the impact of institutionalization on child development (obligatorio).pdf

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Development and Psychopathology,15 (2003), 853884Copyright 2003 Cambridge University PressPrinted in the United States of AmericaDOI: 10.1017.S0954579403000415

The impact of institutionalization

on child development

KIM MACLEAN

St. Francis Xavier University

Abstract

During the past 10 years researchers studying children adopted from Romanian orphanages have had the opportunity

to revisit developmental questions regarding the impact of early deprivation on child development. In the present

paper the effects of deprivation are examined by reviewing both the early and more recent literature on studies of

children who spent the first few years of life in institutions. Special attention is given to the Canadian study of

Romanian adoptees in which the author has been involved. Findings across time and studies are consistent in

showing the negative impact of institutionalization on all aspects of childrens development (intellectual, physical,

behavioral, and socialemotional). Results of studies show, however, that institutionalization, although a risk factor

for less optimal development, does not doom a child to psychopathology. However, the impact of institutionalization

is greater when coupled with risk factors in the postinstitutional environment. Methodological and conceptual

difficulties in research with institutionalized samples of children are discussed and future directions for research are

considered.

The attempt to understand human develop- differ from normal development. Longitudinal

studies of previously institutionalized samplesment is greatly constrained by ethical consid-

erations that make it impossible to examine can address questions concerning whether dep-

rivation results in some skills never fully de-the impact of deprivation on child develop-ment. Experiments in nature afforded by veloping or whether skills are simply delayed.

There is also the opportunity to examinesamples of institutionalized children permit an

examination of the developmental process whether the behavior of orphanage children is

quantitatively or qualitatively different fromwhen conditions are so severe as to impede

normal development. Findings from studies of the behavior of noninstitutionalized samples

of children.institutionalized children provide invaluable

information that can inform theory, research, Institutionalized samples also provide a

rare chance to examine how the roots of par-and social policy with respect to both normal

and atypical development. Orphanage samples ticular pathologies may lie in behavior that

emerges as a result of the environmental con-permit us to evaluate developmental progress

after deprivation and examine how this might text in which children reside. The study of

these behaviors has the potential to inform our

thinking with respect to the roots of pathology

in other clinical samples of children. Re-Thanks to Elinor W. Ames and Megan Gunnar for theirvery helpful and thoughtful comments on earlier drafts of searchers can also examine the ways in whichthis manuscript. The author has previously published un- institutionalized samples are similar to andder the name Kim Chisholm. different from other samples of maltreated

Address correspondence and reprint requests to: Kimchildren. Children from orphanages usually

MacLean, Psychology Department, St. Francis Xavierexperience maltreatment and neglect on everyUniversity, PO Box 5000, Antigonish, Nova Scotia, Can-

ada; E-mail: [email protected]. level (physical, behavioral, social, and emo-

853


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K. MacLean854

tional), but unlike many maltreated groups, alized children were first noted before the

study of attachment began; indeed, it wasthey have experienced the intervention of

adoption into supportive home environments studies of orphanage children that helped to

lead Bowlby to formulate the concept of at-that provide for developmental needs. Exami-

nation of these groups and their progress may tachment (Bowlby, 1951). There is a questionwhether current measures of attachment aresuggest ways in which we might intervene

with other maltreated samples. appropriate for assessing attachment in or-

phanage samples because they were not de-There are, however, inherent limitations to

what can be learned from any one study of signed to evaluate the presence or absence of

an attachment relationship. Rather, these mea-institutionalized children. Such experiments

in nature are often considered to be real-life sures assess the quality of attachment and

make the assumption that an attachment rela-counterparts of experimental animal studies of

early deprivation. However, it might be pref- tionship exists. The measurement of attach-

ment is still not agreed upon; even recenterable, when using the phrase, to place more

emphasis on the word nature and less on ex- studies of orphanage childrens attachment to

their adoptive parents have used different sys-periment. Whereas variables in experiments

are isolated and controlled, this is not the case tems to measure attachment at the preschool

age. Another problem is the need to developin real life. For example, for experimentalpurposes it is possible to restrict animals per- new measures for concepts described but not

measured earlier. The indiscriminate friendli-ceptual experience while keeping the rest of

their environment equivalent to that of ani- ness toward adults often shown by previously

institutionalized children was first describedmals with unrestricted perceptual experience.

For institutionalized children, on the other 58 years ago (Goldfarb, 1945b), but it is only

in the last 8 years that researchers have at-hand, the variable of institutionalization re-

fers to a complex mix of social, perceptual, tempted to develop measures; again, there is

no one agreed-upon measure. Although thephysical, intellectual, and emotional depriva-

tion. As a result, when institution-reared chil- lack of agreement on measurement systems

complicates the comparison of studies, the usedren are found to differ from family-reared

children, it is usually not possible to specify of different systems not only broadens the

number of different behaviors examined butthe type of deprivation that produced the dif-

ferences. In institution studies the ages of may also clarify the meaning of such behavior.

Institutionalization studies also have theentry into and exit from the institution are

not under experimental control. Family needs, problem of having to use measures standard-

ized on home-reared children to assess institu-childrens conditions, and societys threshold

for removing children from their homes are tion-reared children. For example, many items

on tests of capability at young ages are simplyall factors in determining entry. The age of

leaving the institution varies according to not applicable to orphanage populations. One

does not often find a home-reared child whonational social and economic policy and the

childs health, physical attractiveness, and has never had an opportunity to grasp an ob-

ject small enough to require finger involve-gender. When children enter institutions at or

shortly after birth, their age at adoption is ment, but this is common in children who

have been kept in cribs for the first year orconfounded with duration of deprivation, so

that it is never possible to tell whether age of more. Problems may arise with subscales on

standardized tests of behavior problems: Canadoption or length of institutionalization is the

effective variable. In the minority of cases in the same items that have been shown to fall

into factors in nonclinical, or even clinical,which children enter institutions considerably

later than birth, the conditions under which samples be assumed to be organized into the

same factors in a sample reared under suchthey were raised before entering the institu-

tion are also relevant to the outcome. different conditions?

The question of appropriate comparisonIn any topic studied over a period of 60

years the use of different measures becomes a groups for children in or from institutions is

a thorny one. There are many possible com-problem. Attachment problems in institution-


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Institutionalization and child development 855

parison groups, but each answers a different The point to be made is that there is no

perfect comparison group in nature that canquestion and fails to answer other questions.

Previously institutionalized children are both possibly answer all the important questions

that can be asked. Each of the different com-adopted and formerly institutionalized. To sep-

arate the effects of institutionalization from parison groups teaches us something, but noneis a complete control group. Both the re-those of adoption, for example, one might

look at adoptees who did not come from insti- searcher and the reader of research must pay

careful attention to what a particular compari-tutions. Rutter and colleagues (Rutter & the

English and Romanian Adoptees [ERA] Study son group can or cannot tell us. There is also

an advantage to this situation, however. TheTeam, 1998) employed a comparison group

of children adopted in the United Kingdom; fact that different studies have used different

measures or types of comparison groups some-but all of these children were adopted before

6 months of age, which makes them an ade- times makes comparing them more difficult,

but it also increases the number of questionsquate comparison only for children adopted

from Romania before age 6 months. Because that can be asked. In addition, when similar

conclusions are drawn from studies using dif-there are few children who go directly from

the birth home to an adoptive home at later ferent measures and comparison groups, those

conclusions may be accepted with consider-ages, the researcher who wanted to comparegroups of children who have been adopted able confidence.

This article reviews the impact of institu-later would have to compare previously insti-

tutionalized children to domestic adoptees who tionalization on the following areas of child

development: physical development; develop-may have been abused or neglected in their

birth homes and/or then moved through (some- mental milestones, intellectual development,

and academic achievement; behavior prob-times several) foster homes before adoption.

Alternatively, one could use a comparison lems; indiscriminate friendliness; and attach-

ment. Under each area the characteristics ofgroup of children who stay in institutions.

