Dickens, Boys Town or Purgatory : Are Institutions a Place to Call Home?

While most orphanages in Asia and other regions of the world, provide far more humane care than was the case historically in Romania, Dr. Groza's review of the impacts of institutionalism on children adopted from Romania has implications for children remaining in institutions around the world.

By Victor Groza, Daniela F. Ileana, and Ivor Irwin

Normal Child Development -- Keeping Perspective

By understanding what is typical, healthy development, we can better understand how life can be complicated for children growing up in an institution where there is an interruption in the normal path of development. Normally, children develop and grow according to a set schedule. Growth and development begin prenatally and we know that maternal health, nutrition, exposure to stress or toxic chemicals, and the quality of life in general have a profound effect on the developing fetus. After birth, while children vary in their rates of development, they all proceed through the same sequences.

Normal development is governed by intrinsic maturational factors and environmental conditions. Initially, there are rapid changes and gains made in physical development -- children gain weight and grow -- as well as the mastering of physical tasks such as the gross and fine motor skills that allow children to eat, cry, smile, turn over, crawl, stand, walk, jump, etc. To maximize normal growth and development, children need proper nutrition, sunshine, hygienic conditions, warmth, stimulation, attention, and love. At the same time as this is occurring, attachments begin developing, usually between mother and child. At first, the infant becomes attracted to all objects; it is only after several weeks that they begin to prefer humans to inanimate objects. Children will, from birth, give cues to their needs, that, if they are well cared for, will be met by a parent or whoever cares for them. For example, when they are hungry or uncomfortable, they will cry. When they express a need and the need is met in a consistent and timely manner, this results in a foundation of trust for the child toward the attachment figure who is fulfilling their needs. From the first weeks of life, there is a clustering of attachment behaviors that influence both how the child responds to the parent or caregiver as well as how the parent responds to the child. While, initially, children do not differentiate between caregivers, at three-months-old an infant begins to smile more at his primary caregiver than at strangers. By the end of the first six months of life, they learn to discriminate between familiar and unfamiliar attachment figures. From the first year of life, approximately up until the age of three, children will begin to protest when attachment figures leave them and they will engage in various behaviors to remain close to the attachment figure. If an infant develops a trusting relationship with the primary caregiver, the infant will desperately seek to always stay with that one attachment figure. This attachment will enhance the parents' effectiveness in the later socialization of the child.

In addition to attachment behaviors, as a child's cognitive abilities develop, he or she develops ideas about relationships and the manner in which the world works, based on these experiences. These changes in their cognitive and intellectual development affect their personality, moral reasoning, and critical thinking skills.

During the first year of life, children begin to acquire language skills. The first skills are sounds such as cooing, crying, laughing, etc. Often they are introduced or reinforced by the primary caregiver. At a later point, children begin to organize the sounds that will eventually become language.

Finally, all these developmental tasks and activities -- physical growth, attachment, cognitive development, the learning of language -- influence the child as a socially skilled being. Obviously, social skills are important for the development and maintenance of the social relationships that are to soon follow. This includes relating to siblings, peers, extended family members, neighbors and community members at large. Social skills are important by the time children are ready to navigate and negotiate their way to preschool, kindergarten, and other activities outside the home.

This overview of a reasonably normal childhood is important as we look at what happens to children who are institutionalized at an early age. More often than not, they are not exposed to the stimuli of relationships or placed in an environment where the usual needs can be met and the average tasks of childhood are not accomplished.

Recent research strongly suggests that many of the tasks and developmental achievements, those which are not organically or physically based, influence the neurological and biochemical development of the brain. Unfortunately, such ideas are largely based on theoretical models and related research on animals. The degree to which they accurately reflect the capacity of children's brains to be able to reverse childhood trauma is not well known.

In 1996, a new round of sensationalism was added to the media coverage of the problems associated with children who have been institutionalized before adoption. Family tales of suffering and soft science met on TV programs. Adopted Romanian children were treated as guinea pigs as the news media touted brain scans for children who had been institutionalized early in life. Despite all those visual images of all-black brain scans and patches of blue and red activity areas in their brain, most children look good. This type of information, black brain scans, was taken from a very small group of children and is meant to be gathered for research. Indeed, the information from this type of research is still very much in the early stages. The danger, concerning the media in this case, is that it gives the public a skewed, simplistic view of an issue that is as complicated as the brain itself. Knowing that a part of your child's brain isn't functioning doesn't give you any information about what you can do differently. It creates anxiety and fear, but doesn't tell a family or a practitioner what can be done to improve upon the actual problem. Children's brains have amazing recuperative powers. The fact is, that despite the media's relentless attempts to sow panic among a susceptible public, it's still too early to come to any absolute conclusions.

