Monthly Archives: September 2012

Romanian Orphanage Study: Dr. Charley Zeanah at UMB IPMH

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Charley Zeanah presented to the group on September 21 and 22. He has been involved in Romania for 14 years. The Romania initiative traces its beginning to a movement started by the 1909 White House Conference on Children that declared its opposition to the institutionalization of dependent and neglected children. Now institutionalization of children whose families cannot take care of them is rare in the U.S., but not in other parts of the world. Romania is a unique story. The research group was invited to study there in the context of a policy debate about what to do with all the children institutionalized by Ceausescu’s government. Under Ceausescu, the official position was that the State could do a better job in raising children than many mothers could, so mothers who were struggling with poverty or other adversities were encouraged to give up their children in the maternity hospital. After several months in the maternity hospital, if the child had no obvious problems, he was transferred to a nursery, where he stayed until 36 months. At that point, if an exam determined him to be normal, the child was sent to a children’s home.

Although there was wide variability in children’s homes, there were some important common features, including many factors working against the establishment of individualized attachment relationships with the caregivers. The children were fed around the table with little or no talking, there was a lot of “free play time” with little support from the caregivers, and aggressive behavior and expressions of distress were often not attended to.  Films of this “free play time” revealed painful images of children rocking and spinning. 

The study created a model foster home project in which social workers were trained to work closely with the foster families to facilitate attachment and support the foster parents. Interestingly, one of the main effects of this intervention was an increase in IQ of the children in foster families. Also, these children showed greater expression of positive emotion than the institutionalized children within a few months. When assessment was repeated after 42 months in foster families, a community control group had the best attachment to their caregivers, the foster group had medium results, and the institutionalized group had the worst outcome.  The children in this last group included a high percentage of withdrawn, inhibited kids with Reactive Attachment Disorder. It is interesting to note that the characteristic “indiscriminate” attachment behavior of RAD persisted even after the group in foster care had formed attachments to their foster families.

Later, when psychopathology was assessed at 54 months, 55% of the children living in institutions had diagnosable psychiatric disorders in contrast with 22% of children in the (control) community group. Both foster care and institutionalized groups had higher levels of emotional disorders (such as anxiety and depression) and behavioral disorders (such as ADHD, Oppositional Defiant Disorder, and Conduct Disorder) than the community group.  The improved cognitive outcomes in the foster care children were most significant for children placed in foster care before 24 months. Similar sensitive periods were also found for the development of language, attachment, and indiscriminate behavior. An important finding was that secure attachment at 42 months predicted psychopathological outcome at 54 months. Interestingly, there was a big gender difference, with most of the securely attached children at 42 months being girls and most of the children with psychiatric symptoms at 54 months being boys. 

In conclusion, the research group found that children raised in institutions have compromised development across almost all domains, that attachment status moderates many aspects of psychopathology, and that the socio-emotional effect is more profound than the cognitive effect. When you place these children in good foster homes, you get attachment recovery and some – but not all – recovery from psychopathology. The research group strongly recommends intervening in abusive and neglectful caregiving situations as early as possible.  More specifically, they propose removing children from institutions and placing them in foster homes. 

I noted that this was a beautiful presentation of a study of monumental importance in child development and child psychiatry. The study demonstrates the power of the caregiving relationship to influence development. I pointed out, though, that the Romanian orphanages represent – as Dr. Zeanah explained – a rather unique and extreme caregiving situation, and that there is a problem in that is that this study of Romanian orphanages is being used by some international agencies to promote a one size fits all approach to the problem and laws such as LEPINA in El Salvador that require immediate reunification of institutionalized children with their biological families, with little or no support for their severely disadvantaged and dysfunctional families in the community.

Ed Tronick quoted the “old literature “– the first edition of Jerome Kagan’s book on child development that included accounts of children raised in institutions after WWII. These children did relatively well. How can we explain that? One possible reason is that there was a commitment to these children because of something terrible, morally bad that had been done, enhancing the caregivers’ desire to do something for them. Dr. Zeanah talked about the meaning of the children to the caregivers. In the case of Romanian orphanages, the society’s negative attitudes towards the Roma, who make up of 30% of children in orphanages, though they comprise only 6-9% of the population, may affect the caregivers’ commitment to the children. 

 Dr. Zeahah said that their group is interested in individual differences in response to institutionalization among the children. He noted that there may be a relationship between certain genotypes and indiscriminate behavior. They are looking at alleles that are very sensitive to experience and those that seem impervious. In that case, if you have the impervious alleles you fare well no matter what the environment and if you have the sensitive alleles you may struggle in an average expectable environment. Readers of the blog will recognize the “orchids versus dandelions” metaphor.