This is perfectly legitimate but it answers a institutionalized and previously institutional-

ized children are reviewed, especially withdifferent question: how much better off are

adoptees from institutions than those left be- regard to their differences from comparison

groups. Evidence on the persistence of orhind? It does not tell us anything about how

previously institutionalized childrens perfor- changes in the behavior, its relation to length

of institutionalization, and its correlates aremance compares to that of the home-reared

children among whom they now live. also presented. The results of recent studies of

adoptees from Romanian orphanages, espe-Canadian researchers (Ames, 1997) have

used two different age-matched groups to com- cially the Canadian study in which this author

has been involved (Ames & Chisholm, 2001;pare to their orphanage group. One is an early-

adopted group of children who would have Chisholm, 1998, 2000; Chisholm, Carter, Ames,

& Morison, 1995; Fisher, Ames, Chisholm, &gone to Romanian orphanages had they not

been adopted before 4 months of age. This Savoie, 1997; Gunnar, Morison, Chisholm, &

Shuder, 2001; Morison, Ames, & Chisholm,group has thus had the same poor prenatal and

perinatal experience as institutionalized chil- 1995) are emphasized, but pioneer studies of

institutionalization are also referenced anddren but differs from the institutionalized group

in terms of age at adoption and (at any com- their conclusions included wherever relevant

to the more modern work.mon age) length of time spent in the adoptive

home. The second comparison group in the

Canadian study consists of Canadian-bornDevelopmental Milestones, Intellectual

children reared in homes similar to those ofDevelopment, and Academic Achievement

the orphanage children after adoption; how-

ever, in addition to being different with regard Research interest in the developmental conse-

quences of extreme deprivation in infancy be-to the crucial variable of orphanage experi-

ence, the two groups also differ in the pres- gan intensely in the 1940s and 1950s with the

work of Rene Spitz (1945a, 1945b), Williamence or absence of the adoption experience.


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K. MacLean856

Goldfarb (1943a, 1944, 1945a, 1947, 1955), were conducting studies in institutions at-

tempting to ascertain the kinds of interven-and John Bowlby (1953). Most research fo-

cused on intellectual development. Rene Spitz tions that might prevent poor developmental

outcomes. Such interventions included pro-(1945a, 1945b), who studied children in insti-

tutions, reported a drastic drop in infants de- viding sensory stimulation (Broussard & De-carie, 1971), placing infants as houseguestsvelopmental quotients (DQs) over the early

months of institutional care. He reported that with older residents (Skodak & Skeels, 1945,

1949), and improving child to caregiver ratiosby the end of the second year infants DQs

had dropped to a low of 45, as compared to (Hunt, Mohandessi, Ghodessi, & Akiyama,

1976). All of these studies showed that simplean average DQ of 100. Spitz described the de-

terioration of children as progressive in spite changes within the orphanage environment in-

creased childrens developmental competence.of the fact that physical conditions in orphan-

age had improved over the course of his study. Further support for the idea that institution-

alized children were not destined for develop-Given that improvements to orphanage infra-

structure had not resulted in an improvement mental compromise came from the work of

Barbara Tizard and her colleagues with chil-in DQ scores, Spitz concluded that children

were irreparably damaged by institutionaliza- dren who had spent the first 2 years of their

lives in high-quality institutions in the Unitedtion in the first years of life.William Goldfarb (1945a, 1955) studied 15 Kingdom (Tizard, 1977). In these institutions

the child to caregiver ratios were 3:1 and thechildren who had been reared in an institution

for the first 3 years of their lives and were children experienced adequate social stimula-

tion, were taken on outings, and were fed well.subsequently placed in foster care. He com-

pared those children to a group of children The major way in which orphanage childrens

lives differed from the lives of home-rearedwho had been in foster care since early in-

fancy. Goldfarb found that even in adoles- children was that caregivers were discouraged

from forming intimate relationships with themcence the institution group was delayed intel-

lectually relative to the foster care group, and (Tizard & Tizard, 1971). Tizard and Joseph

(1970) first assessed children in the institutionhe claimed that early institutional rearing re-

sulted in developmental deficits that were not when they were 2 years old and compared

them to a sample of home-reared childrenovercome once children were placed in more

stimulating and loving environments. from a working class background. They found

that the institution childrens IQ scores wereResearchers conducting this early work

claimed quite strongly that children were in- only slightly lower than those of the working

class children and that their language wastellectually compromised as a result of early

institutionalization. This claim, however, was only slightly delayed. At age 4.5 the mean IQ

of the children in an institution was in the av-criticized largely on the basis of the method-

ological limitations of the research (Long- erage range and no language problems were

found (Tizard & Rees, 1974). Hodges andstreth, 1981; Pinneau, 1955). Critics reported

that much of the early literature provided few Tizard (1989) reported that children adopted

from the institution had normal IQs at 8 anddetails regarding either the conditions in or-

phanages or the assessments used to evaluate 16 years of age. Tizards findings were more

positive than the findings of the earlier re-children. Very often the number of children

who were tested, the ages at which they were search, but it is important to note that the chil-

dren in Tizards sample had not experiencedtested, and how often assessments were car-

ried out were unspecified. Such limitations theextremedeprivation experienced by earlier

samples of children (e.g., Goldfarb, 1945a).have made it difficult for current researchers

to have confidence in the early data on institu- Therefore, Tizards more positive findings

may be partially explained by less severe dep-tionalized children.

Not all early studies, however, predicted rivation.

Although this research challenged Spitzssuch dire outcomes for institutionalized chil-

dren. In many parts of the world researchers claim that the damage resulting from institu-


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tionalization was irreparable, it did not ad- velopment (Bayley, 1969), Kaler and Free-

man (1994) found that none of the orphanagedress the issue of the extent to which length

of institutionalization made a difference in de- children were functioning at their age level,

and 20 of the 25 children functioned at levelsvelopmental outcomes. Dennis (1973) followed

children from a Lebanese orphanage after they that were less than half their chronologicalage. Childrens Bayley scores were unrelatedwere adopted and compared the developmen-

tal outcomes of children adopted at different to their Apgar scores at birth, suggesting that

these data could not be explained by any ini-ages. He claimed that children who had been

adopted before 2 years of age eventually re- tial biological insult. Similarly, Carlson and

Earls (1997) reported that a group of 2- to 9-gained normal IQs whereas those who were

adopted after 2 years of age showed perma- month-old infants in a Romanian orphanage

scored well below the Bayley norms for theirnent deficits in IQ. Although this claim has

often been cited, it has not been adequately age. Further support for these findings was

provided by Sloutsky (1997), who assessedtested.

Given that much of the data from this ear- differences in IQ scores between 6- to 7-year-

old children reared in a Russian orphanagelier research was descriptive, anecdotal, and

short term, making it difficult to evaluate, and children of the same age reared at home

and found that the orphanage children scoredmore recently researchers have tried to ex-amine larger samples of children using stan- lower in IQ than home-reared children.

Other researchers have been able to evalu-dardized measures of DQ, IQ, and academic

achievement. Although their findings are more ate the intellectual development of previously

institutionalized Romanian children after thehopeful, they are not inconsistent with the

early literature. Both sets of literature clearly profound intervention of adoption. These two

projects, which are ongoing and have now fol-demonstrate that institutionalization early in

life has a negative impact on intellectual de- lowed children up to 8 or more years after

adoption, have provided the clearest informa-velopment and that it is not only institutional-

ization but also the length of institutionalization we have regarding intellectual develop-

ment in postinstitutionalized children. The firsttion that is important.

Most of the recent information we have project, in British Columbia, Canada, com-

prised an initial sample of 46 Romanian chil-concerning the impact of institutionalization

on intellectual development has been the re- dren who had spent at least 8 months (range =

853 months) in a Romanian orphanage (or-sult of the 1989 overthrow of the Ceausescu

regime in Romania, after which the world be- phanage group) prior to their adoption to Can-

ada, when they were a median 18.5 monthscame aware of thousands of children being

housed in Romanian state-run orphanages. De- old (range = 868 months); 29 children who

would have gone to orphanage in Romaniascriptions of these orphanages have been re-

ported elsewhere (Fisher, Ames, Chisholm, & had they not been adopted prior to 4 months

of age (early-adopted group); and 46 Cana-Savoie, 1997; Groza & Ileana, 1996), and it

is clear that they were as bad as or worse than dian-born, nonadopted, never institutionalized

children (Canadian-born group) who were in-the conditions reported in the earlier litera-

ture. dividually matched on demographic charac-

teristics to children in the orphanage groupShortly after the revolution, Kaler and

Freeman (1994) were able to assess children (Ames, 1997). The second project (Rutter &

the ERA Study Team, 1998) comprised a sam-within the orphanage context. They conducted

cognitive assessments on 25 children ranging ple of 165 children adopted to the United

Kingdom from Romania between birth and 42in age from 23 to 50 months who resided in

a Romanian orphanage and compared them to months of age. Most of the children, but not

all, had been adopted from orphanages. Thesesame age peers from a Romanian kindergarten

class. Apgar scores that were available for 13 children were compared to 52 children who

were adopted within the United Kingdom be-of the children indicated that they had normal

births. Using the Bayley Scales of Infant De- fore 6 months of age.


