar
num
ber
of c
ompa
rison
or
cont
rol s
ubje
cts.
IT =
ran
ge o
f tim
e sp
ent i
n in
stitu
tiona
l car
e.
has highlighted a number of social and behav-ioral problems that are more prevalent in thatgroup compared to other children (see Table 2).In particular, research has highlighted problemswith behavior, social competence, play, andpeer and/or sibling interactions. Researchershave also reported “quasi-autistic” behaviors insome severely deprived children (Rutter et al.,1999). Of the 17 studies summarized in Table 2,16 reported some negative social or behavioralconsequences for children raised in institu-tional care compared to controls or childrenwho had spent less time in institutional care.However, the severity and duration of difficul-ties varied greatly across these studies, reflect-ing the different and changing situations andexperiences of the children studied.
Tizard and Rees (1975) described the prob-lems reported by their control sample of “Lon-don mothers” as disciplinary issues (e.g., dis-obedience and not settling down when put tobed). For children raised in institutions, how-ever, the problems were of a different nature.The institutional staff they interviewed re-ported few disciplinary problems with the 4-year-old children in their care. The most fre-quent problems reported by the institutionalstaff included poor peer relations, tempertantrums, clinging, and poor concentration.
Tizard and Hodges (1978) described the be-havioral and emotional development of thesechildren again at age 8. By this age, the majorityof the institutional children had been restored totheir natural parents or had been adopted, only8 of the 65 children described in earlier studies(Tizard & Rees, 1975) remained in institutionalcare. They concluded that behavioral and emo-tional problems were very much a function ofthe environment that the child had been placedin after institutional care. The adopted childrenwere faring much better at age 8 than the re-stored children were. Tizard and Hodges (1978)identified a number of differences between theadoptive and the natural parents. The adoptiveparents had very much wanted a child, whereasthe natural parents were often ambivalent or re-luctant to take their children back from the insti-tutional care they had placed them in. The re-stored children also tended to have more
siblings and particularly younger siblings whothe mother often expressed a preference for.Also, many of the restored children returned toa stepfather who was “indifferent or evenhostile to them, or showed an open preferencefor his own children.”
Although the adopted children in Tizard’ssample fared much better than the children whowere restored, at age 8 the ex-institutional chil-dren generally showed several differences to acomparison group of noninstitutionalized chil-dren. There were large and significant differ-ences between the ex-institutional children andthe comparison group on the teachers’ ratingsof problem behaviors. On total problem scoreand antisocial items, the ex-institutional chil-dren scored much higher and were more oftendescribed by their teachers as attention seekingthan the comparison group.
Hodges and Tizard (1989a, 1989b) also re-ported on the outcome of their sample at age 16.In adolescence, the ex-institutional groups, whohad spent at least the first 2 years of their life inresidential care, had more behavioral and emo-tional problems than their matched compari-sons. According to their teachers, between 35%and 50% of the ex-institutional children showedthe following difficulties to some degree: rest-less, distractible, quarrelsome with peers, irrita-ble, and resentful if corrected by adults. By age16, the adopted group were displaying moresigns of anxiety whereas the restored childrentended toward more antisocial types ofbehavior.
Fisher et al. (1997) investigated behaviorproblems in Romanian orphans aged 18 to 76months who had been adopted to Canada.Three groups of children were compared: a Ro-manian orphanage (RO) group who had spentat least 8 months in a Romanian orphanage, aCanadian-born (CB) group of nonadopted chil-dren matched to the RO group for sex and age,and a Romanian comparison (RC) group whowere adopted to Canada before the age of 4months but had not been placed in an orphan-age. On the CBCL, the RO had higher totalscores and higher internalizing scores (e.g., de-pression, social withdrawal) than the CB andRC matches. Parental reports supported this
48 TRAUMA, VIOLENCE, & ABUSE / January 2006
finding; RO children were described by theirparents as withdrawing from and avoiding sib-ling interaction. There were no differences be-tween the groups for externalizing (e.g., aggres-sion, hyperactivity) scores. Using parentalreports of problems, the RO children reporteddistinctly different types of problem than the CBparents. The RO children had more feedingproblems than the CB children. The problemscited by the RO parents were excessive eatingand dislike of solid foods, which were notreported by the CB parents.
The eating problems reported in the RO chil-dren reflect the conditions in the orphanageswhere the children were malnourished andgiven all of their food in a bottle up to the age of2 years. The number of sleep problems was thesame for the CB and the RO groups but againthe type of problems were different for the twogroups. The RO children did not signal waking,though this was not described as a problem bythe parents. The RO children also slept exces-sively though this may have been a misinterpre-tation of the fact that they did not indicate whenthey had woken. Again this reflects the orphan-age experience where lying quietly in bed wasthe most common activity.
The parents of the RO children also reporteda high prevalence of stereotyped behaviors(84%). These stereotypies have frequently beenobserved in institutionalized children problems(e.g., Beckett et al., 2002), however, they havealso been observed to a lesser extent innoninstitutionalized samples of children(Smyke et al., 2002). Stereotyped behaviors in-clude body rocking, hand rocking, and rhythmi-cal head shaking (Thelen, 1979). These behav-iors are thought to be precursors to movementthat have not been allowed to develop further inthe confines of a crib. The behaviors may serveas a means of self-stimulation in an unrespon-sive environment or as a means to soothe intimes of distress. The stereotyped behaviorproblems of the RO children showed the mostimprovement or complete resolution after timein an adoptive home.
