Development and Psychopathology, 15 (2003), 853–884Copyright 2003 Cambridge University PressPrinted in the United States of AmericaDOI: 10.1017.S0954579403000415

The impact of institutionalizationon child development

KIM MACLEANSt. Francis Xavier University

AbstractDuring the past 10 years researchers studying children adopted from Romanian orphanages have had the opportunityto revisit developmental questions regarding the impact of early deprivation on child development. In the presentpaper the effects of deprivation are examined by reviewing both the early and more recent literature on studies ofchildren who spent the first few years of life in institutions. Special attention is given to the Canadian study ofRomanian adoptees in which the author has been involved. Findings across time and studies are consistent inshowing the negative impact of institutionalization on all aspects of children’s development (intellectual, physical,behavioral, and social–emotional). Results of studies show, however, that institutionalization, although a risk factorfor less optimal development, does not doom a child to psychopathology. However, the impact of institutionalizationis greater when coupled with risk factors in the postinstitutional environment. Methodological and conceptualdifficulties in research with institutionalized samples of children are discussed and future directions for research areconsidered.

The attempt to understand human develop- differ from normal development. Longitudinalstudies 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 isquantitatively or qualitatively different fromwhen conditions are so severe as to impede

normal development. Findings from studies of the behavior of noninstitutionalized samplesof children.institutionalized children provide invaluable

information that can inform theory, research, Institutionalized samples also provide arare 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 thatemerges 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 ofthese behaviors has the potential to inform ourthinking with respect to the roots of pathologyin other clinical samples of children. Re-Thanks to Elinor W. Ames and Megan Gunnar for their

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

ada; E-mail: kmaclean@stfx.ca. level (physical, behavioral, social, and emo-

853

K. MacLean854

tional), but unlike many maltreated groups, alized children were first noted before thestudy of attachment began; indeed, it wasthey have experienced the intervention of

adoption into supportive home environments studies of orphanage children that helped tolead 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 ofan attachment relationship. Rather, these mea-institutionalized children. Such experiments

in nature are often considered to be real-life sures assess the quality of attachment andmake 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 children’s attachment totheir 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 preschoolage. Another problem is the need to developin real life. For example, for experimental

purposes it is possible to restrict animals’ per- new measures for concepts described but notmeasured earlier. The indiscriminate friendli-ceptual experience while keeping the rest of

their environment equivalent to that of ani- ness toward adults often shown by previouslyinstitutionalized children was first describedmals with unrestricted perceptual experience.

For institutionalized children, on the other 58 years ago (Goldfarb, 1945b), but it is onlyin 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 isno one agreed-upon measure. Although thephysical, intellectual, and emotional depriva-

tion. As a result, when institution-reared chil- lack of agreement on measurement systemscomplicates 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 thenumber 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-children’s conditions, and society’s threshold

for removing children from their homes are tion-reared children. For example, many itemson 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. Onedoes not often find a home-reared child whonational social and economic policy and the

child’s 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 whohave 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 onstandardized 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 fallinto 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 thesame 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 isa thorny one. There are many possible com-problem. Attachment problems in institution-

Institutionalization and child development 855

parison groups, but each answers a different The point to be made is that there is noperfect comparison group in nature that canquestion and fails to answer other questions.

Previously institutionalized children are both possibly answer all the important questionsthat 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 paycareful 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 alsoan advantage to this situation, however. TheTeam, 1998) employed a comparison group

of children adopted in the United Kingdom; fact that different studies have used differentmeasures 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 similarconclusions 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, thoseconclusions may be accepted with consider-ages, the researcher who wanted to compare

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

previously institutionalized children’s perfor- changes in the behavior, its relation to lengthof 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 ofadoptees from Romanian orphanages, espe-Canadian researchers (Ames, 1997) have

used two different age-matched groups to com- cially the Canadian study in which this authorhas 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 ofinstitutionalization are also referenced anddren but differs from the institutionalized group

in terms of age at adoption and (at any com- their conclusions included wherever relevantto the more modern work.mon age) length of time spent in the adoptive

home. The second comparison group in theCanadian study consists of Canadian-born

Developmental Milestones, Intellectualchildren reared in homes similar to those of

Development, and Academic Achievementthe 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.

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 developmentaloutcomes. 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 “houseguests”velopmental 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 children’s 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 ofBarbara 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 theirlives in high-quality institutions in the Unitedtion in the first years of life.

William Goldfarb (1945a, 1955) studied 15 Kingdom (Tizard, 1977). In these institutionsthe 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 children’slives 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 discouragedfrom 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 comparedthem to a sample of home-reared childrenovercome once children were placed in more

stimulating and loving environments. from a working class background. They foundthat the institution children’s IQ scores wereResearchers conducting this early work

claimed quite strongly that children were in- only slightly lower than those of the workingclass 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 IQof 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 werefound (Tizard & Rees, 1974). Hodges andstreth, 1981; Pinneau, 1955). Critics reported

that much of the early literature provided few Tizard (1989) reported that children adoptedfrom 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. Tizard’s findings were morepositive 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 Tizard’s sample had not experiencedtested, and how often assessments were car-

ried out were unspecified. Such limitations the extreme deprivation experienced by earliersamples of children (e.g., Goldfarb, 1945a).have made it difficult for current researchers

to have confidence in the early data on institu- Therefore, Tizard’s more positive findingsmay be partially explained by less severe dep-tionalized children.

Not all early studies, however, predicted rivation.Although this research challenged Spitz’ssuch dire outcomes for institutionalized chil-

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

Institutionalization and child development 857

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. Children’s Bayley scores were unrelatedwere adopted and compared the developmen-

tal outcomes of children adopted at different to their Apgar scores at birth, suggesting thatthese 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 andEarls (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 orphanagescored 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 wasprovided 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 homeand 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 previouslyinstitutionalized Romanian children after thehopeful, they are not inconsistent with the

early literature. Both sets of literature clearly profound intervention of adoption. These twoprojects, 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 afteradoption, have provided the clearest informa-velopment and that it is not only institutional-

ization but also the length of institutionaliza- tion 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 =8–53 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 = 8–68 months); 29 children whowould 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 monthsof 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 institutionalizedchildren (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 UnitedKingdom 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 notall, 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 whowere 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.

