The Effects of Institutionalization on Children
Institutionalization of orphaned and unwanted children has been a long-standing Western tradition, and only in the last century has society begun to realize the damning ramifications of the practice on children. This form of care still remains common in a few former Soviet countries, tragically condemning children to a life of stunted development. This article, then, will tackle the effects of institutionalization of children in former Soviet countries in particular, starting first with the history of institutionalization practices the typical institutionalization experience is like in former Soviet orphanages, and then its profound effects on physical well-being, intelligence, and socio-emotional development.
The State of Orphanages in Eastern Europe
Historically, orphanages in Western cultures have followed the “medical model” approach to childcare—namely, that good caretaking consists of meeting a child’s basic physical needs, with little emphasis on caregiver affection and the attachment needs of children. Most developed Western countries moved away from this model in the 1950s, after the pioneering work of John Bowlby’s attachment theory and Harry Harlow’s work with monkeys showed that healthy attachment is essential for normal development. However, both institutionalization and the medical model approach remains prevalent in former Soviet countries, with several hundred Russian orphans still living in orphanages. Infants in these orphanages are fastidiously kept for, well-groomed and well-fed, but human interaction is minimal. Infant-to-staff range anywhere from 8:1 to 35:1, meaning that infants receive only a bare minimum of human interaction. Frequently, they are frequently left in cribs for a good majority of the day and only receive interaction with staff when their basic needs, like feeding and bathing, are met at predetermined times, and the rest of the time, they must lie in their own feces and urine. Staff members rarely hold or cuddle infants, and they routinely ignore crying, both due to policy and due to the sheer number of other children they must attend to. With so many children to manage, individual needs are ignored, prompting a report by Case Western Reserve University to call the orphanages “warehouses."
The actual orphanage environment is no more stimulating. Groza, Ileana and Irwin described typical orphanages as “colorless, shockingly quiet and devoid of any of the usual visual or auditory stimulation,” and recalled one orphanage in which the 4-year-old children there had never once left the room assigned to them. Many orphanages lack proper schools and provide no educational or entertainment material for the children to peruse, meaning they must provide their own stimulation. Punished for being “hyperactive,” many children end up simply doing nothing at all. The sight of children staring blankly into space for lack of anything better to do is tragically common.
The Physical Effects of Institutionalization
The physical effects of such a deprived environment have been long noted. The noted nineteenth-century pediatrician Henry Dwight Chapin, for instance, discovered that there is a significantly higher infant mortality rate in institutions, even when infants were otherwise healthy, and this mortality rate was so high in 19th century orphanages that the term “hospitalism” was coined to describe the common plight of orphaned babies. At one Romanian orphanage, most children were below the 20th percentile for height and weight, rendering them more vulnerable to disease. Officials there estimated that mortality rates in the winter could be as high as 40%, and on any given year, about half of the children died within the first 24 months after arriving at the orphanage. Children who do manage to survive typically suffer stunted growth, generally at a rate of one month’s delay for every three months spent in an orphanage. Growth stunting for some children is so severe that they can be diagnosed with “psychological dwarfism,” a phenomenon in which emotional or abuse disrupts the secretion of growth hormones and stunts normal growth. It is not unheard of for such children to grow three to four inches in just a six-month time span after being adopted. While most health problems resolve within a year of adoption, children nonetheless remain smaller than their non-adopted peers throughout childhood. The longer the orphanage stay, the shorter the child tends to be for their age.
Complementing this physical stunting are motor skill development problems, like possessing low muscle tone and not demonstrating age-appropriate motor skills. One study found gross motor delays and fine motor delays in 70% and 82% of Russian children, respectively. Like the other physical effects mentioned above, these motor skill problems resolve themselves in more stimulating environments.
The Socio-Emotional Effects of Institutionalization
Of course, the effects of institutionalization do not limit themselves to merely physical development. Indeed, the greatest legacy that institutionalization leaves is on children’s socio-emotional development. Perhaps the most well-documented effect is on attachment. John Bowlby noted that all children need a stable, responsible caregiver to attach to; without one, a child is set up to have difficulty with relationships later in life. By definition of being institutionalized, however, children in orphanages do not have a caregiver to attach to, as staff members work on shifts, may switch jobs, and have other children to care for—there is no one dedicated long-term to an individual child.