Rutter et al. (1999) and Beckett et al. (2002) de-scribe a set of autistic-like patterns of behaviorobserved in their sample of Romanian
adoptees. These quasi-autistic patterns in-cluded stereotyped behaviors, repetitivebehaviors, a lack of boundaries, difficultiesforming selective relationships. Only a smallsubsample of the adoptees displayed these be-haviors; 6% showed autistic patterns and a fur-ther 6% showed milder (usually isolated) fea-tures of autism (Rutter et al., 1999). Thesepatterns of behavior were more likely amongchildren who had spent longer in institutionalcare.
Although the clinical features observed inthese children were similar to “ordinary” au-tism, there was an equal sex ratio, a degree of so-cial interest, and there was a great improvementseen in these children between the ages of 4 and6 in these Romanian “autistics.” Rutter et al.(1999) conclude that this quasi-autistic patternof behavior is associated with prolonged experi-ential and perceptual deprivation, cognitive im-pairment, and a lack of opportunity to developclose attachment. However, these behaviorswere only observed in a minority of Romanianadoptees and the etiology of these symptoms isunclear.
Institutional care in early life predisposeschildren to behavioral and social problems laterin life. Many of the problems observed in sam-ples of severely deprived children, such as ste-reotyped behaviors andeating problems, showrapid improvement oncethe child is removed frominstitutional care andplaced in a supportivefamily environment.However, placementwith a family is notenough by itself to over-come difficulties; pooroutcome of some childrenrestored to their naturalfamily (Hodges & Tizard,1989a) shows that thequality of the subsequentfamily environment is animportant factor in the outcome of institution-ally reared children. Whilst subsequent place-ment in a supportive family can result in the for-
Johnson et al. / YOUNG CHILDREN IN INSTITUTIONAL CARE 49
(text continues on page 53)
Placement with afamily is not enough
by itself to overcomedifficulties; poor
outcome of somechildren restored totheir natural family
shows that the qualityof the subsequent
family environment isan important factor in
the outcome ofinstitutionally reared
children.
50
TAB
LE
3:
Co
gn
itiv
e D
evel
op
men
t o
f C
hild
ren
Rai
sed
in In
stit
uti
on
al C
are
Stu
dyIn
stitu
tion
Sam
ple
Inst
itutio
nal C
hara
cter
istic
sD
escr
iptio
n of
Stu
dyF
indi
ngs
Gol
dfar
b (1
944)
n=
15
Mal
e-fe
mal
e 1.
1:1
Age
10-
14 y
ears
IT 2
7-47
mon
ths
Not
des
crib
ed (
see
Gol
dfar
b,19
45)
Inte
llige
nce
and
spee
ch d
evel
opm
ent w
asm
easu
red
in a
dole
scen
ts w
ho h
ad s
pent
thei
r ea
rly in
fanc
y in
inst
itutio
nal c
are
but
who
had
sub
sequ
ently
bee
n fo
ster
ed.
The
se c
hild
ren
wer
e co
mpa
red
with
am
atch
ed c
ompa
rison
gro
up w
ho w
ere
info
ster
car
e an
d ha
d be
en in
fam
ily-b
ased
care
sin
ce b
irth
.
The
chi
ldre
n w
ho h
ad e
xper
ienc
ed in
stitu
tiona
lca
re in
ear
ly in
fanc
y w
ere
infe
rior
to th
e “f
os-
ter”
grou
p on
a n
umbe
r of
cog
nitiv
e m
easu
res;
100%
of t
he “
inst
itutio
n”gr
oup
com
pare
d w
ith40
% o
f the
“fo
ster
”gro
up h
ad b
elow
ave
rage
IQ.A
lso,
the
spee
ch o
f the
inst
itutio
n gr
oup
was
infe
rior
to th
at o
f the
fost
er g
roup
.
Gol
dfar
b (1
945)
n=
15
Mal
e-fe
mal
e 1.
5:1
Age
43
mon
ths
IT 4
-32
mon
ths
Not
des
crib
ed in
det
ail “
adul
t-ch
ild r
atio
is v
ery
low
...
a m
ini -
mum
of a
dult
stim
ulat
ion,
”“th
ech
ild’s
act
iviti
es a
re c
ompl
etel
yre
gula
ted.
”
The
inte
llige
nce
and
lang
uage
dev
elop
-m
ent o
f chi
ldre
n ra
ised
in in
stitu
tiona
lca
re in
the
Uni
ted
Kin
gdom
was
test
ed a
t3
year
s.T
he c
hild
ren
wer
e th
en p
lace
d in
fost
er h
omes
and
a fo
llow
-up
test
car
ried
out 9
mon
ths
afte
r th
e fir
st te
st.T
hese
child
ren
wer
e co
mpa
red
with
a m
atch
edco
mpa
rison
gro
up w
ho w
ere
in fo
ster
care
and
had
bee
n in
fam
ily-b
ased
car
esi
nce
birt
h.
On
both
mea
sure
s of
IQ, t
he fo
ster
-car
e ch
il -dr
en s
core
d hi
gher
than
the
inst
itutio
nally
rear
ed c
hild
ren.
Thi
s w
as a
lso
the
case
at t
hefo
llow
-up
visi
t whe
n al
l the
chi
ldre
n w
ere
info
ster
car
e.A
t bot
h te
stin
g tim
es, t
he fo
ster
-ca
re c
hild
ren
also
had
sup
erio
r la
ngua
gesk
ills;
the
seco
nd te
st s
core
s of
the
inst
itutio
nch
ildre
n w
ere
still
low
er th
an th
e fir
st te
stsc
ores
of t
he fo
ster
gro
up.