K. MacLean858

Morison and colleagues (Morison, Ames, that were related to test scores. The length oftime that children spent in the orphanage was& Chisholm, 1995; Morison & Ellwood, 2000)

examined development in the Canadian sam- positively associated with the number of areasof delay on the R-DPDQ and negatively cor-ple of Romanian orphanage children, once

based on retrospective reports from when their related with children’s scores on the adaptive,personal–social, 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 aninstitution, 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 children’s

developmental condition when they first met the Gesell scales, whereas being described asdirty 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 (personal–social, gross

motor, fine motor–adaptive, and language de- Three years postadoption these researchers(Morison & Ellwood, 2000) evaluated chil-velopment) assessed by the Revised Denver

Prescreening Developmental Questionnaire (R- dren’s intellectual development using the Stan-ford–Binet Intelligence Scale, Fourth EditionDPDQ; Frankenberg, 1986). There was not a

particular 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 scoresamong 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 groupscored 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), andthe 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(24–60 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 ofthe 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 groupresults remained consistent with the earliermental quotients in areas of gross motor,

adaptive, personal–social, and language aver- findings. Canadian-born children, whose fam-ilies were matched to the other groups on de-aged in the borderline range (68–85) 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 24months of age scored even lower (M = 89),whether there were particular correlates asso-

ciated with children’s intellectual test scores and orphanage children who had been adoptedafter 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 onthe 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 children’s institutional experience nonverbal reasoning) at both 3 years after

Institutionalization and child development 859

adoption (Morison & Ellwood, 2000) and 8 age scored at the low end of the normal rangeof intelligence (M = 90). This difference mayyears after adoption (Le Mare et al., 2001),

demonstrating that orphanage experience had be explained by considering differences ingroup 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 theirlives 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 institutionwas +.97 (Morison & Ellwood, 2001). In con-children (O’Connor, Rutter, Beckett, Keave-

ney, Kreppner, & the ERA Study Team, 2000), trast, close to 15% of the U.K. sample did notexperience 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 settingand 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 contributedto 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 Kingdomthan 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 childrenafter 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 whichconditions 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 peersliving 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 standardizedachievement test, the Canada Quick Individ-6 years (O’Connor, 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 ofage and early-adopted children (adopted be-the ERA Study Team, 1998; O’Connor, 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

children’s 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 childand 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 (O’Connor, Rutter, Beckett, et

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

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 IQswhereas 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 adoptedbefore 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; O’Connor, Rutter, Beck-

ett, et al., 2000). Undoubtedly, every child is The findings obtained with the correlationaland 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 datareveals 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 children’s IQ scores 3

years after adoption. Children’s 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, themore 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 butalso 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 orphanagechildren who in spite of their poor start arechildren’s R-DPDQ scores when their parents

first met them, their scores on the HOME functioning well academically and appear notto have been greatly intellectually compro-contributed significantly to intellectual out-

comes. mised by their early experience. Anothercommon finding is that both conditions in or-Development of children in institutions

and children adopted from institutions has phanages and conditions in adoptive homescan 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 betterquality 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 academicachievement 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 isthe 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 orphanagesmust 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-

Institutionalization and child development 861

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 children’s 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 medicalproblems, previously institutionalized childrenthe same backgrounds as institutionalized chil-

dren (e.g., the early-adopted group in Morison are typically small and malnourished after theorphanage experience. Eighty-five percent ofet al., 1995) score lower than home-reared

comparison groups matched on demographic orphanage children in the Canadian samplefell 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 16

Physical 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 theERA 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 headcircumferences below the 3 percentile. Theadoption. Convergent evidence for this find-

ing comes from the Romanian children adopt- evidence of delays in physical growth amongpreviously 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 apparentup 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 heighthas 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). Thelonger that children spent in an orphanage, theage children’s 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 chil- dren 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 havebeen examined are cortisol levels (Carlson &have examined medical problems in previ-

ously institutionalized children from Romania Earls, 1997; Gunnar et al., 2001) and patternsof brain glucose metabolism (Chugani et al.,(Benoit, Jocelyn, Moddeman, & Embree, 1996;

Gyorkos & MacLean, 1992; Jenista, 1992; 2001). Several researchers have proposed thatthe 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 thalamic–pituitary–adrenocorticol (HPA) sys-

K. MacLean862

tem (Gunnar, 2000; Heim, Owen, Plotsky, & months in Romanian orphanages prior to theiradoption were compared to children adoptedNemeroff, 1997). This hypothesis is based on

substantial preclinical evidence that distur- from orphanage before they were 4 months ofage (early-adopted group) and to Canadian-bances in caregiving early in life alters devel-

opment of the HPA axis and its central releas- born children. The children, who ranged inage from 6 to 12 years at the time of cortisoling hormone (Sanchez, Ladd, & Plotsky, 2001).

Although studies in rodents suggest that early sampling, all displayed the normal diurnalrhythm in cortisol. The orphanage children,deprivation of maternal care produces hyper-

responsivity of the HPA system, studies in however, had higher cortisol levels than chil-dren in the comparison groups. Evening levelsnonhuman primates have yielded evidence of

disturbances in the HPA diurnal rhythm and were most highly correlated with the lengthof time children had spent in institution. Chil-low, rather than elevated, basal levels of cor-

tisol, the hormonal product of this system dren’s cortisol levels were unrelated to eitherIQ scores obtained several years prior to corti-(Dettling, Feldon, & Pryce, 2002). Both hy-

per- and hypocortisolemia can have negative sol assessment or their age at cortisol mea-surement. This was a small sample of childreneffects on health and behavioral functioning

(McEwen, 1998), although the impact of ei- (n = 16 orphanage group children), and thusthe generalizability of these results to otherther type of dysregulation during periods of

rapid brain development is not well under- institutionalized children must be viewed withcaution.stood.