Generally, children who are institutionalized after the age of two and have had quality care during their infancy are not terribly affected by this indifference, but children who enter institutions before the age of one tend to do quite poorly. These children realize early on that no one particularly cares about them. Infants in nurseries are eerily silent, a direct result of learning early on that their vocalized distress will never be rewarded with attention. They frequently fail to attach to anyone, and, unused to physical contact, are highly sensory and tactively defensive and recoil from human contact if it is given. Unlike normal children, they become even more upset when someone tries to console them and prefer to “cry it out” by themselves, as that is how they are accustomed to doing.
Infants who present ambivalent and avoidant attachment to caretakers often go on to present characteristic disordered attachment styles later in life. The most common relational style seen in institutions is known as “indiscriminative friendliness.” Starved for affection and used to an ever-changing rotation of caretakers, these children seek affection inappropriately from everyone and anyone, including complete strangers. However, other children completely give up on soliciting affection from unresponsive caregivers and cease to be social altogether, instead developing what is known as “institutional autism.” Although not actually autistic, these children develop stereotypically autistic behaviors, like rocking, head-banging, stereotyped behaviors, and bizarre rituals, seemingly as a way of providing some stimulation in their own, otherwise sensually barren lives. Unlike autistic children, they stop this sensory-seeking upon placement in a more enriched environment.
These disturbed attachment styles, unfortunately, frequently persist after adoption. A full third of adopted Romanian children demonstrated avoidant attachment to caregivers, and an even higher percentage had only ambivalent attachment. Often, the most indiscriminately friendly children violently unravel in a post-institutional environment and become aggressive and controlling, deregulated by the lack of structure and the constant showering of warmth and affection they were denied for so long. Many attachment disordered children do eventually recover, but a significant minority of cases is eventually diagnosed with reactive attachment disorder. The prognosis for reactive attachment disorder is generally fairly poor, especially for older children. After a certain critical point of development, it seems, children simply cannot develop the capacity for normal, warm human relationships.
Related to the problem of attachment is social skills development. According to John Bowlby, if children are institutionalized for too long, the child will lose the ability to interact with other humans in a normal way. In one study of Romanian children, it was reported that while most parents were concerned that their children were too withdrawn and avoidant within the first year after adoption, after a few years, children’s greatest social problems were externalized. Parents frequently complained of aggressive, manipulative behavior and difficulty getting along with peers. The longer children had lived in an orphanage, the greater parents reported their difficulties to be, and the worse the impairment in intelligence, the worse the child’s social skills tended to be. Another study on Romanian children found that an astounding 55% of preschool-aged children were unable to demonstrate developmentally appropriate social skills like meaningful eye contact. Some children are so profoundly deficient in social skills that they arguably lack any sort of conscience or feelings for others at all and instead present symptoms of sociopathy.
The Effects of Institutionalization on Intelligence
Yet another well-documented, deleterious socio-emotional effect of institutionalization is intellectual disability. By school-age, a majority of Russian children living in orphanages are diagnosed with “oligophrenia,” a vague descriptor in Russia for “general mental deficiency," and a study of internationally adopted children showed that upwards to 50%-90% of preschool-aged children had developmental delays upon arriving in their new country. Many children had multiple delays, usually in motor and language skills. Similarly, in another study of Romanian children, every single child in the study was developmentally delayed upon arriving in Canada and frequently tested into the borderline mentally retarded range. The more time a child spends in an orphanage, the more profound the intellectual impairment; for every year that a child spends in an institution, his cognitive development will be delayed by about six months.
Some of this damage is observable at the biological level. Total brain volume is significantly negatively correlated with time spent in an institution. The hippocampus in particular shows markedly decreased volume, which research has demonstrated is due to overproduction of cortisol, a hormone released in stressful situations. Repeated release of cortisol in stressful situations, like that of neglect in orphanages, destroys the hippocampus, which is central in learning and memory. Damage is not limited to the hippocampus, however; FMRIs of formerly institutionalized children have revealed that the prefrontal cortex tends to be both immature and reduced in volume, which leads to problems with impulse control and decision making. Accordingly, then, children do particularly poorly on tests measuring visual memory and attention, learning visual information, and impulse control.
Fortunately, most children usually make rapid gains in intellectual development upon removal from the institution environment. However, the legacy of institutionalization often lingers, as the precipitous drop in intelligence institutionalized children experience is not entirely reversible even after being placed in an optimal adoptive family environment. Three years after adoption, children in one study had only very modest gains in intelligence, and most scored in the low average IQ range. The longer a given child lives in an institution, the worse his intelligence tends to be, especially if the child has lived there since infancy.