Prin
gle
and
Tann
er(1
958)
n=
18
Mal
e-fe
mal
e 1:
0.8
Age
4 a
nd a
hal
f yea
rsIT
6-4
8 m
onth
s
Not
des
crib
ed.R
esid
entia
l nur
s-er
y in
Uni
ted
Kin
gdom
.Goo
dst
anda
rd o
f phy
sica
l car
e.
Lang
uage
dev
elop
men
t in
youn
g ch
ildre
nra
ised
in U
K r
esid
entia
l nur
serie
s w
asco
mpa
red
with
that
of a
gro
up o
fm
atch
ed c
ontr
ols.
For
mal
asp
ects
of
spee
ch, v
ocab
ular
y, a
nd s
ente
nce
stru
c-tu
re a
nd c
hild
ren’
s ab
ility
to u
nder
stan
dan
d ex
pres
s th
emse
lves
wer
ein
vest
igat
ed.
Res
iden
tial n
urse
ry c
hild
ren
wer
e re
tard
ed in
form
al a
spec
ts o
f lan
guag
e an
d ha
d a
poor
ervo
cabu
lary
than
the
cont
rol g
roup
(th
ey c
ould
not n
ame
the
item
s of
per
sona
l pos
sess
ions
).S
peec
h de
velo
pmen
t was
nor
mal
.
Rhe
ingo
ld a
nd B
ayle
y(1
959)
n=
14
Mal
e-fe
mal
e 1:
1A
ge 1
7-22
mon
ths
IT 4
-18
mon
ths
Not
des
crib
ed.
Two
grou
ps o
f chi
ldre
n in
inst
itutio
nal c
are
wer
e co
mpa
red
in a
n ex
perim
enta
l situ
a-tio
n.H
alf t
he c
hild
ren
rece
ived
2 m
onth
sof
car
e fr
om a
sin
gle
care
give
r.T
he c
on-
trol
gro
up w
as c
ompl
etel
y re
ared
und
erin
stitu
tiona
l rou
tine.
The
IQ o
f the
chi
l-dr
en w
as m
easu
red
18 m
onth
s la
ter.
The
IQ o
f chi
ldre
n su
bseq
uent
ly a
dopt
ed o
rre
stor
ed to
thei
r fa
mily
was
als
oco
mpa
red.
The
exp
erim
enta
l gro
up d
id n
ot fa
re a
ny b
ette
rth
an th
e gr
oup
rais
ed u
nder
inst
itutio
nal c
are
alon
e.T
he c
hild
ren
who
wer
e su
bseq
uent
lyad
opte
d ha
d a
high
er IQ
and
a la
rger
voc
abu-
lary
than
thos
e ch
ildre
n w
ho w
ere
rest
ored
toth
eir
natu
ral f
amily
, but
thes
e di
ffere
nces
wer
eno
t sig
nific
ant.
51
Tiz
ard
and
Jose
ph(1
970)
n=
30
Mal
e-fe
mal
e 1:
1A
ge 2
yea
rsIT
4-2
4 m
onth
s
Sta
ff to
chi
ld r
atio
1:3
but
hig
hst
aff t
urno
ver.
Boo
ks, t
oys,
pla
yfa
cilit
ies.
Mix
ed a
ge g
roup
s.H
ome
visi
ts a
nd o
utin
gs.P
er-
sona
l rel
atio
nshi
ps d
isco
urag
ed.
Goo
d st
anda
rd o
f phy
sica
l car
e.
Cog
nitiv
e de
velo
pmen
t and
spo
ntan
eous
lang
uage
was
mea
sure
d in
a s
ampl
e of
child
ren
rais
ed in
a U
K r
esid
entia
l nur
s -er
y.A
sam
ple
of “
wor
king
-cla
ss”c
hild
ren
was
use
d as
a c
ontr
ol g
roup
.
The
men
tal a
ge o
f the
res
iden
tial n
urse
ry c
hil -
dren
was
2 m
onth
s be
hind
the
norm
.The
con
-tr
ol g
roup
voc
aliz
ed m
ore,
had
a la
rger
voc
ab-
ular
y, a
nd u
sed
long
er s
ente
nces
than
the
resi
dent
ial n
urse
ry g
roup
.
Tiz
ard
and
Ree
s(1
974)
n=
65
Mal
e-fe
mal
e 2.
3:1
Age
4 a
nd a
hal
f yea
rsIT
24-
48 m
onth
s
Sam
e as
abo
ve.
Cog
nitiv
e de
velo
pmen
t in
a sa
mpl
e of
chi
l -dr
en r
aise
d in
a U
K r
esid
entia
l nur
sery
was
mea
sure
d.C
hild
ren
wer
e ei
ther
stil
lin
nur
sery
, ado
pted
, or
rest
ored
to th
eir
natu
ral p
aren
ts.A
sam
ple
of “
wor
king
-cl
ass”
child
ren
was
use
d as
a c
ontr
olgr
oup.
No
evid
ence
of c
ogni
tive
reta
rdat
ion.
Chi
ldre
nad
opte
d ha
d hi
gher
IQ s
core
s th
an c
hild
ren
who
wer
e st
ill in
inst
itutio
nal c
are
or w
ho h
adbe
en r
esto
red
to th
eir
natu
ral f
amily
.
Tiz
ard
and
Hod
ges
(197
8)n
= 5
1M
ale-
fem
ale
1.8:
1A
ge 8
yea
rsIT
24-
48 m
onth
s
Sam
e as
abo
ve.
Cog
nitiv
e de
velo
pmen
t in
a sa
mpl
e of
chi
l -dr
en r
aise
d in
a U
K r
esid
entia
l nur
sery
was
mea
sure
d.S
ome
child
ren
wer
e st
illin
the
nurs
ery
but m
ost h
ad b
een
adop
ted
or r
esto
red
to th
eir
natu
ral p
ar-
ents
.A s
ampl
e of
“w
orki
ng-c
lass
”chi
ldre
nw
as u
sed
as a
con
trol
gro
up.