Apropos these last comments, I had a number of thoughts. First, I would underscore the importance of the meaning of the child to the caregivers. For example, a religious or spiritual mission to minister to children in need may allow caregivers to see the child as deserving of loving care and to recognize the unique value of each child, while also sustaining the caregiver through the frustrations and disappointments involved in their tasks. For example, the message that each child is precious to Jesus – no matter what he looks like or how much he achieves – is a powerful message indeed.  It is also important to remember the orchids and dandelions story. This story emphasizes the individual characteristics of each child, including the ability – innate or acquired – to take in the good in their environment and make it part of themselves. These thoughts remind us of the complexity of development and of how important it is to continue to search for a repertoire of solutions so that we can find a unique approach to each unique challenge. 

References:

Kagan, J. (1962). From Birth to Maturity, John Wiley and Sons, Inc.

Nelson, C.A., Zeanah, C.H., Fox, N.A., Marshall, P.J., Smyke, A.T., Guthrie, D. (2007). Cognitive recovery in socially deprived young children: The Bucharest early intervention project. Science, 318:1937-1940. 

Nelson, C.A., Furtado, E.A., Fox, N.A., Zeanah, C.H., The deprived human brain: Developmental deficits among institutionalized Romanian children – and later improvements – strengthen the case for individualized care (2009). American Scientist, 97:222-229.

Whetten, K., J. Ostermann, R.A. Whetten, B.W. Pence, K. O’Donnell, L.C. Messer, N.M. Thielman, The Positive Outcomes for Orphans (POFO) Research Team. “A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6-12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations.” PLoS ONE. 4(12):e8169. 2009.

Plus the new OVC researcher community at http://www.ovcwellbeing.org/ 

 

What is an “Orphanage”?

I have been thinking about an important paper in the recent journal of the Journal of the American Association of Child and Adolescent Psychiatry. The paper reported a study by Michael Rutter and colleagues of the effects of “pure” psychosocial deprivation (Rutter et al, 2012). The authors describe the study as a “natural experiment” in that they studied children in their natural life circumstances. The study group was children who had spent their lives in Romanian orphanages in circumstances of profound psychosocial deprivation up until the time they were adopted. Previous studies had shown that infants who had left the institution before 6 months of age had no significant deficits on any of the authors’ measurements at the age of 11 y. However, if they left the institution between 6 and 12 months, there was a large stepwise increase in deficits and no dose-response association with the duration of deprivation afterwards. Therefore the authors in this study pooled all the children who experienced institutional care beyond the age of 6 months and compared them with a composite group of children whose institutional care had ceased by 6-months, children who had experienced deprivation in their families but not in an institution, and children who were adopted into families in the U.K. and who had never experienced institutional care.  The authors were able to exclude the factors of subnutrition, extreme prematurity, and fetal alcohol syndrome. Thus the study design was able to isolate the variable of institutional psychosocial deprivation remarkably well. 

The authors focused on four outcomes that seemed specific to psychosocial deprivation: “quasi-autism” (autistic features but greater social interest and flexibility); disinhibited attachment (disregard of social boundaries and undue familiarity with strangers); inattention/overactivity (persistent inattention and overactivity); and cognitive impairment (IQ below 80).

The results showed that in the “pure” psychosocial deprivation group, the rate of “deprivation-specific patterns” (DSPs) at age 15 y was substantially and significantly higher in the 27 children in the study group whose institutional care lasted longer than 6 months, than those in the comparison group, whose institutional care lasted less than 6 months. Also there was a finding that pure psychosocial deprivation had a large effect on head growth if the institutional care had lasted for 6 mos. 

Therefore, there was strong evidence that “pure” psychosocial deprivation has a major effect in leading to DSPs. The study also found that whereas subnutrition had a significant but relatively small effect on intelligence, it did not have an effect on DSPs, a distinction that no previous study had made. The finding that pure psychosocial deprivation has an effect on head size is important because head size is related to brain growth, and this suggests that pure psychosocial deprivation has neurological consequences and can impair brain growth.

The main clinical implication of the study, the authors state, is that “profound institutional deprivation results in unusual and specific psychopathologic patterns.” They also conclude that “Important questions have still to be addressed, the most important being whether a similar effect on DSPs can derive from profound deprivation within a family context.” (Rutter et al, p. 769)

 This study drew my attention for three reasons – the elegance of the study design, its relevance to my interest in supporting caregivers in institutions, and its effectiveness in isolating a particular variable in the development of a specific deprivation-related psychopathology. (I am also a big fan of Michael Rutter’s and read anything he writes that comes out in one of my journals.) The study referred to the “profound deprivation” experienced by children in institutions. 