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K. MacLean858

Morison and colleagues (Morison, Ames, that were related to test scores. The length of

time that children spent in the orphanage was& Chisholm, 1995; Morison & Ellwood, 2000)

examined development in the Canadian sam- positively associated with the number of areas

of delay on the R-DPDQ and negatively cor-ple of Romanian orphanage children, once

based on retrospective reports from when their related with childrens scores on the adaptive,personalsocial, and language scales of theparents first met them, once when the children

had been in their adoptive homes for 11 Gesell. In addition to the length of time in an

institution, the availability of toys and havingmonths, and once when they had been in their

adoptive homes for approximately 3 years. been a favorite in the institution were associ-

ated with fewer delays and higher scores onBased on parents reports of their childrens

developmental condition when they first met the Gesell scales, whereas being described as

dirty when first met by parents was associatedthem, Morison et al. (1995) found that 78%

of orphanage children were delayed in all four with more delays and lower Gesell scores

(Morison et al., 1995).areas of development (personalsocial, gross

motor, fine motoradaptive, and language de- Three years postadoption these researchers

(Morison & Ellwood, 2000) evaluated chil-velopment) assessed by the Revised Denver

Prescreening Developmental Questionnaire (R- drens intellectual development using the Stan-

fordBinet Intelligence Scale, Fourth EditionDPDQ; Frankenberg, 1986). There was not aparticular area of development in which or- (SB4: Thorndike, Hagen, & Sattler, 1986).

Given Dennis (1973) earlier claim, IQ resultsphanage children were specifically compro-

mised; rather, delay was pervasive across all were analyzed separately for orphanage chil-

dren who had been adopted before and afterareas. Rutter and his colleagues reported simi-

lar findings with their sample of adoptees in they were 2 years old. In comparing IQ scores

among the younger children, who were 4.5the United Kingdom (Rutter & the ERA

Study Team, 1998). years old when assessed, Morison and Ell-

wood (2000) found a clear ordering amongBy 11 months postadoption, improvement

was evident in the Canadian sample (Morison the groups, in which the Canadian-born group

scored highest (M = 109), the early-adoptedet al., 1995). At that time the majority of or-

phanage children remained delayed in two or children scored in the middle (M = 99), and

the orphanage children scored lower (M= 91).more areas of development according to their

parents report on the R-DPDQ. In addition, The orphanage children adopted at later ages

(2460 months old) had the lowest IQs of allRevised Gesell Developmental Schedules (Kno-

bloch, Stevens, & Malone, 1980) administered (M = 68).

Le Mare, Vaughan, Warford, and Ferny-to 23 of the orphanage children showed that,

although children were progressing at more hough (2001) conducted a later follow-up of

the Canadian sample, when the children werethan 1 month developmentally for each chro-

nological month in Canada, their develop- 9.5 years old or older. The pattern of group

results remained consistent with the earliermental quotients in areas of gross motor,

adaptive, personalsocial, and language aver- findings. Canadian-born children, whose fam-

ilies were matched to the other groups on de-aged in the borderline range (6885) and their

fine motor abilities averaged in the low end mographic variables, scored highest (M= 108),

early-adopted children scored lower (M= 99),of the average range (85+). Morison and col-

leagues (Morison et al., 1995) examined orphanage children adopted between 8 and 24

months of age scored even lower (M = 89),whether there were particular correlates asso-

ciated with childrens intellectual test scores and orphanage children who had been adopted

after 2 years of age scored lowest of all (M =at 11 months postadoption. Although no de-

mographic characteristics of the family (i.e., 71). Not unlike their earlier performance on

the R-DPDQ, the scores of later-adopted chil-parents age and education, family income,

and socioeconomic status) were associated with dren were lower across all scales of the SB4

(i.e., overall IQ, verbal comprehension, anddevelopment at this time, there were charac-

teristics of childrens institutional experience nonverbal reasoning) at both 3 years after


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adoption (Morison & Ellwood, 2000) and 8 age scored at the low end of the normal range

of intelligence (M = 90). This difference mayyears after adoption (Le Mare et al., 2001),

demonstrating that orphanage experience had be explained by considering differences in

group composition between the two studies.a general impact on all areas of intelligence.

Rutter and colleagues used the General The orphanage children in the Canadian studyhad all spent at least 8 months in an orphan-Cognitive Index of the McCarthy Scales (Mc-

Carthy, 1972) and reported a similar ordering age and had spent the great majority of their

lives in institutions. The correlation betweenamong their groups of 4-year-old (Rutter &

the ERA Study Team, 1998) and 6-year-old age at adoption and total time in institution

was +.97 (Morison & Ellwood, 2001). In con-children (OConnor, Rutter, Beckett, Keave-

ney, Kreppner, & the ERA Study Team, 2000), trast, close to 15% of the U.K. sample did not

experience an institutional upbringing: somewith within-U.K. adoptees and Romanian chil-

dren adopted before 6 months of age scoring children had been reared in a family setting

and others had been institutionalized for as lit-better than Romanian children adopted be-

tween 6 and 24 months of age, who in turn tle as 2 weeks (Rutter & the ERA Study Team,

1998). Inclusion of children with little or noscored better than Romanian children adopted

between 24 and 42 months of age. This con- orphanage experience may have contributed

to higher average IQ scores in the childrensistent ordering of groups across studies dem-onstrates the negative and cumulative effect adopted after age 2 to the United Kingdom

than in their counterparts in the Canadianof institutionalization on IQ. Institutionaliza-

tion may not, however, be the only factor un- sample.

Poor academic achievement has been foundderlying this ordering. The fact that the IQs

of the early-adopted children in the Canadian in both children in orphanages and children

after adoption from orphanage. A study ofstudy were lower than those of Canadian-born

children in homes matched on demographic children reared in Greek orphanages in which

conditions were far superior to the conditionsvariables also suggests possible effects of ge-

netic background, prenatal and perinatal care, found in Romania found lower academic per-

formance among 9-year-old orphanage chil-and adoption, which were shared by the early-

adopted and orphanage children (Morison & dren compared to same gender and age peers

living at home (Vorria, Rutter, Pickles, Wol-Ellwood, 2000).

The importance of length of institutional- kind, & Hobsbaum, 1998). Le Mare et al.

(2001) studied children after they had beenization for IQ is also supported by several re-

ports of negative correlations between the two in Canada 8 years or more and found that,

according to teachers reports of academicvariables: r = .75 3 years after adoption

(Morison & Ellwood, 2000), r = .48 at age performance and results on a standardized

achievement test, the Canada Quick Individ-6 years (OConnor, Rutter, Beckett, et al.,

2000), and r = .44 at 8 or more years after ual Educational Test (Wormelli & Carter, 1990),

Canadian-born children performed best, or-adoption (Le Mare et al., 2001). Several re-

ports (Morison & Ellwood, 2001; Rutter & phanage children adopted before 2 years of

age and early-adopted children (adopted be-the ERA Study Team, 1998; OConnor, Rut-

ter, Beckett, et al., 2000) found that length of fore 4 months) obtained intermediate scores,

and orphanage children adopted after 2 yearsinstitutionalization was the best predictor of

childrens IQ when entered in multiple regres- of age performed the worst. In addition, 12%

of orphanage children adopted before 2 yearssions with other variables.