The
chi
ldre
n st
ill in
inst
itutio
nal c
are
at a
ge 8
and
thos
e w
ho h
ad b
een
rest
ored
to th
eir
nat -
ural
fam
ily h
ad a
vera
ge IQ
s.T
he c
hild
ren
adop
ted
befo
re th
e ag
e of
4 a
nd a
hal
f yea
rsha
d ab
ove-
aver
age
IQs.
IQ h
ad r
emai
ned
sta-
ble
for
each
gro
up s
ince
the
age
of 4
and
aha
lf.C
hild
ren
in in
stitu
tiona
l car
e ha
d th
e lo
w-
est I
Qs
but w
ere
still
in th
e no
rmal
ran
ge.
Hod
ges
and
Tiz
ard
(198
9b)
n=
42
Mal
e-fe
mal
e 2:
1A
ge 1
6 ye
ars
IT 2
4-48
mon
ths
Sam
e as
abo
ve.
The
cog
nitiv
e de
velo
pmen
t of e
x-in
stitu
-tio
nal a
dole
scen
ts r
aise
d un
til a
t lea
st th
eag
e of
2 in
a U
K r
esid
entia
l nur
sery
was
mea
sure
d at
16
year
s.T
he IQ
of t
he c
hil-
dren
who
had
sub
sequ
ently
bee
nad
opte
d an
d re
stor
ed to
thei
r fa
mily
was
com
pare
d an
d al
so w
ith a
con
trol
gro
upof
ado
lesc
ents
.
The
gro
up o
f chi
ldre
n ad
opte
d be
fore
the
age
of 4
and
a h
alf y
ears
stil
l had
the
high
est I
Q.
The
oth
er e
x-in
stitu
tiona
l gro
ups
did
not d
iffer
sign
ifica
ntly
.Non
e of
the
grou
ps h
ad a
mea
nIQ
of l
ess
than
94.
Kal
er a
nd F
reem
an(1
994)
n=
25
Mal
e-fe
mal
e 1.
5:1
Age
23-
50 m
onth
sIT
1-4
7 m
onth
s
Des
crib
ed a
s re
pres
enta
tive
ex-
ampl
e of
a R
oman
ian
orph
an-
age
(i.e.
, dep
rived
env
ironm
ent
with
nut
ritio
nal a
nd p
sych
olog
i-ca
l priv
atio
n an
d po
or p
hysi
cal
cond
ition
s)
The
cog
nitiv
e de
velo
pmen
t of R
oman
ian
orph
ans
was
com
pare
d w
ith a
gro
up o
fR
oman
ian
kind
erga
rten
chi
ldre
n.
Non
e of
the
child
ren
from
the
orph
anag
e w
ere
func
tioni
ng a
t age
leve
l;20
out
of 2
5 w
ere
func
tioni
ng a
t lev
els
less
than
hal
f the
ir ch
ro-
nolo
gica
l age
.The
con
trol
gro
up s
how
ed n
ode
velo
pmen
tal d
elay
.
Slo
utsk
y (1
997)
n=
52
Mal
e-fe
mal
e 1:
1A
ge 7
0-88
mon
ths
IT 2
7-70
mon
ths
Sta
ff to
chi
ld r
atio
1:8
-10.
Bas
icbu
t ade
quat
e fa
cilit
ies
(toy
s,bo
oks)
.No
pers
onal
pos
ses-
sion
s.P
erso
nal r
elat
ions
hips
disc
oura
ged.
Goo
d st
anda
rd o
fph
ysic
al c
are.
The
cog
nitiv
e de
velo
pmen
t of c
hild
ren
plac
ed in
a R
ussi
an o
rpha
nage
was
com
-pa
red
with
a g
roup
of R
ussi
an k
inde
rgar
-te
n ch
ildre
n.
The
chi
ldre
n ra
ised
in th
e or
phan
age
had
low
erIQ
sco
res
than
the
kind
erga
rten
chi
ldre
n.
(con
tinu
ed)
52
Rut
ter
et a
l.(1
998)
n=
111
Mal
e-fe
mal
e 2.
3:1
Age
4 y
ears
IT <
6 m
onth
s, 7
-24
mon
ths
Sev
erel
y de
priv
ed e
nviro
nmen
t.N
utrit
iona
l and
psy
chol
ogic
alpr
ivat
ion.
Poo
r ph
ysic
alco
nditi
ons.
The
cog
nitiv
e de
velo
pmen
t of t
wo
grou
psof
Rom
ania
n or
phan
s (R
O)
who
had
sub
-se
quen
tly b
een
adop
ted
to th
e U
nite
dK
ingd
om w
ere
com
pare
d w
ith a
sam
ple
of U
K a
dopt
ees.
Rom
ania
n ch
ildre
n w
hoha
d be
en a
dopt
ed b
efor
e th
e ag
e of
6m
onth
s w
ere
com
pare
d w
ith th
ose
adop
ted
afte
r th
is a
ge.
In c
ompa
rison
to U
K a
dopt
ees,
RO
cat
ch-u
p in
cogn
itive
leve
l was
com
plet
e at
age
4 fo
rth
ose
adop
ted
befo
re th
e ag
e of
6 m
onth
s.G
ood
prog
ress
but
not
com
plet
e re
cove
ry fo
rth
ose
adop
ted
afte
r 6
mon
ths.
O’C
onno
r et
al.