What is certain is that the quality of a family and social environment is crucial. If we accept that a family is an ideal environment for a child, then we need to understand what happens to children who spend their formative years in some kind of group or institutional setting.

The Effects of Institutionalization

The negative effects of early institutionalization have made headlines in England and America for the past 90 years. Institutionalization early in life interrupts the parent/child cycle of bonding, which results in attachment difficulties as well as slowing emotional, social, and physical development.Early deprivation can affect a person's ability to make smooth transitions from one development stage to another throughout life.

Henry Dwight Chapin was one of the first researchers to examine child development in institutionalized settings. The director of pediatrics at Columbia University Medical School, Chapin began his work after realizing that, by the turn of the century, the infant mortality rate in institutions had reached an astonishing 100%. Chapin discovered that there was a critical period for development in institutionalized infants -- that the first year of life is absolutely crucial for normal development and the first six months even more important than the second. He reported that the first noticeable effect of institutionalization was a progressive loss of weight. If weight loss got beyond a certain point, no change in the amount of food intake or environmental change could save the child. Dryness of skin, loss of hair, and dehydration accompanied this condition. The predominant cause of death was not starvation but pneumonia.

Chapin became convinced that infants were at a great risk for developmental difficulties and a quick death when placed in institutions. In the early 1890s, he opened the first hospital social service in the United States. He believed it was essential that infants only be institutionalized briefly, if at all. Acting on this belief, Chapin began a boarding-out or fostering system in 1902, where hospitalized infants were placed in the homes of private families. This was one of the forerunners of the foster care movement in the U.S.

Society took note: humanitarian changes were made in the U. S. system of institutions. Still, despite serious improvements in hygienic conditions and sanitary practices, increased knowledge of infection control, and better food, the mortality rate of infants in institutions did not substantially decline. The single most important factor, Chapin felt, was a lack of proper individual attention, care and stimulation; that which, under normal circumstances, were provided by maternal love and care. He also concluded that it was not the length of time spent in an institution, but the age at which the child was initially placed: the younger the child, the more serious the effects and greater the risk of negative effects.

Once the family foster system was properly established, the high infant mortality rate declined. Photos and data from Chapin's research clearly show how children looked on the day they were removed from institutions and then how they looked six months after they entered a foster home. The most drastic change was weight gain. By 1917, Chapin had concluded that this effect was a consequence of close individual care, especially the holding of infants when they were fed (as opposed to just holding the bottle in an upward position and feeding the infant in its crib without any physical contact).

Subsequent to Chapin, several researchers did seminal work in the areas of the effects of institutions on early growth and development. There is ample evidence that early institutionalization can result in severe emotional and behavioral problems as well as fundamental problems with learning, reading ability, and basic intellectual functions. Behavioral problems included aggressive or antisocial behavior, and difficulty in forming close, intimate relationships. Still, such results have had no absolutes; there have been many cases of remediation or the reversibility of early trauma. For example, in one of the earliest studies conducted, Professor Goldfarb in England concluded that some children adjust well socially and emotionally despite their negative experiences of institutional deprivation in early childhood. Other researchers also found that prolonged institutionalization does not necessarily lead to emotional problems or character defects in all children. This suggests that there will always be some children who fare well, who are resilient, regardless of their experiences in early childhood. However, these earlier studies should be viewed with caution. The institutions in these studies were not prototypical of Romanian institutions. Children in these studies who had been institutionalized had access to individual space, good nutrition, education programs, and adequate child-to-staff ratios.

Still, this work leads to certain conclusions. It certainly is a fact that, while children can be positively affected by moving from institutions to families, the effects of the past do not necessarily disappear over time. Just as is the case with typical families, beyond issues of economic well-being, environment and social class, one comes to a clear conclusion that most of us already know instinctively: a lot depends on parental willingness to devote a great deal of time and attention to their children to help them recover.

A helpful set of studies, for the sake of perspective, is one involving twins done by Jarmila Koluchova in 1972 and 1976. These twins, born and raised in a conventional family setting with the appropriate care up until the age of eighteen months, had then been institutionalized, isolated and neglected until the age of seven. Despite initial diagnoses that were pessimistic, by age eleven the children had made amazing progress. These children ultimately performed at average levels in school. Within four years, they attached strongly with a mother figure and a carefully trained, networked team of multi-disciplinary professionals. Koluchova found that, with good stimulation and care over the first two years of life, children can recover from subsequent bouts of neglect and isolation. A unanimous opinion of experts involved in these early studies is that the children who adjust the least well of all when it comes to coping with separation are the ones who are institutionalized before the age of one.