Compared to the Canadian sample (Mori- of age and 60% of orphanage children adopt-

ed after 2 years of age had repeated a grade.son & Ellwood, 2000) in which orphanage

children adopted after 2 years of age scored In comparison, only one early-adopted child

and no Canadian-born children repeated ain the low end of the slow learner range on

IQ (M = 68), the Romanian children in the grade in school. Le Mare et al. (2001) con-

cluded, however, that even though many or-U.K. sample (OConnor, Rutter, Beckett, et

al., 2000) who were adopted after 2 years of phanage children were struggling within the


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K. MacLean860

school context, a noticeable number of them Dennis (1973) assertion (based on insuffi-

cient evidence) that children adopted before 2were functioning well within the average

range academically. years of age eventually regained normal IQs

whereas those who were adopted after age 2There is no doubt that the intervention of

adoption out of orphanage is a powerful one; showed permanent deficits, and second, be-cause the great majority of children adoptedthis is supported by the recent literature dem-

onstrating improvements in IQ after adoption from orphanages since 1990 have been adopted

before the age of 2, thus making it difficult to(Le Mare et al., 2001; Morison et al., 1997;

Morison & Ellwood, 2000; Rutter & the ERA get an older-adopted group if group divi-

sion lines are set higher than the 2-year mark.Study Team, 1998; OConnor, Rutter, Beck-

ett, et al., 2000). Undoubtedly, every child is The findings obtained with the correlational

and the group differences data are congruent,doing better intellectually than he or she

would be doing had they remained in an or- but it is unfortunate that under-2 versus over-

2 comparisons have become so common. In-phanage, but the environment they encounter

postadoption also makes a difference. Mori- spection of scatterplots of correlational data

reveals that the relationship of length of insti-son and Ellwood (2000) found that not only

institutionalization but also the home environ- tutionalization to cognitive measures is gener-

ally continuous and does not show any clearment contributed to childrens IQ scores 3years after adoption. Childrens home envi- dividing point at 2 years of institutionaliza-

tion.ronments were measured using the Home Ob-

servation for Measurement of the Environ- The older children are when adopted, the

more difficult is the task, because they notment (HOME; Caldwell & Bradley, 1984). The

more stimulating and supportive the home en- only have greater deficiencies to make up but

also have less time to recover before theyvironments provided by parents, the higher

the IQs of the children. Morison and Ellwood have to cope with formal school classes. Be-

cause of this, many of them repeat a grade in(2000) found in a multiple regression that in

addition to length of institutionalization and school. There are, however, some orphanage

children who in spite of their poor start arechildrens R-DPDQ scores when their parents

first met them, their scores on the HOME functioning well academically and appear not

to have been greatly intellectually compro-contributed significantly to intellectual out-

comes. mised by their early experience. Another

common finding is that both conditions in or-Development of children in institutions

and children adopted from institutions has phanages and conditions in adoptive homes

can modify the amount of cognitive deficit.been studied for over 60 years. The strongest

finding from the many studies is that spending Children do better if they are reared in better

quality institutions (e.g., those studied by Tiz-time in an orphanage is related to lower DQs,

IQs, and academic achievement. The longer ard, 1977) or in institutions in which percep-

tual or social environments have been enriched.the length of institutionalization, the greater

the decline in these measures. After removal They also have higher IQs and academic

achievement after adoption if their home en-from orphanage, children improve on devel-

opmental and intellectual measures, but those vironments are more stimulating and sup-

portive.who have been institutionalized for a long pe-

riod of time may still show significant delays Although comparisons of previously insti-

tutionalized children with home-reared chil-for many years after adoption. The effect of

length of institutionalization on development dren suggest that institutionalization per se is

the operative factor affecting their performance,has been demonstrated both through correla-

tions and through group differences, most of- the reason that children end up in orphanages

must not be forgotten. Whereas there are casesten by comparing groups that spent less than

2 years with those who have spent more than in which children from sound biological, eco-

nomic, and social backgrounds are institution-2 years in an orphanage. The division at 2

years arose for two reasons: first, because of alized, it is more commonly the case that chil-


9/32


dren require institutional care because of a who had adopted children from Korea, Ban-

gladesh, Columbia, India, and Indonesia andparental problem that may have genetic or be-

havioral implications for the child (e.g., alco- found that malnutrition, intestinal parasites,

and skin diseases were common. Fisher et al.holism, drug abuse, mental retardation, mental

illness) or because of social or economic con- (1997) found that 3 years after adoption theRomanian childrens medical problems hadditions in the family that also mean that chil-

dren receive poor prenatal or perinatal care or greatly improved but that children from Ro-

manian orphanages still had more medicaleven abuse before entering an orphanage. The

possible effect of these extrainstitutional, but problems than both the early-adopted and Ca-

nadian-born comparison groups.associated, factors is shown when children with

little or no institutional experience but from In addition to having particular medical

problems, previously institutionalized childrenthe same backgrounds as institutionalized chil-

dren (e.g., the early-adopted group in Morison are typically small and malnourished after the

orphanage experience. Eighty-five percent ofet al., 1995) score lower than home-reared

comparison groups matched on demographic orphanage children in the Canadian sample

fell below the 10th percentile and 59% of chil-characteristics of their homes.

dren fell below the 5th percentile for weight

(Morison et al., 1995). In another group of 16Physical DevelopmentRomanian children adopted to Canada, 50%

were below the 5th percentile for weight andDana Johnson and colleagues (Johnson et al.,

1992) examined the medical condition of 65 44% were below the 5th percentile for height

(Benoit et al., 1996). Similarly, in the U.K.previously institutionalized Romanian children

who were adopted to the United States. They sample of Romanian adoptees, Rutter and the

ERA Study Team (1998) reported that half offound that only 15% of these children were

considered physically healthy at the time of the children had heights, weights, and head

circumferences below the 3 percentile. Theadoption. Convergent evidence for this find-

ing comes from the Romanian children adopt- evidence of delays in physical growth among

previously institutionalized children is fairlyed to Canada (Fisher et al., 1997). In this sam-

ple, 85% of children had a reported medical consistent, and such delays are still apparent

up to 3 years postadoption (Carlson & Earls,problem. Similarly, Hostetter, Iverson, Thomas,

McKenzie, Dole, and Johnson (1991) found 1997; Chugani et al., 2001; Johnson et al.,

1992; Rutter & the ERA Study Team, 1998).that at least one medical problem was re-

ported for a majority of children adopted from In several studies growth retardation in height

has been shown to be associated with the15 countries in East and South Asia, Central

and South America, Africa, and the Caribbean length of time that children had spent in insti-

tutions (Ames, 1997; Johnson et al., 1992;and Pacific Islands. Fisher et al. (1997) found

that according to their parents reports orphan- Rutter & the ERA Study Team, 1998). The

longer that children spent in an orphanage, theage childrens most common medical prob-

lems when they were first adopted were intes- shorter they were for their age.

Very few studies of orphanage-reared chil-tinal parasites (31% of children), hepatitis B

(28% of children), and anemia (15% of children have focused on the impact of institu-

tionalization on physiological development.dren). These medical problems are consistent

with those noted by other researchers who The only physiological measures that have

been examined are cortisol levels (Carlson &have examined medical problems in previ-

ously institutionalized children from Romania Earls, 1997; Gunnar et al., 2001) and patterns

of brain glucose metabolism (Chugani et al.,(Benoit, Jocelyn, Moddeman, & Embree, 1996;

Gyorkos & MacLean, 1992; Jenista, 1992; 2001). Several researchers have proposed that

the impact of early adversity on physical andMarcovitch, Cesaroni, Roberts, & Swanson,

1995) and from several other countries (Hoks- psychological development is mediated, in part,

through effects on the stress-sensitive hypo-bergen, 1981; Hostetter et al. 1991). Hoksber-

gen surveyed parents from The Netherlands thalamicpituitaryadrenocorticol (HPA) sys-


10/32


11/32


peared to have resulted from lacerations, that 11 months after adoption Romanian or-

phanage children adopted to Canada had higherburns, or broken bones. This rate of physical

abuse is much higher than in any other study internalizing and total scores on the Child Be-

havior Checklist (CBCL; Achenbach, Edel-of Romanian adoptees. It is possible therefore

that the brain dysfunction found by Chugani brock, & Howell, 1987) than did early-adoptedor Canadian-born children. No differenceset al. (2001) may be at least partially related

to pain and fear beyond the levels typical of were found between the groups on externaliz-

ing behavior problems at that time. Wheninstitutional life.

In summary, studies agree that children children had been in Canada for 3 years, how-

ever, their externalizing and total scores wereadopted from orphanages tend to be in poor

health, malnourished, and small. The longer higher than those of Canadian-born children

(Ames, 1997), and these scores remainedchildren remain in an orphanage, the shorter

they are for their age. There is some evidence higher than scores in the comparison groups

more than 8 years after adoption (Warford,that orphanage children lack the normal diur-

nal pattern of cortisol production and have 2002). Marcovitch et al. (1997) reported simi-

lar results in their sample of 3- to 5-year-oldlower than normal brain glucose metabolism,

but the full meaning of these findings is un- Romanian children. Children adopted after 6

months of age had higher externalizing andclear. Further studies using a wider range ofphysiological variables will be necessary to total scores on the CBCL than Romanian chil-

dren adopted before 6 months of age. In theelucidate this area of research.