The first study to examine cortisol levels Chugani and colleagues (2001) examinedbrain dysfunction in ten 7- to 11-year-oldamong orphanage children was conducted by

Carlson and Earls (1997). They measured am- children who had spent on average 38 months(range, 16–90 months) in a Romanian or-bulatory cortisol levels in 2-year-old children

residing in a Romanian orphanage and com- phanage prior to their adoption to the UnitedStates. At the time of assessment, childrenpared them to a sample of 2-year-old family-

reared children. Carlson and Earls found that had been in their adoptive homes for an aver-age of 67 months (range = 15–113 months).orphanage children’s cortisol levels were not

elevated as compared to family-reared chil- Abnormalities in brain glucose metabolismwere examined using functional neuroimagingdren. Group differences were apparent, how-

ever, in the pattern of cortisol production over with positron emission tomography. The or-phanage children were compared to 17 normalthe day. Family-reared children displayed the

typical pattern: cortisol levels were highest in adults and to 7 children (age range = 7–13years) with medically refractory focal epi-the early morning and decreased over the day.

Orphanage children, on the other hand, did lepsy but who had normal brain glucosemetabolism in the unaffected hemisphere.not display this pattern; indeed none of the

children they studied exhibited the typical di- Chugani et al. (2001) found lower glucosemetabolism in several areas of the brain amongurnal pattern of cortisol production. Noon lev-

els of cortisol were positively correlated with Romanian adoptees than in either the adult orchild comparison groups. They suggested thatdelays in cognitive functioning in the orphan-

age group. Carlson and Earls (1997) sug- the decreased brain glucose metabolism likelyresulted from the Romanian adoptees’ experi-gested that orphanage experience disturbs the

diurnal pattern of cortisol production but does ence of early deprivation and may be one ex-planation for the cognitive and behavioral def-not result in increased levels of cortisol con-

centrations overall. icits seen in many previously institutionalizedchildren. The reader is cautioned that earlyGunnar and colleagues (2001) examined

cortisol levels in the Canadian sample of Ro- deprivation in Chugani et al’s sample appearsto have included an unusually high frequencymanian adoptees tested 6.5 years after adop-

tion to determine whether adoption into fami- of physical abuse. Chugani et al. (2001) re-ported that 5 of the 10 Romanian childrenlies would normalize the diurnal activity of

this axis. Children who had spent more than 8 they assessed had physical scarring that ap-

Institutionalization and child development 863

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 groupsmore 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 6months of age had higher externalizing andclear. Further studies using a wider range of

physiological 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 Problemsternalizing, orphanage children had becomeless internalizing from 11 months to 3 yearsAcross studies researchers have consistently

found that children with orphanage experi- postadoption. However, this resulted from adifference 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- to3-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 atthe 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 higherthan 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 scorehigher 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 Versluis–Den Bieman (1990a,

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

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 hadno 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 (Beckettet al., 2002). Marcovitch et al. (1995) and2002). Fisher et al. (1997) suggested that these

problem 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 1.5–2 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 tosit, stand, or walk (Thelan, 1979, 1981). Itported that during the first 11 months after

adoption 85% of the orphanage children’s may also reflect a self-soothing strategy or anattempt 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 11months 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 children’s malnutri-

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

Institutionalization and child development 865

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

of which was reported for either Canadian- comparison group children on the AttentionProblems 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 children’s scores were intermediate subscale than comparison group children at11 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 supportfor 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, O’Connor, 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 fromRomania 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 higherinattention/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 adoptedbefore 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 childrenon 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 Children’s 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 loweron the questionnaire’s Attention Focusing sub-children living in a Greek orphanage were more

inattentive and more often engaged in nonpro- scale. These findings were consistent acrossboth 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-deficitdisorder (ADD) or attention-deficit/hyperac-levels, inability to attend, and distractibility as

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

K. MacLean866

that children had spent in orphanage (Krepp- phanage. What causes some children to havepersistent 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 children’s 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 themfrom learning normal patterns of social inter-In accordance with early studies, the more

recent studies of Romanian adoptees have action. When they do become comfortableenough 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, theyhave 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 thevery 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 stimulationof an adoptive home without any opportunitydren, however, they seem more correctly

characterized as behavioral adaptations to or- to gradually learn how to deal with greatersensory 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. Inschool 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 todiagnoses of ADD or ADHD.age children show the same stereotyped be-

haviors as family-reared children just startingto sit, stand, or walk (Thelen, 1979), but when

Indiscriminate Friendlinessrestriction to a crib for 18–20 hr/day doesnot 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 stimulationand 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 ownstimulation 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 andstereotyped movements decrease with time dren’s behavior toward a stranger cannot be

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

Institutionalization and child development 867

child’s 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 thework of O’Connor and his colleagues in theon the social development of institutionalized

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

progress of 14 previously institutionalized Rutter, & the ERA Study Team, 2000). Usinga 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 similarto those used by Chisholm (1998; Chisholmported that these children were indiscrimi-

nately friendly to all adults. Tizard followed et al., 1995), O’Connor et al. (1999) foundthat 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 hadhigh 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 adoptedbefore 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.O’Connor et al. (2000a) found that high scores(Tizard & Hodges, 1978), demonstrating the

enduring nature of this behavior. A few adopt- were obtained by more 6-year-old Romanianchildren 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 whohad 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 Canadiansample, orphanage children were just as indis-foster care placements.

More recently, researchers have attempted criminate 3 years after adoption as they hadbeen 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 indiscriminatefriendliness 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 children’sindiscriminate 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 children’s scoresnate friendliness than both early-adopted and

Canadian-born children at both 11 months at these two points in time. O’Connor andhis colleagues reported a positive correlationand 3 years after adoption (Chisholm, 1998).

Providing corroborative evidence for this find- between disinhibited attachment disturbancescores 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 (O’Connor,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 categorychange (“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

K. MacLean868

is disagreement among studies as to whether children’s scores on indiscriminate friendlinessat 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 morethan 8 years after adoption. Consistent with(or their age at adoption) and the amount of

indiscriminate friendliness they display. O’Con- the Canadian findings, in the U.K. samplechildren’s scores on disinhibited attachmentnor and his colleagues found modest correla-

tions at both 4 years (O’Connor, et al., 1999) disturbance were positively correlated withtheir scores on hyperactivity and disruptiveand 6 years of age (O’Connor, Rutter, et al.,

2000) between duration of deprivation (age at behavior measures at age 4 (O’Connor et al.,1999) and hyperactivity, disruptive behavior,adoption) and children’s scores on disinhib-

ited attachment behaviors in the U.K. group. and emotional difficulties measures at 6 yearsof age (O’Connor, 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 doesnot 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 (O’Connor, Rutter, et children’s IQ scores at 3 years postadoptionand their displays of indiscriminate friendli-al., 2000). Chisholm et al. (Chisholm, 1998;