Linguistic Development in Institutionalized Children
With no one talking to them, it hardly comes as a surprise that linguistic development is severely retarded by institutionalization, too. Language delays, in fact, are the most commonly diagnosed problem in post-institutionalized children. Children learn from interacting, not from passively hearing others, but this is exactly the opposite of what institutionalized children doing. Glennen discovered in an observation of a Russian orphanage that when language was spoken in the presence of children, it was usually between caregivers, and on the seldom occasion a child was spoken to, it was typically in the form of simple commands. Most activities, like meals, were conducted in almost complete silence. Accordingly, with no opportunity for actual practice, about 60% of 2 1/2 institutionalized children in one study had no expressive language whatsoever, and at age 3 1/2, only an astounding 14% were capable of speaking two-word sentences. Nonverbal communication skills are often no better; children’s skills tend to be either minimal or negative in nature, like hitting. Deficient language development is one of the hardest effects of institutionalization to undo; after certain critical linguistic periods are missed, no amount of intervention will ever fully remediate a child's language deficits. A child's rate of acquisition, then, literally determines his capacity for language later in life.
The Legacy of Institutionalization on Mental Health
Finally, institutionalization leaves individuals with a significantly hiked risk of mental illness and disturbed behavior. So common is disordered development that a specific mental disorder has been suggested specifically for post-institutionalized children, known as Developmental Trauma Disorder. This disorder is hallmarked by what is known as “mixed maturity,” in which children demonstrate normal maturity in some areas, but act like a much younger child in other areas. Academic skills, depth and appropriateness of relationships, and social skills tend to be more representative of those of a younger child. Frequently, these symptoms will mimic those of ADHD and PTSD’s, with poor social skills and hyperactivity. The stress of repeated traumatic events, such as institutionalization, changes the make-up of the central nervous system in such a way that children are biologically conditioned for a heightened fear/stress response. Children are maladaptively hypervigilant as a result, and because they frequently misperceive totally innocuous events as threats, they present immature, aggressive, and socially inappropriate behavior. The inability to pay attention and the hyperactivity is directed related to the degree of neglect, and is unrelated to low birthweight, nutrition, or intellectual disability.
Unsurprisingly, the prospects for children who are not adopted from these institutions is often grim. Of the approximately 15,000 children who grow out of Russian orphanages every year, the Russian Interior Ministry University estimates only about 20% are successful post-institution—10% commit suicide, 30% end up in jail, and 40% end up homeless. The cycle of child institutionalization tends to repeat itself, with many orphanages reporting that they have children who are the third or even fourth generation to have been institutionalized.
Adoptees do better, but still struggle, as these problems follow them even after they leave the orphanage. In her landmark study on institutionalized Romanian children, for instance, Ames noted that children frequently try to apply maladaptive behavioral strategies learned while in the orphanage to their post-adoption lives. Many children, for instance, engage in behaviors like stealing, manipulating, fighting, and lying, because doing so earned them extra attention or food in orphanages. Similarly, as testament to their highly regimented, unstimulating lifestyle, children can be highly dependent on others telling them what to do, often for years after adoption. Many cannot determine for themselves when to stop eating, and one study recounts that some children will lie in bed quietly for hours until prompted to get up.
Although many of these behaviors disappear as children acclimate to a stable post-adoption life, many other behaviors persist. Even in the best of adoptive environments, adoptees suffer a rate of mental illness about 70% higher than the general population. Their difficulties are not necessarily due to poor genetics, either; adoptees from China and Korea, which eschew institutions in favor of foster care, experience mental illness at a rate three to seven times lower than adoptees from former Soviet countries, which use institutions. Indeed, 72% of parents in Ames' study of Romanian children cited their biggest concern with their children not to be anything physical or intellectual, but socio-emotional. More than a third of the children in the study needed professional help for behavioral problems several years after adoption. Children who are older at the time of adoption, who experience abuse, and who have multiple changes in caregivers were more likely to have problems. The most common problems included conduct disorder, antisocial behavior, poor relationships, and affective disorders.
Clearly, as has been demonstrated, institutionalization has a profound impact on every aspect of a child’s functioning. The gross amount of neglect, both physical and emotional, causes severe damage that is not always possible to undo, and the longer the time spent in the institution, the worse the effects. The vast majority of children never get adopted, meaning they languish in stunted emotional, cognitive, physical and social development forever. While there is hope for those who do get adopted, the effects of institution more often than not leave a damning legacy.
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