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.
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.