Yet, it is important to remember the context in which the study was done and with which the reader might be expected to be familiar – famous studies of the Rumanian orphanages by Rutter and his group, Zeanah, Nelson, and others (Bos et al, 2011). Never the less, it is unfortunate that – to my mind – not enough care is taken to define the “institutions” in which children are deprived (Williamson & Greenberg) (Zeanah, Nelson, & Fox, 2010). Based on studies such as those in Rumanian orphanages, the assumption is often made that the sooner children can be removed from orphanages the better. Yet, recall the last sentence of the paper – ““Important questions have still to be addressed, the most important being whether a similar effect on DSPs can derive from profound deprivation within a family context”. 

I think it is essential to study the various contexts in which children can experience “profound deprivation”. This is so important for one reason because laws such as LEPINA in El Salvador derive some of their legitimacy from these studies.  One proponent of the law asked me, “Don’t you think every child deserves a family?” I was taken aback. I would have liked to ask her, “What is a family?” “What is a community?” At what point are elements in a society so broken, so fragmented – by generations of war, domestic violence, substance abuse, criminality – that they lose their association with these terms, that they lose their ability to nurture and protect their children?  How do you know which “families” can be helped to be “good enough” parents in time to care for their children and which cannot? I would invite the supporters of laws like this to compare the sounds of children laughing and shouting in a soccer game on the terrace of the “institution” that is a “children’s home”, with the sounds in the “community” where they have been reunited with their biological relatives. I would invite them to compare the sight of a dozen children snuggled in their pajamas watching a video, while several others help the cook make papusas in another part of the big room, with the sight of children on the street at night where they now live. We must consider multiple alternatives as we seek to heal the caregiving environments of the children born into such hardship (Spratt et al, 2012). One is to support their biological families with which they can be reunited. But that does not always work. Another is a good “home” where they can be nurtured and protected in a way that can “break the cycle” so that slowly, over generations, a new “community” with “families” can emerge.

References:

Bos, K., Zeanah, C., Fox, N., Drury, S., McLaughlin, K., & Nelson, C. (2011), Psychiatric outcomes in young children with a history of hospitalization, Harv Rev Psychiatry, January/February 2011, pp. 15-24.

Rutter, M., Kumsta, R., Schlotz, W., Sonuga-Barke, E., (2012), Longitudinal studies using a “natural experiment” design: The case of adoptees from Romanian institutions, JAACAP, 51(8): 762-770. 

Spratt, E. et al, (2012), The effects of early neglect on cognitive, language, and behavioral functioning in childhood, Psychology, Vol. 3, No. 2, pp. 175-182.

 Williamson, J. & Greenberg, A. (2011), Families not orphanages, The Better Care Network. 

Zeanah, C., Nelson, C., & Fox, N., (2010), Letters: Orphans, especially very young ones, need families, The Wall Street Journal, January 28. 

 

 

Read this blog in Spanish.

 

 

 

 

What is an “Orphanage”?

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I have been thinking about an important paper in the recent journal of the Journal of the American Association of Child and Adolescent Psychiatry. The paper reported a study by Michael Rutter and colleagues of the effects of “pure” psychosocial deprivation (Rutter et al, 2012). The authors describe the study as a “natural experiment” in that they studied children in their natural life circumstances. The study group was children who had spent their lives in Romanian orphanages in circumstances of profound psychosocial deprivation up until the time they were adopted. Previous studies had shown that infants who had left the institution before 6 months of age had no significant deficits on any of the authors’ measurements at the age of 11 y. However, if they left the institution between 6 and 12 months, there was a large stepwise increase in deficits and no dose-response association with the duration of deprivation afterwards. Therefore the authors in this study pooled all the children who experienced institutional care beyond the age of 6 months and compared them with a composite group of children whose institutional care had ceased by 6-months, children who had experienced deprivation in their families but not in an institution, and children who were adopted into families in the U.K. and who had never experienced institutional care.  The authors were able to exclude the factors of subnutrition, extreme prematurity, and fetal alcohol syndrome. Thus the study design was able to isolate the variable of institutional psychosocial deprivation remarkably well. 