Chisholm et al., 1995), Fernyhough et al. ness. Consistent with Chisholm’s finding,O’Connor et al. (1999) found no correlation(2002), and Tizard et al. (Tizard & Hodges,

1978; Tizard & Rees, 1975) all found no rela- between children’s IQ scores and disinhibitedattachment 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, O’Connor, Rutter, et al. (2000) reporteda 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 ofduration 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 ininstitutionalized children, displays of indis-care, whether toys were available (Chisholm

et al. 1998), or children’s weight or develop- criminate friendliness do not appear to dissi-pate over time but are still in evidence up to 8mental delay at adoption (O’Connor et al.,

1999; O’Connor, Rutter, et al., 2000) were years after leaving the orphanage environment(Fernyhough et al., 2002; O’Connor, Rutter,unrelated to children’s 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 mayserve an adaptive function in the context ofof indiscriminate friendliness. Researchers have

consistently found associations between or- the orphanage environment where emotionalresources are extremely limited. Amid thephanage children’s indiscriminate friendliness

and their behavior problems. Chisholm (1998) passivity of the orphanage an indiscriminatelyfriendly child may receive what little attentionfound that at 3 years postadoption, children’s

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

Institutionalization and child development 869

this contention but does not explain what were items that most clearly capture securebase behavior. Similarly, O’Connor et al. (2003)function such behavior serves after adoption.

It may be behavior that is reinforced by both reported that children in their sample whoscored 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 onO’Connor’s 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 innew 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 Chisholm’stwo extreme items. Although orphanage chil-priate.

Given that indiscriminate friendliness in dren in the Canadian sample scored higherthan 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 havingbeen shy, and eagerly approaching new adults)may reflect the expression of those difficulties

as applied to interactions with strangers. On were not associated with children’s insecureattachment 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 O’Connor et al.(2003) found some securely attached childrenment relationship and thus may reflect a de-

lay in the attachment system. O’Connor 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 children’s 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 acrossstudies to be weak or nonexistent.portunity to form an attachment relationship.

This is precisely the situation of children reared Indiscriminate friendliness has little or norelation to IQ, but it is positively correlatedin orphanage environments, so researchers have

focused on linking this behavior to children’s with behavior problems, especially problemsof 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 failureor developmental delay in attachment. Thewithout distress) were associated with inse-

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

K. MacLean870

ness measurement items reflecting lack of se- vided one-on-one attention to children. Tizardand Rees (1975) described 4-year-old children’scure base behavior, and not those reflecting

eager approach and engagement with new behavior toward their caregivers as very clingybut 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 ofthem 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. Thiswork 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.

AttachmentChisholm (1998) suggested that there are

reasons to suppose why developing an attach-Researchers have focused enormous energyon attempting to evaluate the impact of insti- ment relationship may be more difficult for

previously institutionalized children. Accord-tutionalization on the ability of children toform attachment relationships. Given that at- ing to attachment theory, a child’s attachment

behavior becomes organized toward a partic-tachment usually develops some time duringthe 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 housedin institutions during the first year or 2 of life quate caregiver readily responds to an infant’s

needs for close contact and understands an in-necessarily develop an attachment relation-ship with adoptive parents later than is typi- fant’s distress if separated from the caregiver.

When a child is beyond 2 years of age, care-cal. Although little evidence exists on thispoint, most researchers have assumed that the givers may be less responsive to the child’s

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 child’s

need for contact may be viewed as “clingy”givers within the institution, given the veryhigh 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 ashigh 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 acontext 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 whoexamined children’s 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-reared2-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 anyonethat children knew well. The only “favorite” postadoption, 14% of children did not show

signs of experiencing pain and 31% of chil-people in children’s lives were people theysaw 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-

Institutionalization and child development 871

behavior may also make it difficult for parents ports whether children had truly been unableto 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 didhave 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 parent’s ability to be sensitively

responsive. of the stability of placement for the childrenpostinstitutionalization. Children in Goldfarb’sFindings in the early literature were incon-

sistent regarding whether institutionalized study very often went to unstable foster careplacements. 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 to

foster homes were described as withdrawn and relationships contributed to children’s emo-tional coldness. Children in Tizard’s 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 timechildren 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 attachmentcoding systems (Chisholm, 1998; Marcovitchwere permanent. In contrast to Goldfarb’s work,

Tizard (1977) concluded that children could et al., 1997; O’Connor et al., 2003). In eachof 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 roomwith 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. Thisprocedure was carried out in children’s homesattached to them.

Ames and Chisholm (2001) have suggested by both Chisholm (1998) and O’Connor 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. Inall studies children’s 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 bytrained coders for quality of attachment. Chis-farb’s sample were delayed in every area of

development. In contrast, children in Tizard’s holm (1998) used Crittenden’s (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, whereasboth Marcovitch et al. (1997) and O’Connor(Tizard, Cooperman, Joseph, & Tizard, 1972).

These factors would bode well for the forma- et al. (2003) used the Cassidy, Marvin, andMacArthur Working Group (1992) Preschooltion of an attachment relationship with par-

ents. Second, it is unclear from Tizard’s re- Attachment System. Both of these coding sys-

K. MacLean872

tems have reported validity (Solomon & Dijkstra, & Bus, 1995). In addition, in allthree studies (Chisholm, 1998; Marcovitch etGeorge, 1999).