(200
0b)
n=
165
Mal
e-fe
mal
e 1:
1.2
Age
6 y
ears
IT <
6 m
onth
s, 7
-24
mon
ths,
25-4
2 m
onth
s
Sev
erel
y de
priv
ed e
nviro
nmen
t.N
utrit
iona
l and
psy
chol
ogic
alpr
ivat
ion.
Poo
r ph
ysic
alco
nditi
ons.
The
cog
nitiv
e de
velo
pmen
t of t
he R
oma -
nian
orp
hans
(R
O)
stud
ied
by R
utte
r et
al.
(199
8) w
as te
sted
aga
in a
t age
6 y
ears
.Afu
rthe
r gr
oup
of “
late
-pla
ced”
adop
tees
wer
e al
so in
clud
ed.T
hese
gro
ups
wer
eco
mpa
red
with
a s
ampl
e of
UK
ado
ptee
s.
Dur
atio
n of
priv
atio
n w
as th
e m
ost i
mpo
rtan
tpr
edic
tor
of c
ogni
tive
outc
ome.
In c
ompa
rison
to U
K a
dopt
ees,
RO
rec
over
y at
age
4 w
asm
aint
aine
d at
age
6 b
ut s
ome
defic
its a
t age
4fo
r th
ose
adop
ted
afte
r 6
mon
ths
wer
e pr
esen
tat
age
4 w
ere
also
pre
sent
at a
ge 6
yea
rs.
Tim
e sp
ent i
n ad
optiv
e ho
me
beyo
nd a
per
iod
of 2
yea
rs d
id n
ot im
prov
e de
velo
pmen
t
Har
den
(200
2)n
= 3
5M
ale-
fem
ale
1.5:
1A
ge 9
-30
mon
ths
IT 9
-27
mon
ths
Sta
ff to
chi
ld r
atio
1:2
(bu
t diff
er-
ent w
eeke
nd s
taff)
.Wel
l pro
-vi
sion
ed.C
areg
iver
-chi
ld in
ter-
actio
n en
cour
aged
.Goo
dst
anda
rd o
f phy
sica
l car
e.
The
men
tal d
evel
opm
ent o
f inf
ants
and
todd
lers
in U
.S.c
ongr
egat
e ca
re s
ettin
gsw
as c
ompa
red
with
a g
roup
of U
.S.c
hil-
dren
fost
ered
in fa
mili
es.
The
chi
ldre
n ra
ised
in c
ongr
egat
e ca
re fa
red
wor
se th
at th
e ch
ildre
n fo
ster
ed in
fam
ilies
inth
eir
men
tal d
evel
opm
ent.
NO
TE
:nre
fers
to th
e in
stitu
tiona
l sam
ple
subj
ects
onl
y;th
e st
udie
s ha
d a
sim
ilar
num
ber
of c
ompa
rison
or
cont
rol s
ubje
cts.
IT =
ran
ge o
f tim
e sp
ent i
n in
stitu
tiona
l car
e.
TAB
LE
3 (
con
tinu
ed)
Stu
dyIn
stitu
tion
Sam
ple
Inst
itutio
nal C
hara
cter
istic
sD
escr
iptio
n of
Stu
dyF
indi
ngs
mation of close attachments within that familyunit, many institutionally raised children willstill have problems interacting with peers andadults outside the family unit (Hodges &Tizard, 1989a).
CONSEQUENCES FOR COGNITIVEDEVELOPMENT
A summary of the 13 studies that have inves-tigated the cognitive development of childrenraised in institutional care is provided in Table 3.A total of 12 of the 13 studies illustrate a nega-tive effect of institutional care on cognitive de-velopment although some of these studies alsosuggest that early intervention, (i.e., removal tofamily-based care) can result in recovery.Rheingold and Bayley (1959) did not find anysignificant difference in IQ between childrenwho were raised in institutional care and chil-dren who were raised in institutional care butwho received 2 months of care from a singlecaregiver.
The early research into the cognitive develop-ment of children raised in institutions sug-gested that infants who were raised in institu-tions would be severely retarded, with specificdifficulties in language development and atten-tion, and that these difficulties would be perma-nent (e.g., Goldfarb, 1945). Subsequent researchby Barbara Tizard and her colleagues (Hodges& Tizard, 1989b; Tizard & Hodges, 1978; Tizard& Joseph, 1970, 1974), which followed a groupof children who were raised in institutions, gavea more optimistic prognosis for cognitive devel-opment. At 2 years of age, the nursery group(children who had been placed in institutionalcare before the age of 4 months) were 2 monthsbehind the contrast group (noninstitutionalizedbut from a working-class background) for men-tal age (Tizard & Joseph, 1970). The nurserygroup also had lower verbal competence scores,a smaller vocabulary, and made fewer wordcombinations than the contrast group did(Tizard & Joseph, 1970). But by 4 years of age,the children who were still in institutional caredid not show any signs of retardation and it wasthe children who had been restored to their bio-logical family who scored the poorest on mea-sures of intelligence (Tizard & Rees, 1974). At
age 8, the children still in institutional care hadaverage IQ scores (Tizard & Hodges, 1978) andby the time the children reached the age of 16,Hodges and Tizard (1989b) concluded that in-stitutional rearing does not have the “devastat-ing long-term effects described in some earlystudies.”