Canadian sample (Ames, 1997) it initially ap-

peared that in addition to becoming more ex-Behavior Problems

ternalizing, orphanage children had become

less internalizing from 11 months to 3 yearsAcross studies researchers have consistently

found that children with orphanage experi- postadoption. However, this resulted from a

difference in the items comprising the inter-ence have more behavior problems than chil-

dren without orphanage experience. Goldfarb nalizing scales on the CBCL version for 2- to

3-year-olds used at the earlier time and the(1943b) found that previously institutional-

ized 6- to 8-year-old children who had been CBCL version for 4- to 18-year-olds used at

the later time. Although 3 years after adoptionplaced in foster care at age 3 scored higher on

behavior problem checklists than noninstitu- the orphanage children no longer scored higher

than comparison groups on the internalizingtionalized children of the same age who had

spent their lives in foster care. The same dif- scale of the CBCL, they continued to score

higher on the same internalizing items on whichference between these groups was also found

during adolescence (Goldfarb, 1943a). Even they had scored higher at 11 months post-

adoption, that is, stares into space, strange be-children who were adopted from the relatively

benign orphanage environment studied by havior, acts too young, and speech problems.

After 3 years in Canada there was little changeTizard were described by their teachers as

having more behavior problems than their in their early internalizing behaviors.

Indications that length of institutionaliza-classmates at both 8 (Tizard, 1977) and 16

years old (Hodges & Tizard, 1989). Verhulst, tion is positively related to number of behav-

ior problems have been found by Ames (1997),Althaus, and VersluisDen Bieman (1990a,

1990b) found that 10- to 15-year-old children Beckett, Bredenkamp, Castle, Groothues,

OConnor, Rutter, and the ERA Study Teamwho had been adopted from other countries to

the Netherlands between birth and 10 years of (2002), Fisher et al. (1997), Marcovitch et al.

(1997), Verhulst et al. (1990a, 1990b), andage had more behavior problems than same-

age nonadopted children. Warford (2002).

Having experienced institutionalization inRecent studies of Romanian adoptees have

found similar results but have gone further in the first year or two of life has been associ-

ated not only with children experiencing morespecifying the problems and tracking their

changes over time. Fisher et al. (1997) found behavior problems than normative samples


12/32

K. MacLean864

but also with particular kinds of behavior lems have been found to decrease over time

(Ames, 1997, Marcovitch et al., 1997). Threeproblems. In the Canadian sample, research-

ers conducted in-depth interviews with par- years after adoption, orphanage children had

no more eating problems than did Canadian-ents regarding any behavior problems they

were experiencing with their children at or born or early-adopted children (Ames, 1997).A common behavior problem found insoon after adoption (Fisher et al., 1997). The

main areas of problematic behavior were eat- most samples of orphanage children is stereo-

typed behavior, that is, repeating the sameing, stereotyped behavior, and peer relation-

ships. Eleven months after adoption 65% of movement over and over, as in body rocking.

In the Fisher et al. (1997) sample 84% of or-orphanage children had eating problems: par-

ents reported that one-third of children re- phanage children displayed one or more ste-

reotyped behaviors whereas no Canadian-bornfused to eat solid foods and almost one-third

of children overate. The refusal to eat solid and only one early-adopted child had a stereo-

typy. Sixty-seven percent of children rocked,foods has also been reported for toddlers adopt-

ed from Bulgarian orphanages (Ripley, 1992) and 19% moved their hands stereotypically.

In the U.K. sample, 47% of the Romanianand children adopted to the United Kingdom

from Romanian orphanages (Beckett et al., children rocked when first adopted (Beckett

et al., 2002). Marcovitch et al. (1995) and2002). Fisher et al. (1997) suggested that theseproblem behaviors were directly attributable Groza and Ileana (1996) also reported stereo-

typed behaviors in their samples of Romanianto orphanage life. It is not surprising that Ro-

manian orphanage children had difficulty with children, and this behavior was previously de-

scribed by Flint (1978), Goldfarb (1945a),solid foods, given that they were fed entirely

by bottle for the first 1.52 years of life. Such and Tizard (1977). Fisher et al. (1997) sug-

gested that the stereotyped behavior of or-behavior is not unlike the refusal to eat solid

foods found among North American infants phanage children may represent the prolonga-

tion of the stereotyped behaviors found inwhen the foods are first introduced (Wasser-

man, 1987). Parents in the Canadian study re- normal infants around the time they learn to

sit, stand, or walk (Thelan, 1979, 1981). Itported that during the first 11 months after

adoption 85% of the orphanage childrens may also reflect a self-soothing strategy or an

attempt to self-stimulate in the barren orphan-eating problems had improved or were com-

pletely resolved (Fisher et al., 1997). Beckett age rooms.

In the Canadian sample, stereotyped be-et al. (2002), however, reported that 15% of

children adopted from Romania to the United havior was the most frequently reported be-

havior problem of orphanage children but itKingdom were still experiencing difficulties

eating solid foods at 6 years of age. It appears was also a behavior that improved quite rap-

idly (Fisher et al., 1997). Only 2% of orphan-this is a longstanding problem for some chil-

dren. age children had not improved at all after 11

months in Canada. In some children, however,The problem of overeating was also re-

ported in the earlier literature on institutional- vestiges of stereotyped behavior persisted:

41% of orphanage children still displayed atization (Flint, 1978; Goldfarb, 1943b; Hoks-

bergen, 1981; Lowrey, 1940; Provence & least some of this behavior 3 years after adop-

tion, although its frequency had decreased inLipton, 1962; Tizard, 1977). In the Canadian

sample, many parents of orphanage children all children (Ames, 1997). Beckett et al. (2002)

also reported a decrease in stereotypies, butreported that they continued to offer food to

children after a meal and that it was never 18% of Romanian children in their U.K. sam-

ple still rocked at 6 years of age. The degreerefused. Given orphanage childrens malnutri-

tion and small size, such overeating probably of improvement was negatively correlated with

length of institutionalization (Fisher et al., 1997;represents their bodies natural catch-up mech-

anism. Children in orphanage had never eaten Beckett et al., 2002).

Investigators have also examined the ques-enough food to allow them to learn feelings

of satiety (Fisher et al., 1997). Eating prob- tion of whether orphanage children experi-


13/32


ence more problems with peers than compari- from orphanage to foster care at age 3. Chu-

gani et al. (2001) found that ten 7- to 11-year-son groups of children. Based on parents

reports when their children had been in Can- old children adopted from Romanian orphan-

ages scored on standardized tests in the mildlyada for 11 months, Fisher et al. (1997) found

that 32% of orphanage children had problems impaired range on attention and in the se-verely impaired range on impulsivity.with peers. The most common problems in-

volved either avoiding contact with peers or At 3 years postadoption, orphanage children

in the Canadian sample scored higher thanbeing overwhelmed by peers attention, neither

of which was reported for either Canadian- comparison group children on the Attention

Problems subscale of the CBCL (Ames, 1997).born or early-adopted children. Based on both

parents and teachers reports at 3 years after They were also reported by their parents ac-

cording to the Parenting Stress Index (Abidin,adoption, orphanage children continued to dis-

play more social behavior problems than the 1990) to be more distractible but not more hy-

peractive on the Distractibility/HyperactivityCanadian-born children (Ames, 1997). Early-

adopted childrens scores were intermediate subscale than comparison group children at

11 months after adoption (Mainemer, Gilman,between the other two groups. By the time the

orphanage children had been in Canada for 8 & Ames, 1998) and more distractible and hy-

peractive than comparison children 3 years af-or more years, their peer relationships had im-proved (Warford, 2002). Orphanage children ter adoption (Ames, 1997). Further support

for these findings comes from the U.K. study,were not different from early-adopted or Ca-

nadian-born children on acceptance ratings from in which Kreppner, OConnor, and Rutter

(2001) found that at both 4 and 6 years oftheir school peers or on their parents ratings

of the number of good friends they had or the age the children who had been adopted from

Romania after 6 months of age were rated byease with which they made new friends. Their

feelings of social competence and loneliness both teachers and parents on the Revised Rut-

ter Parent and Teacher scales (Hogg, Rut-were also similar to those of the two compari-

son groups. On the other hand, orphanage ter, & Richman, 1997) as displaying higher

inattention/overactivity than did Romanianchildren felt less social support from their

peer group or a close friend than did children children or U.K. children who were adopted

before 6 months of age.in the other groups. The longer children had

spent in institution, the less peer support they The Canadian adoptees from Romania con-

tinued to display more attention problems 8 orfelt.

Another problem area concerns attentional more years after adoption (Le Mare & Audet,

2002): orphanage children scored higher thandifficulties, which have been reported in chil-

dren who reside in institutions and in most both Canadian-born and early-adopted children

on the Attention subscale of the CBCL andstudies of previously institutionalized children.