The authors focused on four outcomes that seemed specific to psychosocial deprivation: “quasi-autism” (autistic features but greater social interest and flexibility); disinhibited attachment (disregard of social boundaries and undue familiarity with strangers); inattention/overactivity (persistent inattention and overactivity); and cognitive impairment (IQ below 80).

The results showed that in the “pure” psychosocial deprivation group, the rate of “deprivation-specific patterns” (DSPs) at age 15 y was substantially and significantly higher in the 27 children in the study group whose institutional care lasted longer than 6 months, than those in the comparison group, whose institutional care lasted less than 6 months. Also there was a finding that pure psychosocial deprivation had a large effect on head growth if the institutional care had lasted for 6 mos. 

Therefore, there was strong evidence that “pure” psychosocial deprivation has a major effect in leading to DSPs. The study also found that whereas subnutrition had a significant but relatively small effect on intelligence, it did not have an effect on DSPs, a distinction that no previous study had made. The finding that pure psychosocial deprivation has an effect on head size is important because head size is related to brain growth, and this suggests that pure psychosocial deprivation has neurological consequences and can impair brain growth.

The main clinical implication of the study, the authors state, is that “profound institutional deprivation results in unusual and specific psychopathologic patterns.” They also conclude that “Important questions have still to be addressed, the most important being whether a similar effect on DSPs can derive from profound deprivation within a family context.” (Rutter et al, p. 769)

 This study drew my attention for three reasons – the elegance of the study design, its relevance to my interest in supporting caregivers in institutions, and its effectiveness in isolating a particular variable in the development of a specific deprivation-related psychopathology. (I am also a big fan of Michael Rutter’s and read anything he writes that comes out in one of my journals.) The study referred to the “profound deprivation” experienced by children in institutions. 

Yet, it is important to remember the context in which the study was done and with which the reader might be expected to be familiar – famous studies of the Rumanian orphanages by Rutter and his group, Zeanah, Nelson, and others (Bos et al, 2011). Never the less, it is unfortunate that – to my mind – not enough care is taken to define the “institutions” in which children are deprived (Williamson & Greenberg) (Zeanah, Nelson, & Fox, 2010). Based on studies such as those in Rumanian orphanages, the assumption is often made that the sooner children can be removed from orphanages the better. Yet, recall the last sentence of the paper – ““Important questions have still to be addressed, the most important being whether a similar effect on DSPs can derive from profound deprivation within a family context”. 

I think it is essential to study the various contexts in which children can experience “profound deprivation”. This is so important for one reason because laws such as LEPINA in El Salvador derive some of their legitimacy from these studies.  One proponent of the law asked me, “Don’t you think every child deserves a family?” I was taken aback. I would have liked to ask her, “What is a family?” “What is a community?” At what point are elements in a society so broken, so fragmented – by generations of war, domestic violence, substance abuse, criminality – that they lose their association with these terms, that they lose their ability to nurture and protect their children?  How do you know which “families” can be helped to be “good enough” parents in time to care for their children and which cannot? I would invite the supporters of laws like this to compare the sounds of children laughing and shouting in a soccer game on the terrace of the “institution” that is a “children’s home”, with the sounds in the “community” where they have been reunited with their biological relatives. I would invite them to compare the sight of a dozen children snuggled in their pajamas watching a video, while several others help the cook make papusas in another part of the big room, with the sight of children on the street at night where they now live. We must consider multiple alternatives as we seek to heal the caregiving environments of the children born into such hardship (Spratt et al, 2012). One is to support their biological families with which they can be reunited. But that does not always work. Another is a good “home” where they can be nurtured and protected in a way that can “break the cycle” so that slowly, over generations, a new “community” with “families” can emerge.

References:

Bos, K., Zeanah, C., Fox, N., Drury, S., McLaughlin, K., & Nelson, C. (2011), Psychiatric outcomes in young children with a history of hospitalization, Harv Rev Psychiatry, January/February 2011, pp. 15-24.

Rutter, M., Kumsta, R., Schlotz, W., Sonuga-Barke, E., (2012), Longitudinal studies using a “natural experiment” design: The case of adoptees from Romanian institutions, JAACAP, 51(8): 762-770. 

Spratt, E. et al, (2012), The effects of early neglect on cognitive, language, and behavioral functioning in childhood, Psychology, Vol. 3, No. 2, pp. 175-182.

 Williamson, J. & Greenberg, A. (2011), Families not orphanages, The Better Care Network. 

Zeanah, C., Nelson, C., & Fox, N., (2010), Letters: Orphans, especially very young ones, need families, The Wall Street Journal, January 28. 

 

Read this blog in Spanish.