Marcovitch et al. (1997) examined attach- al., 1997; O’Connor et al., 2003), fully onethird 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 relationshipwith 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 casethat across studies the percentage of securelygroup comprised healthy 4-year-old Canadian

children. O’Connor 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 comparisonsample (Chisholm, 1998; Marcovitch et al.,before 6 months of age and the other adopted

between 6 and 24 months of age. Most, but 1997; O’Connor 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 studybetween their institution and home groups.prised U.K. born children who were adopted

before 6 months of age. Chisholm examined Ames and Chisholm (2001) have suggestedthat 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 smallnumber 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 orto 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 thehome group was that children had spent lessthe early-adopted (adopted before 4 months of

age) and Canadian-born comparison groups, than 6 months in either a hospital or orphan-age in Romania. There may have been someand groups did not differ on family demo-

graphic variables. children in the home group who had spentclose to 6 months in orphanage and thereforeAcross all three studies there was no evi-

dence of a child being unattached to his or her there would be little difference in the amountof institutional experience between the twocaregiver. It is important to note, however,

that the coding systems used were initially de- groups.In all three studies a large percentage ofsigned to evaluate the quality of attachment

rather than the presence or absence of an at- previously institutionalized children had at-tachments to their primary caregivers thattachment relationship. Nevertheless, children’s

attachment patterns were related to other mea- were either secure or typical insecure (i. e.,insecurely attached in a manner that is com-sures in ways consistent with attachment the-

ory, which provides some construct validation mon in normative North American samples).In Chisholm’s (1998) study, 67% of the or-for use of these measures with institutional-

ized children (Chisholm, 1998; O’Connor et phanage children had either secure or typicalinsecure attachment patterns. In other words,al., 2003). Chisholm (1998) found that, com-

pared to orphanage children classified as se- they had developed attachment patterns thatwere identical to those displayed by 95% ofcure, those who were classified as insecure

had lower IQs, more behavior problems, par- the Canadian-born and early-adopted children.This finding suggests that in spite of havingents who reported higher levels of parenting

stress, and lower socioeconomic status back- spent 8 months or more in an extremely de-priving environment and developing an at-grounds. Each of these variables has been as-

sociated with insecurity in previous studies of tachment later than is typical, most orphanagechildren were still able to form an attachmentattachment (Greenberg, 1999; Teti, Gelfand,

Messinger, & Isabella, 1995; van IJzendoorn, relationship with their adoptive parents that

Institutionalization and child development 873

was similar to those found in normative sam- This is not the case for most previously insti-tutionalized children: although orphanage chil-ples.

It was also the case in all three studies, dren have experienced extreme neglect, it wasnot perpetrated by their postadoption attach-however, that a considerable number of or-

phanage children had developed very unusual ment figures.Orphanage children in the Canadian sam-and atypical insecure attachment patterns with

their adoptive parent, which were rare in com- ple also displayed a higher percentage of com-pulsive caregiving (A3), a pattern more com-parison group children. Chisholm (1998) re-

ported that 33% of her orphanage sample had monly seen in neglected samples than in abusedsamples of children (Crittenden & Claussen,developed an atypical insecure attachment pat-

tern, as compared to 7% of Canadian-born and 2000). Twelve percent of orphanage childrendisplayed a compulsive caregiving pattern, as4% of early-adopted children. In parallel to

Chisholm’s findings, both O’Connor et al. compared to 4% of early-adopted Romanianchildren and 2% of Canadian-born children.(2003) and Marcovitch et al. (1997) found that

slightly over 40% of their orphanage samples The compulsive caregiving pattern is adoptedin response to a withdrawn or unresponsivehad developed an atypical insecure attach-

ment pattern. Such atypical insecure patterns caregiver. A child displaying an A3 patterninhibits negative affect and attempts to cheerare rare in normative samples and are found

more commonly in clinical samples of mal- an unresponsive caregiver with overbrightnessand nurturance (Crittenden, 1992a). Critten-treated children (Carlson, Cicchetti, Barnett,

& Braunwald, 1989; Cicchetti & Barnett, den suggested that in the case of neglect, sucha strategy increases the likelihood of a child1991; Crittenden, 1988; Lieberman & Zeanah,

1995). Some researchers have suggested that gaining the parents’ attention. Children’s ex-perience of extreme neglect earlier in theirsuch attachment patterns may be risk factors

in the development of psychopathology (Carl- lives may have resulted in their developing acompulsive caregiving strategy that would en-son & Sroufe, 1995).

The distribution of atypical patterns in pre- sure they received what little attention wasavailable to them in the orphanage context.viously institutionalized children is not the

same as in other maltreated samples. One dif- For some children, this seems to continue intheir adoptive homes, especially if a parent isference is that orphanage samples display a

lower percentage of the Defended/Coercive withdrawn because of the burden of dealingwith the child. Chisholm (2000) described such(A/C) insecure pattern than do other maltreated

samples. A child classified as A/C shifts back a case in which an overburdened parent waswithdrawn and unresponsive in interactionand forth between defended and coercive strat-

egies in response to the behavior of an often with her child. The child displayed false, over-bright affect and took most of the responsibil-unpredictable caregiver. Twelve percent of

the Canadian orphanage sample was classified ity for maintaining the interaction with theparent. This child was classified as compulsiveas A/C. Whereas this percentage is higher

than is found in normative samples of chil- caregiving (A3) and may have implementedsuch a strategy because of his experience of ex-dren, it is far lower than the 58% of A/C pat-

terns reported by Crittenden (1988) and the treme neglect in orphanage, experience with anunresponsive caregiver, or both.27% reported by Cicchetti and Barnett (1991)

for maltreated children who have come to the Another difference is that the Insecure(other) pattern is more common in orphanageattention of social services. The characteris-

tics of the parents may explain this difference samples than in maltreated samples. Insecure(other), by definition indicates behavior thatbetween institutionalized samples and other

maltreated samples of children. In maltreated is difficult to classify. This classification isgiven when a child is clearly insecure, but thesamples, children are subjected to abuse and/

or neglect at the hands of their attachment fig- strategy that he or she uses in interaction doesnot fit any of the established insecure pat-ures and have developed a flexible, organized

strategy for coping with an abusive caregiver. terns. Nine percent of the Canadian orphanage

K. MacLean874

sample was classified as Insecure (other), problems, parenting stress, and indiscriminatefriendliness and higher on IQ. Chisholm (1996)whereas Crittenden (1992a) only found 3 or 4

out of 100 maltreated children classified as concluded that Secure (other) children weremore similar to children classified as secureInsecure (other).