Although the longitudinal research by Tizardand her colleagues (Hodges & Tizard, 1989b;Tizard & Hodges, 1978; Tizard & Joseph, 1970,1974) suggest that institutional care does nothave a detrimental effect on cognitive develop-ment, there are some important points that needto be considered before conclusions can bedrawn. First, the institutional care that the chil-dren in Tizard’s study received was of a highstandard. The nursery environment for thesechildren was well equipped with plenty of toysand books, the children were read to daily andthe children were taken on outings and occa-sionally made weekend visits to the homes ofstaff members. The children lived in “familygroups” of six children, each group had its ownsuite of rooms and two assigned nurses. Al-though the children who remained in the insti-tution had average IQ scores, it was the childrenwho were adopted from the institution beforethe age of 4 and a half years old, who made thelargest gains in IQ, and these gains were main-tained over the subsequent 12 years (Hodges &Tizard, 1989b). Being adopted after this age didnot have the same effect; only one child out ofthe five adopted after the age of 4 and a half hadincreased in IQ by age 8.
Although the sample size from these studieswas small, the results from Tizard’s work(Hodges & Tizard, 1989b; Tizard & Hodges,1978; Tizard & Joseph, 1970, 1974) suggest thatchildren who are raised in small well-staffedand well-equipped institutions will not be se-verely cognitively delayed. However, unlesschildren are placed with families before the ageof 4, they will be at a cognitive disadvantagecompared with children who have spent theirearly years in a family setting.
Of course, one of the problems of trying toconsider the impact of institutional care on chil-dren is that standards and practices of institu-tional care vary enormously. Whilst the researchby Tizard demonstrates that retardation is not
Johnson et al. / YOUNG CHILDREN IN INSTITUTIONAL CARE 53
an inevitable consequence of institutional care,the conditions in the nurseries studied byTizard were of a high standard and not all insti-tutions can be described as such. This becameall too apparent when the fall of the Ceausescuregime in Romania brought the attention of theworld to more than 100,000 children who hadeffectively been “warehoused” typically with-out sufficient food, clothing, heat or caregivers(see Johnson, 2000).
Kaler and Freeman (1994) set out to describe arepresentative group of such children and con-ducted a number of tests on a group of 25 chil-dren. As with many studies that have sought toinvestigate the children from Romanian institu-tions, a lack of systematic records made it im-possible to rule out the influence of genetic fac-tors or the possibility that children had beenplaced into an institution because of a handicap.However, anecdotal material from the recordsthat were available suggested that the majorityof the children were not true orphans but the in-fants of adolescent mothers or the youngestchildren from a large family. Therefore, the pri-mary reasons for child placement were socio-economic factors. The children studied by Kalerand Freeman (1994) were aged between 23 to 50months and the mean length of time spent in theorphanage was approximately 26 months. Thecognitive development of the “orphanage”sample was compared with a group of childrenof a similar age who were attending a local kin-dergarten. The kindergarten group was func-tioning at chronological age level whereas 20children from the sample of 25 orphanagechildren were functioning at levels less thanhalf their chronological age.
The plight of children in Romanian orphan-ages attracted international media attentionand subsequently, many of these children were“rescued” and adopted internationally. Thisprovided a unique opportunity for researchersto study the effects of early deprivation and toinvestigate whether the effects of such depriva-tion in early life on cognitive development werereversible. Michael Rutter and his team at theInstitute of Psychiatry in London have followeda large sample (n = 111) of Romanian childrenwho were adopted into the United Kingdomfollowing severe early global privation. The
children in this sample had all been brought tothe United Kingdom before the age of 2 yearsand their level of cognitive functioning wasmeasured at age 4 (Rutter et al., 1998) and age 6(O’Connor et al., 2000b). On entry to the UnitedKingdom the children were severely develop-mentally impaired; the mean score for the groupon the Denver Scales was 63 (59% had a devel-opmental quotient below 50) and 51% werebelow the 3rd percentile in weight.
By the age of 4, the children had made sub-stantial physical and developmental catch-up;2% were under the 3rd percentile for weight andthe mean score on the Denver Scales rose to 107.The Romanian children who were adopted intothe United Kingdom before the age of 6 months(0-6 months) appeared to have made a completerecovery and were no different from compari-son samples of within–United Kingdomadoptees or Romanian children who had notbeen institutionalized. However, the catch-upin children who were adopted into the UnitedKingdom after the age of 6 months (7-24months), although still promising, suggestedthat the recovery in these children was not yetcomplete. Therefore, at age 4, there was a dose-response link between duration of deprivationand cognitive functioning.
At age 6, the Romanian adoptees were testedagain (O’Connor et al., 2000b). In addition to thesample of 111 children tested at age 4, a secondgroup of Romanian adoptees, “late-placedadoptees” (n = 48), who entered the UnitedKingdom between 24 and 42 months of agewere also tested at age 6. The late-placed groupallowed further testing of the dose-response hy-pothesis of deprivation and cognitive develop-ment and also, after more than 2 years of severedeprivation, this group provided a unique op-portunity to test resilience. All three groups ofadoptees (0-6 months, 7-24 months, and 25-42months) were equally delayed at entry into theUnited Kingdom).
At age 6, after between nearly 3 to 4 years inan adoptive home, the late-placed adoptees hadmade significant progress. On entry into theUnited Kingdom, more than 90% of the late-placed group had Denver scores below 70,where as at age 6, only 18% were below 70 onthis measure. Comparing the other groups on
54 TRAUMA, VIOLENCE, & ABUSE / January 2006
measures of cognitive ability at age 6, the earlyRomanian adoptees (0-6 months) did not differfrom the UK adoptee comparison group,though both of these groups scored signifi-cantly higher than the other samples (6-24months and 25-42 months). The strongest pre-dictor of cognitive ability at age 6 years was ageat entry into the United Kingdom and this wasalso the case when only the longitudinal sample(0-6 months, 7-24 months) was considered. Fur-ther analysis revealed that it was duration ofprivation rather than length of time in the adop-tive home (beyond a period of approximately 2years) that was the most important predictor ofcognitive level. In general, all of the adopteesmade remarkable progress in their cognitivefunctioning suggesting a resilience of develop-ment to early deprivation. However, the effectsof deprivation in the early months of life werestill apparent at age 6 and O’Connor et al.(2000b) conclude that the data provides strongevidence that early deprivation doescompromise long-term development.