Vorria, Rutter, Pickles, Wolkind, and Hobs- on the Impulsivity and Inhibitory Control sub-

scales of the Childrens Behavior Question-baum (1998) found that, compared to same-

aged peers living at home, 9- to 11-year-old naire (Ahadi, Rothbart, & Ye, 1993) and lower

on the questionnaires Attention Focusing sub-children living in a Greek orphanage were more

inattentive and more often engaged in nonpro- scale. These findings were consistent across

both parent and teacher reports. Supportingductive activities in the classroom. Parents of

previously institutionalized Romanian children these data was the additional finding that 29%

of children in the orphanage group had re-who ranged in age from 7 months to 11 years

(median age = 3 years) reported high activity ceived a clinical diagnosis of attention-deficit

disorder (ADD) or attention-deficit/hyperac-levels, inability to attend, and distractibility as

ongoing problems in their children (Marco- tivity disorder (ADHD) whereas none of the

comparison group children had received suchvitch et al., 1995). These findings are consis-

tent with the earlier work of Goldfarb (1945b) a diagnosis (Le Mare & Audet, 2002).

Across studies, attentional difficulties havewho reported distractibility and a lack of con-

centration among adolescents who had moved been consistently related to the length of time


14/32

K. MacLean866

that children had spent in orphanage (Krepp- phanage. What causes some children to have

persistent rather than transient problems inner et al., 2001; Le Mare & Audet, 2002;

Marcovitch et al. 1997). In addition, Le Mare these areas is still unknown.

Peer problems are also believed to ariseand Audet (2002) found that childrens atten-

tional difficulties at 8 years of age were nega- from the characteristics of the orphanage en-vironment. Young children in Romanian or-tively correlated with their HOME environ-

ment scores (Caldwell & Bradley, 1984) at 3 phanages are generally quiet and unrespon-

sive to each other, so after adoption they areyears postadoption. The more nurturing and

stimulating the home environment, the fewer wary of and withdraw from family-reared chil-

dren who are noisier, more active, and moreattentional difficulties children experienced

later. It was not only institutionalization but unpredictable than their peers in the orphan-

age (Fisher et al., 1997). This unwillingnessalso the postadoption environment that aided

in the prediction of attention difficulties. to interact with peers further prevents them

from learning normal patterns of social inter-In accordance with early studies, the more

recent studies of Romanian adoptees have action. When they do become comfortable

enough to interact with peers in their new en-shown that children reared in institutions have

more behavior problems than family-reared vironment, they externalize (act out) in un-

acceptable ways that do not endear them tochildren, that the number of behavior prob-lems is related to the length of institutional- those peers. Several years after adoption, they

have improved on most indices of behaviorization, and that some behavior problems last

up to 8 or more years after removal from the with peers but still have externalizing prob-

lems and feel less social support from peers orinstitution. Fisher et al. (1997) have pointed

out that most of the characteristic early prob- a close friend than family-reared children do.

Even problems in attending may be at leastlems of children adopted from orphanages

might indicate brain damage or emotionally partly explained by the abrupt move from the

very low levels of stimulation in the orphan-produced pathology if they were found in

children reared in families. In orphanage chil- age to the overwhelming sensory stimulation

of an adoptive home without any opportunitydren, however, they seem more correctly

characterized as behavioral adaptations to or- to gradually learn how to deal with greater

sensory complexity. Attention problems mayphanage life. Children who have had inade-

quate nutrition in orphanage initially overeat go unnoticed when children are very young,

but by preschool age they are apparent, anduntil they reach the proper weight. Children

who have been fed entirely by bottle for the are often accompanied by hyperactivity. In

school years these problems may interferefirst 2 years of life resist solid food when it is

introduced for the first time. Young orphan- with academic performance, and even lead to

diagnoses of ADD or ADHD.age children show the same stereotyped be-

haviors as family-reared children just starting

to sit, stand, or walk (Thelen, 1979), but whenIndiscriminate Friendliness

restriction to a crib for 1820 hr/day does

not permit them to develop their motor skills Another behavior problem that is particular-

ly enduring in previously institutionalized(Ames, 1997), these early stereotyped behav-

iors are practiced for a prolonged period. In children is indiscriminate friendliness. Tizard

(1977) characterized indiscriminate friendli-the general absence of sensory stimulation

and soothing by adults, for example, by rock- ness as behavior that is affectionate and

friendly toward all adults (including strang-ing, children may learn to provide their own

stimulation or soothing by making stereo- ers) without the fear or caution that is typical

in young children. In these cases the chil-typed movements. Both eating problems and

stereotyped movements decrease with time drens behavior toward a stranger cannot be

discriminated from their behavior toward theirafter adoption, but in each case there remains

a small proportion of children who still have primary caregivers. It appears as though any

adult is sufficient for the child as long as thethe problem several years after leaving the or-


15/32


childs needs are met (Provence & Lipton, Further support for the suggestion that in-

discriminate friendliness is a characteristic be-1962). References to indiscriminately friendly

behavior were evident in the early literature havior of orphanage children comes from the

work of OConnor and his colleagues in theon the social development of institutionalized

children who were later fostered or adopted. United Kingdom (OConnor, Bredenkamp, Rut-ter, & the ERA Study Team, 1999; OConnor,Provence and Lipton (1962) followed the

progress of 14 previously institutionalized Rutter, & the ERA Study Team, 2000). Using

a scale of disinhibited attachment distur-children who had been placed in foster care

between 18 and 24 months of age. They re- bance, which contained three items similar

to those used by Chisholm (1998; Chisholmported that these children were indiscrimi-

nately friendly to all adults. Tizard followed et al., 1995), OConnor et al. (1999) found

that approximately 20% of Romanian children24 children who had spent their first 2 years

in orphanage and were subsequently either adopted between 6 and 24 months of age had

high scores on the scale compared to approxi-adopted or restored to their biological parents.

Based on parents reports these children dis- mately 10% of Romanian children adopted

before 6 months of age and 2% of a group ofplayed indiscriminate friendliness to adults at

4 (Tizard & Rees, 1975) and 8 years of age children adopted within the United Kingdom.

OConnor et al. (2000a) found that high scores(Tizard & Hodges, 1978), demonstrating theenduring nature of this behavior. A few adopt- were obtained by more 6-year-old Romanian

children who had spent between 6 and 42ees were still indiscriminately friendly with

adults at 16 years of age (Hodges & Tizard, months in orphanage than by 6-year-olds who

had been adopted from either Romania or the1989). Goldfarb (1955) found that indiscrimi-

nate friendliness was still present in adoles- United Kingdom before 6 months of age.

Several studies have examined indiscrimi-cents who had been institutionalized as chil-

dren but who were later fostered to unstable nate friendliness over time. In the Canadian

sample, orphanage children were just as indis-foster care placements.

More recently, researchers have attempted criminate 3 years after adoption as they had

been 11 months after adoption, and 90% ofto develop measures of indiscriminate friend-

liness. Chisholm (1998; Chisholm et al., 1995) parents reported no improvement in this be-

havior over that period of time (Chisholm,developed a 5-item measure of indiscriminate

friendliness. Parents were asked five questions 1998). In contrast, displays of indiscriminate

friendliness had decreased over the same timeassessing (a) whether their child wandered

without distress, (b) whether their child was period in the early-adopted Romanian chil-

dren. In a follow-up study of the Canadianwilling to go home with a stranger, (c) how

friendly their child was with new adults, (d) sample more than 8 years after adoption, Fer-

nyhough and colleagues (2002) found a posi-whether their child was ever shy, and (e) what

their child typically did upon meeting new tive correlation between orphanage childrens

indiscriminate friendliness scores 3 years post-adults. Orphanage children in the Canadian

study displayed significantly more indiscrimi- adoption and more than 8 years postadoption.

There were no differences in childrens scoresnate friendliness than both early-adopted and

Canadian-born children at both 11 months at these two points in time. OConnor and

his colleagues reported a positive correlationand 3 years after adoption (Chisholm, 1998).

Providing corroborative evidence for this find- between disinhibited attachment disturbance

scores at 4 and 6 years of age for Romanianing, 71% of parents in the orphanage group

described their children as overly friendly. adoptees to the United Kingdom (OConnor,

Rutter, & the ERA Study Team, 2000). Sixty-Eight years after adoption, orphanage children

continued to display significantly more indis- two percent of children showed no category

change (none, mild, or marked) in thesecriminately friendly behavior than the Cana-

dian-born or early-adopted groups of children, behaviors from 4 to 6 years of age.