Such atypicality in orphanage children’s than to children classified as Insecure (other).This suggests that the PAA is able to classifyattachment was also apparent in the attach-

ment patterns of orphanage children classified children appropriately as secure and insecure,and yet reveals that orphanage children mayas secure. The PAA (Crittenden, 1992a) has a

secure classification labeled “Secure (other).” display even secure patterns of attachment dif-ferently from both normal samples and nonin-This classification is given when children are

clearly secure but the strategies they use in stitutional, high-risk samples of children. Forexample, in a case study Chisholm (2000) de-interaction with their caregiver do not reflect

any of the standard subpatterns of secure. Crit- scribed the behavior of a previously institu-tionalized child who had been classified astenden has not reported any children classified

as Secure (other) in her published results (Crit- Secure (other). During a separation–reunionprocedure the child’s interaction with hertenden, 1985, 1988, 1992b; Crittenden, Par-

tridge, & Claussen, 1991) with maltreated mother was warm and relaxed, prior to sep-aration there were clear indicators of opensamples, and Teti and his colleagues (Teti et

al., 1995) reported only 1 child classified as negotiation regarding the separation, and neg-ative feelings upon reunion were openly re-“Secure (other)” in their sample of 54 chil-

dren of depressed and nondepressed mothers. solved. The behavior that contributed to theSecure (other) classification and set her apartIn the Canadian sample (Chisholm, 1996)

only 1 of the 42 children classified as secure from other secure children was her behaviortoward the stranger. The child initiated all in-in the comparison groups was classified as

Secure (other), but 37.5% of the 16 secure or- teraction with the stranger, watched the strangerquite openly, and at one point left the interac-phanage children were classified as Secure

(other). This represents a much higher per- tion with the parent to search out the stranger.This is clearly not behavior that would be dis-centage of Secure (other) children than is

found in the literature on other high risk sam- played by a child classified as typically se-cure. However, we cannot assume that, be-ples using the PAA.

This finding suggested the possibility that cause the behavior of orphanage children maymanifest itself in somewhat different ways inthe coding systems that were developed using

normative samples of children were inade- the context of a separation–reunion proce-dure, they are necessarily insecure. This is anquate to evaluate attachment in institutional-

ized samples, that is, that children classified important way in which orphanage childrenhave reshaped our thinking about the meaningas Secure (other) might not truly be secure.

Chisholm (1996) compared Secure (other) chil- of behavior in the context of procedures thatwere developed with normative samples.dren to both the remaining secure children and

to children classified as Insecure (other) to Bowlby claimed that the development of afirst attachment relationship occurs sometimefind out which of these groups they resembled

more. (It is important to note that all attach- during the second half of the first year of life(Bowlby, 1969/1982) and therefore it was onlyment coding was done by two independent

coders who were blind to children’s group after this time that separation from an attach-ment figure would be psychologically harm-membership and all other behavior besides

attachment.) Secure (other) children did not ful. He reported that infants who had beenadopted between 6 and 9 months of age oftendiffer from secure orphanage children on be-

havior problems, parenting stress, or indiscrim- showed little or no socioemotional damage.The findings from orphanage samples concurinate friendliness, but they did have lower IQs

than secure orphanage children. In contrast, with Bowlby’s theory and with studies fromnoninstitutionalized samples. In all three Ro-they differed greatly from children classified

as Insecure (other), scoring lower on behavior manian studies, children who were removed

Institutionalization and child development 875

from the institution prior to the time when at- time they had spent in institution. This agreeswith Tizard and Hodges (1978), who did nottachment is expected to develop (Chisholm’s

(1998) “early-adopted” group, adopted before find a relationship between whether a parentconsidered his or her child to be attached at 84 months; Marcovitch et al.’s (1997) “home”

group, adopted before 6 months; and O’Con- years of age and the length of time the childhad spent in institution: the majority of chil-nor et al.’s (2003) “early-placed” group, adopt-

ed before 6 months) were no more likely to dren who had spent at least 4.5 years in insti-tution were reported to be closely attached todevelop insecure attachment relationships than

children who were never institutionalized. In- their parent at 8 years of age.Given the lack of a general relationship be-stitutionalization, even under the extremely

poor conditions found in Romania, does not tween length of institutionalization and thequality of relationships that children later formappear to have an impact on attachment when

it ends before the appropriate time for such with their adoptive parents, it remains unclearwhether there is a length of time beyonddevelopment. Thus, there is theoretical and

empirical agreement concerning the onset of which developing a secure attachment rela-tionship may become impossible. Bowlby ini-a possible sensitive period for attachment.

Bowlby (1969/1982) felt that a child was tially claimed that if the opportunity to forman attachment was delayed until after the agemaximally ready to become attached quickly

at least through the end of the first year, but of 2.5 years, it was “almost useless” (Bowlby,1953), thereby implying a short window ofthereafter attachment would be more difficult

(e.g., require a longer time or better parenting opportunity for developing attachment. AsBowlby’s theory developed, the length he at-or take a less adaptive form). In both the Ca-

nadian and U.K. samples (Chisholm, 1998; tributed to this sensitive period increased. By1973, he claimed that the sensitive period forO’Connor et al., 2003), children who had ex-

perienced more than 6 months of institutional- attachment likely extended through the de-cade beyond a child’s fifth birthday, but thatization, that is, children who remained in in-

stitution without a primary caregiver at the such development would become increasinglymore difficult as a child grew older. This wastime when a first attachment would have been

expected to develop, were more likely to be in line with a more modern emphasis on riskand resilience in a probabilistic, rather thaninsecurely attached than comparison group

children. deterministic, model of development (Rutter& O’Connor, 1999).In other areas of child development the im-

pact of institutionalization has been shown to Ames and Chisholm (2001) have notedthat the statistical analyses used in most stud-depend on how long a child has spent in the

institution. In terms of attachment this asso- ies do not enable an examination of such a“sensitive period” hypothesis. They claim thatciation has not been found. Chisholm et al.

(1995) did not find a relationship between or- such a hypothesis is better examined by acareful inspection of data rather than by eitherphanage children’s age at adoption and par-

ents’ reports of their children’s attachment se- correlations (that investigate how well data fita straight line) or average differences betweencurity 11 months postadoption. In a follow-up

study using a separation reunion procedure to age groups. In a reanalysis of the Chisholm(1998) data, Ames and Chisholm (2001) foundmeasure attachment patterns when children

were 4.5 years or older, previously institution- that the median and ranges of length of insti-tutionalization were 16.5 (range = 9–39 months)alized children classified as insecure were no

more likely than previously institutionalized for orphanage children subsequently classifiedas secure; 14 (range = 9–53) months for chil-children classified as secure to have spent a

longer time in institution or to have been older dren classified as typical insecure; and 21(range = 8–53) months for children classifiedwhen they were adopted (Chisholm, 1998).