A specific problem, of concern to parents and professionals, is the effects of institutionalization on attachment. Attachment is a term you'll hear a lot. It applies to a durable, lasting relationship between a child and one or more persons with whom he or she interacts regularly: ideally a family and other siblings. Attachment serves a variety of functions, such as basic nurturing, interaction, discipline and affection. Attachment is the connection that allows parents to teach values and expectations, and for children to accept these values and expectations.

Attachment develops over time; it is not a static process, but a continuum from weak to strong, influenced by life's experiences, that has to be labored at and developed. So, it changes over time. The impact of institutionalization on long-term attachment patterns is not well known. It is clear that institutionalization places children at-risk for attachment problems, and this contributes to fear and anxiety among parents and professionals.

When we walked into the room, about a dozen children, ages two and three, were sitting on the floor. About half of them immediately got up and ran to us with outstretched arms to be picked up. They were persistent, trying to climb up our bodies if we were not quick enough to pick them up. Some of the bigger or stronger ones would push the smaller ones away. They would touch our face, look at us and say Mama or Tata (father). They were indiscriminately affectionate. There were a few children who just looked at us blankly and continued to sit on the floor. They would avoid our attention if we looked at them. They made no attempt to move towards or away from us. But a few children looked at us, screamed, and ran to their nurses for protection and comfort. The reactions of these children, all in the same setting with the same experiences, represent different patterns of attachment. What we could not tell potential families is which of these patterns would change.

John Bowlby, who worked for the World Health Organization early in his career, provided the basis for most of attachment theory and practice. He argued that institutions fail to provide children with the intimate, warm, and continuous relationships that primary caregivers (usually mothers) can give. According to Bowlby, such a relationship is an absolutely necessary condition for successful human development. If a child is institutionalized for long enough, he or she may become incapable of forming the breadth and depth of human relationships necessary for survival and development. Attachment also provides the foundation of a conscience. In a "normal" home, attachment to parents results in the child wanting to act in ways that please the parent. If early connections are weakened or problematic, there is a decrease in the desire to please the people important to us -- because people are just not that important to us. Related research has identified children with histories of early childhood abuse or neglect as being at greater risk for experiencing attachment difficulties.

We were told that the Institutions for the Irrecoverables were the training ground for Securitate. It was the perfect place to raise children into mindless, guiltless puppets who would rob, torture or kill for a reward. As an example, one of the children in the institution was considered educable, even though he had some retardation. While we were there, he had been taken to a farm for training. The farmers taught him how to string up and butcher a pig. The next night, he put his skills into action. All night long we had been kept awake by the pitiful howls and moans of a dog. When we asked one of the guards, he said it had been a dog in labor all night. One of the nurses told us, outside the hearing range of the guard, that he was a liar. The boy who had been taken to the farm had taken a dog, strung it up, and tortured it -- using the butchering of the pig as his guide. He did this to the jeers and encouragement of the guards. What we heard that night was the suffering of the dog, who after hours of torture was left to die on her own. The next day the boy was beaming as he was praised by the guards, and relished the fear shown by the nurses.

Adults who formed healthy attachments during early childhood will have the capacity to experience healthy adult life. Children who were emotionally deprived, however, will continue to remain emotionally isolated as adults, have difficulty with relationships, and may act in deviant or delinquent ways. They are all too often manipulative in their behavior, using others for their emotional support without reciprocating or letting anyone get close to them emotionally. Some are haunted by loneliness. As adults they often cannot hold on to either jobs or relationships.

These studies clearly have many implications concerning the health and development of children from Romanian institutions. These children can be considered at risk for health and developmental problems. Families adopting them need to be prepared for their special needs. We are still learning to identify the trauma that is reversible and the trauma that is manageable, since the effects of some trauma are long term and unlikely to change.

Dr. Victor Groza is an Associate Professor and the Interim Associate Dean for Research and Training at Case Western Reserve University in Ohio. He is a prolific author and editor in the field of adoption studies; four books and over 40 professional articles are in publication. His most recent publication is Adopting Older Children: A Practical Guide to Adopting and Parenting Children Over Age Four
Excerpted with permission from "A Peacock or a Crow : Stories, Interviews, and Commentaries on Romanian Adoptions."