Unlike the findings for intellectual devel-who did not differ from each other (Ferny-

hough, Audet, & Le Mare, 2002). opment and for other behavior problems, there


16/32

K. MacLean868

is disagreement among studies as to whether childrens scores on indiscriminate friendliness

at 3 years after adoption were positively cor-there is a relationship between the length of

time that children have spent in orphanages related with their attention problem scores more

than 8 years after adoption. Consistent with(or their age at adoption) and the amount of

indiscriminate friendliness they display. OCon- the Canadian findings, in the U.K. samplechildrens scores on disinhibited attachmentnor and his colleagues found modest correla-

tions at both 4 years (OConnor, et al., 1999) disturbance were positively correlated with

their scores on hyperactivity and disruptiveand 6 years of age (OConnor, Rutter, et al.,

2000) between duration of deprivation (age at behavior measures at age 4 (OConnor et al.,

1999) and hyperactivity, disruptive behavior,adoption) and childrens scores on disinhib-

ited attachment behaviors in the U.K. group. and emotional difficulties measures at 6 years

of age (OConnor, Rutter, et al., 2000).They pointed out, however, that some chil-

dren who were adopted after 2 years in Roma- In contrast to behavior problems, IQ does

not appear to be strongly related to indiscrimi-nia showed no signs of disinhibited attach-

ment behaviors and other children who were nate friendliness. In the Canadian sample,

Chisholm (1998) found no association betweenadopted within the first 6 months of life showed

signs of the behavior (OConnor, Rutter, et childrens IQ scores at 3 years postadoption

and their displays of indiscriminate friendli-al., 2000). Chisholm et al. (Chisholm, 1998;Chisholm et al., 1995), Fernyhough et al. ness. Consistent with Chisholms finding,

OConnor et al. (1999) found no correlation(2002), and Tizard et al. (Tizard & Hodges,

1978; Tizard & Rees, 1975) all found no rela- between childrens IQ scores and disinhibited

attachment disturbance when the children intionship between length of institutionalization

and indiscriminate friendliness. the U.K. sample were 4 years old. In their fol-

low-up study when children were 6 years ofIn an attempt to better understand indis-

criminate friendliness, researchers have exam- age, OConnor, Rutter, et al. (2000) reported

a significant correlation between disinhibitedined particular correlates that may be associ-

ated with this behavior, focusing on aspects attachment disturbance and IQ; but this rela-

tionship was no longer significant when theof the institutional environment, child charac-

teristics, and family characteristics. In the Ca- analysis was controlled for age at adoption,

suggesting that both IQ scores and disinhib-nadian sample Chisholm (1998) found that

high scores on indiscriminate friendliness 3 ited attachment behavior were the result of

duration of deprivation.years postadoption were positively correlated

with the child having been a favorite in the Researchers do not yet have a clear under-

standing of indiscriminate friendliness. Unlikeinstitution. Other measures of the quality of

institutions, for example, quality of physical many of the initial behaviors of concern in

institutionalized children, displays of indis-care, whether toys were available (Chisholm

et al. 1998), or childrens weight or develop- criminate friendliness do not appear to dissi-

pate over time but are still in evidence up to 8mental delay at adoption (OConnor et al.,

1999; OConnor, Rutter, et al., 2000) were years after leaving the orphanage environment

(Fernyhough et al., 2002; OConnor, Rutter,unrelated to childrens indiscriminate friendli-

ness. et al., 2000) and may persist even longer

(Goldfarb, 1955). Chisholm (1998) has sug-Particular characteristics of the child after

adoption have also been examined as correlates gested that indiscriminate friendliness may

serve an adaptive function in the context ofof indiscriminate friendliness. Researchers have

consistently found associations between or- the orphanage environment where emotional

resources are extremely limited. Amid thephanage childrens indiscriminate friendliness

and their behavior problems. Chisholm (1998) passivity of the orphanage an indiscriminately

friendly child may receive what little attentionfound that at 3 years postadoption, childrens

indiscriminate friendliness scores were posi- caregivers have to offer. The fact that indis-

criminate friendliness was associated with hav-tively correlated with their scores on the

CBCL. Le Mare and Audet (2002) found that ing been a favorite in the orphanage supports


17/32


this contention but does not explain what were items that most clearly capture secure

base behavior. Similarly, OConnor et al. (2003)function such behavior serves after adoption.

It may be behavior that is reinforced by both reported that children in their sample who

scored high on their Disinhibited Attachmentparents and strangers. Chisholm et al. (1995)

reported that at 11 months postadoption, par- Disturbance scale were overwhelmingly clas-sified as Insecure/Other in terms of their at-ents were pleased that their child appeared to

be fond of everyone. According to parents tachment patterns. Two of the three items on

OConnors scale (readiness to go off with areports newly adopted orphanage children were

often approached, talked to, and hugged by stranger, failure to check back with parent in

new anxiety provoking situations) appear tototal strangers, so it is not difficult to imagine

that they felt that such behavior was appro- measure the same behaviors as Chisholms

two extreme items. Although orphanage chil-priate.

Given that indiscriminate friendliness in dren in the Canadian sample scored higher

than comparison groups on each of the fiveorphanage children has been consistently as-

sociated with attentional difficulties like dis- items on the indiscriminate friendliness mea-

sure, the other three items on the scale (i.e.,tractibility, lack of focus, impulsivity, and

lack of inhibitory control, to some extent it being friendly with new adults, never having

been shy, and eagerly approaching new adults)may reflect the expression of those difficultiesas applied to interactions with strangers. On were not associated with childrens insecure

attachment patterns and may measure simplethe other hand, Chisholm et al. (1995) sug-

gested that indiscriminately friendly behavior uninhibited friendliness rather than involve-

ment of the attachment system.is not unlike the indiscriminate behavior seen

in infants prior to the formation of an attach- Both Chisholm (1998) and OConnor et al.

(2003) found some securely attached childrenment relationship and thus may reflect a de-

lay in the attachment system. OConnor et al. who are indiscriminately friendly, and Mar-

covitch et al. (1997) reported that some se-(1999) also suggested that indiscriminate friend-

liness may represent a form of developmental curely attached children were observed to be ex-

tremely friendly to the stranger in the Strangedelay in the attachment behavioral system, al-

though their use of the term disinhibited at- Situation. It seems unlikely, therefore, that in-

discriminate friendliness necessarily indicatestachment disturbance seems to suggest atten-

tion problems as well as involvement of the an attachment disorder (Chisholm, 1998).

In summary, research has shown that indis-attachment system.

Indiscriminate friendliness is particularly criminate friendliness is a common character-

istic of previously institutionalized children,relevant to the study of attachment, given sug-

gestions that this behavior may be indicative which persists years after removal from or-

phanage. In contrast to the negative relation-of nonattachment (Lieberman & Pawl, 1988)

or the disinhibited/indiscriminate subtype of ships found between length of institutionaliza-

tion and orphanage childrens height, IQ,reactive attachment disorder (Zeanah, 1996,

2000). Both Lieberman and Pawl (1988) and academic achievement, and behavior problems,

the relation of length of institutionalization toZeanah (2000) described these disorders as re-

sulting from an infant not having had the op- indiscriminate friendliness has been found across

studies to be weak or nonexistent.portunity to form an attachment relationship.

This is precisely the situation of children reared Indiscriminate friendliness has little or no

relation to IQ, but it is positively correlatedin orphanage environments, so researchers have

focused on linking this behavior to childrens with behavior problems, especially problems

of attention. To some extent, therefore, it mayattachment. Chisholm (1998) found that the

two most extreme items on her measure of reflect distractibility and impulsivity as ap-

plied to interactions with strange adults. Itindiscriminate friendliness (i.e., being willing

to go home with a stranger and wandering also has been theorized to represent a failure

or developmental delay in attachment. Thewithout distress) were associated with inse-

cure attachment in the Canadian sample. These finding that only those indiscriminate friendli-


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K. MacLean870

ness measurement items reflecting lack of se- vided one-on-one attention to children. Tizard

and Rees (1975) described 4-year-old childrenscure base behavior, and not those reflecting

eager approach and engagement with new behavior toward their caregivers as very clingy

but claimed that the children did not careadults, are related to insecure attachment sug-

gests a possible differentiation of two compo- deeply about anyone. By the time the childrenwere 8 years old there were only 7 institutionnents of indiscriminate friendliness: uninhib-

ited friendliness toward all adults and lack of children left to study and only a minority of

them were suspected to have formed any at-the secure base behavior characteristic of at-

tachment. How distinguishable these two com- tachment to their institutional caregiver. This

work provides the only direct evidence thatponents are in terms of their antecedents and

consequences remains to be explored further. institutionalized children would have been un-

likely to have the opportunity to form an at-

tachment with their caregivers.Attachment

Chisholm (1998) suggested that there are

reasons to suppose why developing an attach-Researchers have focused enormous energy

on attempting to evaluate the impact of insti- ment relationship may be more difficult for

previously institutionalized children. Accord-tutionalization on the ability of children to

form attachment relationships. Given that at- ing to attachment theory, a childs attachmentbehavior becomes organized toward a partic-tachment usually develops some time during

the second half of the first year of life (Bowl- ular caregiver sometime between 6 and 12

months of age (Bowlby, 1969/1982). An ade-by, 1969/1982) children who have been housed

in institutions during the first year or 2 of life quate caregiver readily responds to an infants

needs for close contact and understands an in-necessarily develop an attachment relation-

ship with adoptive parents later than is typi- fants distress if separated from the caregiver.