Thus, examination within the orphanage group as atypical insecure. These differences werenot statistically significant, but it is importantdid not reveal an association between chil-

dren’s attachment patterns and the length of to note that the oldest children who had de-

K. MacLean876

veloped a secure attachment relationship with these children scored above the clinical cutoffon behavior problems, and three of the fouran adoptive parent had spent only 39 months

in an orphanage. In this sample there were for whom parenting stress scores were avail-able had higher than average parenting stressonly 5 children who had spent more than 39

months in an orphanage. All of those children scores for the orphanage group. Three of themhad a sibling who was adopted from Romaniahad developed an insecure attachment rela-

tionship, and 4 of the 5 had an atypical inse- at the same time. All of these factors wouldundoubtedly compromise their parents’ abilitycure attachment. It is clear that on the basis of

5 children no firm conclusions can be drawn to respond sensitively to them. Therefore,rather than assume that length of institutional-concerning the end of a sensitive period for

the development of a first attachment. More- ization per se explains their lack of secure at-tachment, it appears more reasonable to sug-over, the insecure attachments that children

developed were also associated with particu- gest that they were adopted into families inwhich the resources were not sufficient tolar factors of both the child and the parent,

suggesting that the insecurity of attachment allow parents to provide children who hadmany problems with the high level of sensi-might be associated with those factors rather

than with any upper limit on the timing of a tive responsiveness that would be required todevelop a secure attachment.period for the formation of a first attachment.

Characteristics of both the child and the The suggestion that stressors that interferewith parents’ sensitive responsiveness nega-parent have been associated with attachment

security. Children with lower IQs (Chisholm, tively affect children’s attachment fits withTizard and Hodges’ (1978) findings with a1998; Tizard & Hodges, 1978) and more be-

havior problems (Chisholm, 1998; Marcovitch group of children who had been admitted toinstitution before 4 months of age and had re-et al., 1997) have more difficulty forming at-

tachment relationships with their adoptive par- mained there until at least two years of age.Between 2 and 4 years of age, 24 of the chil-ents, most likely because these factors in-

terfere with parents’ ability to be sensitively dren were adopted out of institution and 15children were restored to their natural fami-responsive to their children. Ames and Chis-

holm (2001) found another factor that may lies. In comparing the adoptive and restoredgroups of children, Tizard and Hodges (1978)have interfered with parents’ ability to be sen-

sitively responsive. Although only 14% of se- found that whereas 84% of adoptive mothersfelt that their child was deeply attached tocurely attached and typical insecurely attached

children were adopted by families that had them, only 54% of mothers of restored chil-dren felt this was the case. Children in theadopted another Romanian child at the same

time, 57% of children classified as Atypical restored group were reunited with their bio-logical mothers who often were ambivalent orInsecure had a sibling who had been adopted

from Romania at the same time. Additional reluctant to have their child return home. Whencompared to children in the adopted group,family factors that were associated with chil-

dren’s insecure attachment patterns were lower restored children typically were returned tofamilies who had a larger number of childrensocioeconomic status and a higher level of

parenting stress (Chisholm, 1998). These stress- (Tizard & Hodges, 1978), whose mothers wereyounger and whose fathers had jobs of aors are among those believed by Belsky (1999)

to have a negative impact on parents’ ability lower socioeconomic status (Tizard & Rees,1974). Parents of restored children also spentto be sensitively responsive to their infants.

These factors may help to explain the inse- less time in play and educational activitieswith their children than parents in the adop-cure attachments of the oldest five children in

the Ames and Chisholm (2001) reanalysis. All tive group (Hodges & Tizard, 1989). In con-trast, adoptive parents wanted their childrenfive of these children had IQ scores lower

than 85, and four of the five came from fami- and devoted a great deal of time to them. Tiz-ard and Hodges (1978) concluded that form-lies whose income was lower than the average

for the orphanage group as a whole. Three of ing a secure attachment relationship did not

Institutionalization and child development 877

so much depend on institutionalization as on that are similar to those found in normativesamples. The remaining third show quitethe “willingness of the new parents to accept

a dependent relationship and to put a lot of atypical attachment patterns, and the types ofatypical patterns they display differ fromtime and effort into developing it” (p. 115).

To summarize: it is very rare to find chil- other maltreated samples. It is worth notingthe value of the Secure (other) classificationdren who have received so little one-on-one

attention from adults as children reared in the that is included in Crittenden’s (1992b) PAAsystem. Although coders were blind to chil-extremely deprived environment of orphanages.

Therefore, studies of institutionalized children dren’s group membership, they were able todiscriminate between the Secure (other) andhave provided researchers with a unique op-

portunity to examine the development of a Insecure (other) patterns. This provides con-struct validity for the PAA system and accen-first attachment beyond the time it appears in

family-reared children. Early researchers dis- tuates the importance of the Secure (other)pattern in examining attachment in atypicalagreed as to whether previously institutional-

ized children were able to form an attachment samples. Even when children have atypicalways of showing a secure attachment, theyrelationship with their adoptive parents, but

this disagreement was likely the result of con- can be accurately coded as secure.The length of institutionalization for chil-ditions in the institution and the post institu-

tional environment, both of which varied wide- dren who remained in institution beyond thefirst half of the first year of life does notly across studies. Goldfarb (1943a, 1945b)

provided the most pessimistic view by claim- appear to be related to the quality of the at-tachment relationship that they subsequentlying that after the experience of early insti-

tutionalization children were incapable of formed. Chisholm (1998) found that after 3.5years or more of orphanage life, children wereforming attachment relationships. He, how-

ever, studied children who were housed in able to form attachments with their adoptiveparents. One child who spent 39 months invery poor-quality institutions and who subse-

quently experienced several foster home place- orphanage had developed a secure attachment,and another child who had spent 53 monthsments. In contrast, Tizard and Hodges (1978)

were optimistic and claimed that even after in orphanage had developed a typical insecureattachment. The majority of adoptive parents4.5 years in institution children were capable

of forming attachment relationships. They, in Tizard’s sample whose children had spent4.5 years in orphanage claimed their childhowever, studied children from orphanages in