One area that is typically reported as beingdelayed in children raised in institutional care islanguage development. Goldfarb (1944, 1945)investigated speech sounds, intelligibility ofspeech and language organization in early in-fancy, at 6 to 8 years of age and in adolescence.At all three age levels, institutionalized childrendisplayed a clear deficiency in language devel-opment as compared with a group of fosteredchildren. Numerous other researchers havesince reported deficits in the language skills ofchildren raised in institutions. These deficits in-clude poorer vocabulary and less spontaneouslanguage (Tizard & Joseph, 1970) and retarda-tion in formal aspects of language and languagedevelopment (Pringle & Tanner, 1958).
The degree of cognitive and language delayvaries depending on the standard of care pro-vided by different institutions, which explainsthe variations in findings across research stud-ies. Tizard and Joseph (1970) describe twoextreme types of child-care environment:institution-oriented facilities that result in de-layed development and child-oriented settingsthat promote normal development. Withinchild-oriented facilities, the staff do not adhereto a strict routine and tend to spend more time
interacting with and scaffolding the develop-ment of children. An institution-orientedapproach typically occurs under conditions ofscarce personnel resources and staff withinthese types of facilities are primarily concernedwith the physical care of the children.
Other features of institutional care that havealso been suggested as contributing to delayedlanguage development include poor provisionof books and play equipment, low staff-child ra-tios, staff experience, staff autonomy, children’slack of personal possessions, and children’s lackof “everyday” experience (Pringle & Tanner,1958; Tizard & Joseph, 1970).
Overall, the evidence suggests that institu-tional care is typically detrimental to the cogni-tive development of children. Severe depriva-tion, such as that encountered by children inRomanian orphanages after the collapse of theCeausescu regime, has a profound effect on cog-nitive development and complete recovery hasonly been observed, so far, in children who wereplaced in family-based care before the age of 6months. Children who were placed later madesignificant improvements in their developmentafter leaving institutional care but were still at acognitive disadvantage some years later(O’Connor et al., 2000b). However, not all chil-dren raised in institutional care display the se-verely delayed development observed in sam-ples of “Romanian orphans.” A child-orientedapproach, with adequate personnel and re-sources, can result in a similar cognitive out-come for both children who remain in less rigidresidential care routines and children who arerestored to their biological families who maystill be high risk for child abuse and neglect.However, children who are raised in a familysetting with parents who do have the personalresources to nurture them, have a better cogni-tive outcome than children in institutional careand the sooner a child is moved frominstitutional care to a family setting, the betterthe cognitive outcome will be.
DISCUSSION
The evidence for the detrimental effects of ex-posure to institutional care without a primarycaregiver on children is overwhelming when
Johnson et al. / YOUNG CHILDREN IN INSTITUTIONAL CARE 55
compared to the expo-sure of family-basedcare with a primarycaregiver. Of 12 stud-ies on attachment inchildren raised in in-stitutional care onlyone found no sup-porting evidence foran increase in attach-ment difficulties. Of17 studies on socialand behavioral devel-opment of children,again only one foundinconclusive evi-dence in relation toage of exposure toinstitutional care. Of13 studies on cogni-tive development, allexcept one report apoorer cognitive per-formance associatedwith insti tutionalcare.
When consideringthe consequence of in-stitutional care onemajor difficulty is thatthe standards of carethat children receive
in institutions varies enormously. To try and ad-dress this issue, two bodies of research havebeen the focus of this review. First, the researchwork that has described the development ofchildren who have been raised in “good” resi-dential care, and second, the research outliningthe development of children raised in ex-tremely poor institutional settings.
Comparing these two bodies of researchhighlights the fact that some of the detrimentaleffects of “institutionalization” are the result ofa lack of resources rather than institutional careper se. However, when “good” institutionalcare leads to a poor outcome this suggests thatthere are aspects of institutional culture, whichare fundamentally damaging to a developingchild. On a practical level, it is important to con-sider which aspects of institutional care are the
most damaging and how damage can be lim-ited, rather than simply write off institutionalcare completely. For many children institutionalcare is the only care available and attempts tode-institutionalize children without adequatesupport may be more damaging thaninstitutional care itself.
In the absence of foster care services and suit-able adopting parents, it is difficult to judgewhether children are better off in a residentialcare institution that may provide at least aphysically safe environment rather than reinte-grating them into potentially abusive and ne-glectful homes; for example, with parents whomay not have been adequately rehabilitatedfor mental health problems, substance abuse,and violent outbursts. Therefore, a comprehen-sive-assessment process is necessary before re-turning a child to their family. Nevertheless itmust be recognized that children in institutionalcare are not immune from maltreatment by theirpeers (e.g., bullying) and abuse and neglect bystaff. Indeed, physical and sexual abuse hasbeen reported as existing in a number of institu-tions worldwide (e.g., Barter, 2003; UNICEF,2002).
In a nonabusive environment with reason-able provision of resources, institutional carecan result in adequate cognitive developmentwithin the normal range. Nevertheless, childrenwho have been raised entirely in a supportivefamily will show higher IQs on average.