When a child is beyond 2 years of age, care-cal. Although little evidence exists on this

point, most researchers have assumed that the givers may be less responsive to the childs

needs for close contact and may expect himchildren would have been unlikely to have de-

veloped an attachment relationship with care- or her to display more autonomy. The childs

need for contact may be viewed as clingygivers within the institution, given the very

high child to caregiver ratios within institu- rather than cuddly behavior, and a parent

may not be as patient with such behavior.tions (Chisholm, 1998). In Romanian orphan-

ages the child to caregiver ratios ranged from Given that attachment theory suggests that

sensitive responsiveness predicts the quality10 to 1 for children under 2 years of age to as

high as 20 to 1 for children over 3 years of of the attachment relationship (Ainsworth,

Blehar, Waters, & Wall, 1978; DeWolff &age. It is unlikely that caregivers in such a

context would have had time to spend in sen- van IJzendoorn, 1997), if a caregiver is less

responsive, developing an attachment rela-sitive responsive care with particular children

(Chisholm, 1998). tionship later may be more difficult. Chisholm

et al. (1995) also reported that children fromTizard has been the only researcher who

examined childrens behavior toward their institutions did not initially display proximity-

promoting behaviors like smiling, crying, andcaregivers within the institution context. Tiz-

ard and Tizard (1971) found that when com- making eye contact, behaviors that often pro-

mote contact with caregivers. Parents in theparing children in institution to family-reared

2-year-olds, a list of preferred persons could Canadian sample reported that when they first

met their children fewer than half of the chil-easily be constructed for family-reared chil-

dren whereas lists of preferred persons for dren would smile back at someone who smiled

at them. Based on parents reports at 11 monthschildren from institutions included anyone

that children knew well. The only favorite postadoption, 14% of children did not show

signs of experiencing pain and 31% of chil-people in childrens lives were people they

saw rarely (i.e., a parent who visited), but dren would not signal parents upon waking

(Chisholm et al., 1995). The absence of suchsuch persons were the only ones who pro-


19/32


behavior may also make it difficult for parents ports whether children had truly been unable

to form an initial attachment with caregiversto know when and how to respond appropri-

ately to their children. A third reason why de- in the institution. Tizard and Rees (1975) re-

ported that even though the institutions main-veloping an attachment may be difficult is be-

cause of the neglect children experienced in tained a policy that discouraged caregivers fromforming relationships with particular children,the institution. As a result they may have de-

veloped expectations of others as untrustwor- there were some indications that children did

have preferences among their regular caregiv-thy, and this might promote difficult or passive

interaction styles that would have a negative ers. Perhaps most important, there was a radi-

cal difference between the two studies in termsimpact on a parents ability to be sensitively

responsive. of the stability of placement for the children

postinstitutionalization. Children in GoldfarbsFindings in the early literature were incon-

sistent regarding whether institutionalized study very often went to unstable foster care

placements. By the time children were be-children were capable of forming an attach-

ment with their adoptive parents. Goldfarb tween 10 and 14 years of age they had experi-

enced care in three or four different foster(1943a) found that the majority of 10- to 14-

year-olds who had been in orphanage for the homes (Goldfarb, 1943a). It is likely that hav-

ing experienced a series of broken attachmentfirst 3 years of life and were later removed tofoster homes were described as withdrawn and relationships contributed to childrens emo-

tional coldness. Children in Tizards sample,removed with both family members and their

caseworkers, and appeared unperturbed by ei- however, went to stable adoptive homes, evi-

denced by the report that only 14% of adop-ther threats of removal from the home or

changes in foster care placements (Goldfarb, tive placements had broken down by the time

children were 16 years old (Hodges & Tizard,1945b). None of the comparison children who

had spent their lives in foster care were de- 1989).

More recently, researchers have examinedscribed in this way. Goldfarb concluded that

orphanage children were unable to develop at- attachment in previously institutionalized chil-

dren using standard separation reunion proce-tachment relationships with their foster par-

ents and that the effects of institutionalization dures and relying on validated attachment

coding systems (Chisholm, 1998; Marcovitchwere permanent. In contrast to Goldfarbs work,

Tizard (1977) concluded that children could et al., 1997; OConnor et al., 2003). In each

of these studies researchers used a separationbecome attached to parents after leaving an

institution. In her sample, 20 of 25 children reunion procedure with preschool-aged chil-

dren in which children first interacted withwere reported to have formed an attachment

relationship with their adoptive parents within their mothers in play, stayed in the same room

with a stranger while their mother left, anda year of leaving the institution and a majority

of parents reported that their child was deeply then were reunited with their mothers. This

procedure was carried out in childrens homesattached to them.

Ames and Chisholm (2001) have suggested by both Chisholm (1998) and OConnor et al.

(2003), but Marcovitch et al. (1997) carriedseveral reasons for these inconsistent findings.

First, the conditions in the orphanages studied out the procedure in a hospital laboratory. In

all studies childrens behavior during this pro-by Goldfarb were much worse than the condi-

tions in the Tizard study. Children in Gold- cedure was videotaped and then coded by

trained coders for quality of attachment. Chis-farbs sample were delayed in every area of

development. In contrast, children in Tizards holm (1998) used Crittendens (1992a) Pre-

school Assessment of Attachment (PAA) tosample were chosen for good health and had

average IQs when they left the institution code preschool attachment patterns, whereas

both Marcovitch et al. (1997) and OConnor(Tizard, Cooperman, Joseph, & Tizard, 1972).

These factors would bode well for the forma- et al. (2003) used the Cassidy, Marvin, and

MacArthur Working Group (1992) Preschooltion of an attachment relationship with par-

ents. Second, it is unclear from Tizards re- Attachment System. Both of these coding sys-


20/32

K. MacLean872

tems have reported validity (Solomon & Dijkstra, & Bus, 1995). In addition, in all

three studies (Chisholm, 1998; Marcovitch etGeorge, 1999).

Marcovitch et al. (1997) examined attach- al., 1997; OConnor et al., 2003), fully one

third of children were classified as securelyment in a sample of 4-year-old Romanian

children adopted to Canada who had spent 6 attached. This clearly argues against the Gold-farb contention that children from institutionsmonths or more in an institution (institution

group) and compared them to Romanian chil- are unable to form an attachment relationship

with their adoptive parents.dren who had spent less than 6 months in in-

stitution (home group). A second comparison On the other hand, it is clearly the case

that across studies the percentage of securelygroup comprised healthy 4-year-old Canadian

children. OConnor et al.s (2003) sample attached children in any previously institu-

tionalized sample was lower than the percent-comprised two groups of 4-year-old children

adopted from Romania, one group adopted age of secure children in any comparison

sample (Chisholm, 1998; Marcovitch et al.,before 6 months of age and the other adopted

between 6 and 24 months of age. Most, but 1997; OConnor et al., 2003). The one excep-

tion to this general conclusion is that no dif-not all, of these children had been adopted

from orphanages. The comparison sample com- ferences were found in the Marcovitch study

between their institution and home groups.prised U.K. born children who were adoptedbefore 6 months of age. Chisholm examined Ames and Chisholm (2001) have suggested

that failure to find a clear difference betweenattachment in 30 orphanage children aged 54

months and 13 orphanage children who ranged these groups may be due either to the small

number of children in the sample who hadin age from 65 to 110 months. Each of these

children had spent between 8 and 53 months more than 6 months of institutionalization or

to the mixed backgrounds of the home sam-in orphanage. These children were individu-

ally matched on age and sex to children in ple. The only criterion for inclusion in the

home group was that children had spent lessthe early-adopted (

the impact of institutionalization on child development (obligatorio).pdf

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