In terms of behavioral problems, the distinctset of behavioral problems seen in the severelydeprived Romanian orphans (e.g., difficultieswith solid foods, quasi-autistic behaviors) areextremely responsive to intervention and typi-cally disappear once the child is removed frominstitutional care and placed with a family.However, there do seem to be a number of prob-lems that persist in children who have spent theearly years in institutional care and these prob-lems seem to be due to a lack of close attach-ments during the early years. The Romanianadoptees studied by Fisher et al. (1997) showedthe least improvement in peer and sibling rela-tions. The children studied by Hodges andTizard (1989a, 1989b) also were still havingproblems with peers at age 16. Difficulties withpersonal relationships may be a lasting conse-
56 TRAUMA, VIOLENCE, & ABUSE / January 2006
The evidence for thedetrimental effects ofexposure to institutionalcare without a primarycaregiver on children isoverwhelming whencompared to theexposure of family-based care with aprimary caregiver. Of 12studies on attachment inchildren raised ininstitutional care onlyone found no supportingevidence for anincrease in attachmentdifficulties. Of 17 studieson social andbehavioraldevelopment ofchildren, again only onefound inconclusiveevidence in relation toage of exposure toinstitutional care. Of 13studies on cognitivedevelopment, all exceptone report a poorercognitive performanceassociated withinstitutional care.
quence of early institutional care and this wouldbe predicted from the neurobiological perspec-tive. The long-term consequences of institu-tional care on attachment have yet to be investi-gated fully but again the neurobiologicalperspective would suggest that these problemswill be ongoing for a number of children whospent their early years without a one-to-one sen-sitive caregiver. Many of these children will beemotionally vulnerable and their craving foradult attention and readiness to go off with astranger will make them obvious targets for sexoffenders (Elliott, Browne, & Kilcoyne, 1995).
In summary, the evidence clearly indicatesthat institutional care does not support the opti-mal development of children. Intervening earlywith children in institutional care and returning
them to a family is important for subsequent de-velopment. The international communityshould be encouraged to promote the humanrights of children in residential care and to pro-tect children from the abuse inherent in institu-tional care systems. According to the UnitedNations Convention on the Rights of the Child(United Nations, 1989), every child has the rightto grow up in a family and research suggeststhat children who are moved from residentialcare before the age of 6 months can still reachoptimal development (O’Connor et al., 2000b;Rutter et al., 1998). A longer period results insignificant risk of harm to physical andpsychological development and constitutesinstitutional maltreatment.
IMPLICATIONS FOR PRACTICE, POLICY, AND RESEARCH
Practice
Analytical epidemiological study designs(i.e., including a control and/or comparisongroup) show that young children placed in in-stitutional care without parents are at risk ofharm in terms of attachment disorder and de-velopmental delays in social, behavioral andcognitive domains. Delays in physical growth,neural atrophy and abnormal brain develop-ment have also been implicated in studies ofchildren in institutional care. The neglect anddamage caused by privation is equivalent toviolence to a young child.
Infants who are placed into residential carewill suffer harm to their development if notmoved to family-based care by the age of 6months.
Policy
Countries with young children in institu-tional care must develop alternative strategies
such as foster care and adoption. Rehabilitatingchildren to their families of origin is an optionbut this needs to be adequately supported andmonitored.
The international community should be en-couraged to promote the human rights of chil-dren in residential care and to support the de-velopment of family-based care alternatives.
Research
Research must identify good practices for thedeinstitutionalization of children in residentialcare that considers the needs of the child and re-duces the potential for trauma from change.
Alternative forms of family-based careshould be evaluated to identify the advantagesand disadvantages for the child, as well as fac-tors related to successful or unsuccessfulplacements.
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Rebecca Johnson, PhD, is a chartered psychologistand research fellow in applied developmental psychologyat the School of Psychology, University of Birmingham.After working on child feeding problems and family vio-lence, recently she has been involved with two EuropeanUnion Daphne-funded research projects that haveinvestigated the number and characteristics of youngchildren in institutional care and good practice in thedeinstitutionalization of young children across Europe.She spent 6 months last year as a volunteer for the NGOHope and Homes for Children, Romania working withchildren who have been raised in institutional care.
Kevin Browne, PhD, is a chartered psychologist and achartered biologist and is a professor in the School of Psy-chology, at the University of Birmingham, and director ofthe Centre for Forensic and Family Psychology. He hasbeen researching family violence and child maltreatment
Johnson et al. / YOUNG CHILDREN IN INSTITUTIONAL CARE 59
for more than 25 years and has published extensively onthese subjects, acting as coeditor (with Margaret Lynch) ofChild Abuse Review from 1992 to 1999. His most recentbook is titled Early Prediction and Prevention of ChildAbuse: A Handbook (coedited with H. Hanks, P.Stratton, and C. Hamilton; Wiley, 2002). After 12 yearsas an executive councillor of the International Society forthe Prevention of Child Abuse and Neglect (ISPCAN), heis currently consultant to the European Commission,World Bank, UNICEF, and the World Health Organisa-tion on Child Protection. He has worked and presented inmore than 40 countries worldwide and has recently beenthe chief executive of the High Level Group for RomanianChildren.
Catherine Hamilton-Giachritsis, PhD, is a charteredforensic psychologist and senior lecturer at the Universityof Birmingham. Previously, she worked in BirminghamSocial Services Psychology Department, undertakingassessments of families where there was considered to be arisk to children or assessing the needs of children and ado-lescents in such families. She is coauthor (with J. Douglas,K. Browne, and J. Hegarty) of Community HealthApproach to the Assessment of Infants and their Par-ents to be published in 2006 by Wiley. Having worked asprincipal co-investigator with K. Browne on two Euro-pean Union Daphne-funded projects looking atinstitutionalization of children, she has received a furthergrant to disseminate these findings across Europe.
60 TRAUMA, VIOLENCE, & ABUSE / January 2006