which the conditions were far superior to the was deeply attached to them a few years afteradoption (Tizard & Hodges, 1978). We do notconditions found in Romania, and the children

in Tizard’s studies were typically adopted into yet know whether the period during which at-tachment is possible might be extended throughstable homes in which parents were highly in-

vested in them. adolescence, as Bowlby (1988) has suggested,or whether there is an earlier time after whichRecent studies of attachment in previously

institutionalized Romanian children are con- the development of attachment becomes im-possible.sistent in indicating that after children have

been in institution for many months without It is probably better at present to conceiveof attachment formation as being related toan opportunity to form an attachment relation-

ship they are able to form attachments with factors that compromise the ability of parentsto be sensitively responsive to their child,their adoptive parents, and that furthermore, a

third or more of these attachments are secure. rather than to some age-based offset of a sen-sitive period for formation of a first attach-Attachments in previously institutionalized chil-

dren may be slower to develop, and a higher ment. Such factors include the child’s lowerIQ, more behavior problems, and the adoptionpercentage of orphanage children than family-

reared children form insecure attachment rela- of more than one child at a time. High levelsof parenting stress and lower socioeconomictionships, but almost two-thirds of children

from orphanages are able to form attachments status also compromise parents’ ability to

K. MacLean878

handle children’s problems. All of these influ- and quiet); and when the index Distractibility/Hyperactivity subscale was divided into twoences on the attachment relationship can be

considered using a transactional argument sets of items, it was found that parents of or-phanage children perceived them as more dis-(Cicchetti, 1996; Sameroff, 1983). As a result

of the orphanage experience, children arrived tractible but not more hyperactive. Later, asthe children spent more time in their adoptivein their adoptive homes with medical, physi-

cal, intellectual, and socioemotional problems homes, they added hyperactivity to the dis-tractibility. This result helped to explain whatthat undoubtedly led to more stress for their

parents; such stress interfered with parents’ appeared to be contradictory findings in theearlier literature, with previously institutional-ability to respond sensitively to their child’s

cues, which led to more problems on the part ized children having been reported to be bothvery passive and very active (Goldfarb, 1943b,of children and the further compromise of the

attachment relationship. It could be argued 1945a).A similar example of the poor fit of a stan-then that it takes more than “good enough”

parenting to promote secure attachment in dardized measure was found when the CBCLwas used to rate orphanage children. Fisher etpreviously institutionalized children, particu-

larly when they present with a myriad of al. (1997) found that 11 months after adoptionorphanage children scored higher on Internal-problems and family resources are limited in

terms of dealing with such problems. izing, but not on Externalizing, than did com-parison children. At 3 years after adoption,however, they scored higher on Externalizing

Discussionbut not Internalizing (Ames, 1997). Becauseobservers and parents had reported that theThe methodological problems of studies of in-

stitutionalized children are many and complex. children still had several unusual behaviors,the individual items that made up the Internal-Measures that were standardized on nonclini-

cal or even clinical populations sometimes are izing scale at the early age were traced and itwas found that at the later testing the orphan-not appropriate for the institutionalized sam-

ple. In the study of Romanian orphans adopted age children still showed their earlier specific“internalizing” behaviors (stares blankly, strangeto Canada it has sometimes proven necessary

to go to the level of subscales or even individ- behavior, acts too young, speech problems)even though those items had shifted onto dif-ual items to clarify what is happening. This

creates a problem of multiple comparisons, ferent subscales in the CBCL version used totest older children.and it is certainly not recommended that re-

searchers routinely look at group differences Although standardized measures require carewhen applied to institutionalized children,on all items. But when there is a reason for

separating items that have been grouped to- studying variables that do not have standard-ized measures requires the development ofgether in measures standardized on nonin-

stitutional populations, the researcher must new measures that lack proven validity. Suchwas the case with measures of Indiscriminatego beyond merely reporting the scale scores

yielded by the standardized test. For example, friendliness, which is a strong characteristicof orphanage children. Both the CanadianMainemer et al. (1998) found that adoptive

parents scored their previously institutional- study (Chisholm, 1998; Chisholm et al., 1995)and the U.K. study (O’Connor et al., 1999,ized children higher on the Distractibility/

Hyperactivity subscale of the Parenting Stress O’Connor, Rutter, et al., 2000) developedmeasures of descriptively similar behavior,Index (Abidin, 1990) than did parents of Ca-

nadian-born children. There was nothing in but the measures are slightly different andhave been given different names (Chisholm’sparent interviews or in home visitors’ obser-

vations, however, that pointed to orphanage “indiscriminate friendliness” vs. O’Connor’s“disinhibited attachment disturbance”), whichchildren being hyperactive (indeed, they were

generally described as being fairly passive indicate the researchers’ preferences for the

Institutionalization and child development 879

measure’s theoretical relationship or lack of that the availability of toys and having been afavorite in the institution were associated withrelationship to attachment. The difference in

theoretical emphasis between the measures is fewer delays among orphanage children, where-as having been described as dirty when firstlikely to generate fruitful research in the fu-

ture. met by parents was associated with more de-lays. It is unclear, however, whether one orAlthough there is the temptation to claim

that samples of previously institutionalized chil- more institutional factors explain delays in allareas or whether there are specific factors thatdren can address questions concerning sensi-

tive periods in development, the answers that are associated with outcomes in specific ar-eas. For example, intellectual delay may becan be provided are limited. Ames and Chis-

holm (2001) have discussed the difficulties of explained either by the impact of malnutritionon brain development or by the lack of cogni-trying to use studies of postinstitutionalized

children to demonstrate the presence or ab- tive stimulation in the orphanage environmentor by both factors operating together.sence of sensitive periods. To prove that a

sensitive period exists it is necessary to show Given the profound general deprivation thatoften characterizes orphanages, researchersboth the exact ages that are important and the

length of time the operative factor (in this have been unable to specify which aspects ofdeprivation caused the outcomes that havecase, institutionalization) must be in place for

effects to occur. To conclude that it is depri- been found. The only exception is Tizard’swork (1977) with orphanage children in thevation during a particular age period that mat-

ters, it is necessary to demonstrate not only United Kingdom, who experienced only so-cial emotional deprivation but were well caredthat a shorter duration of deprivation is insuf-

ficient to produce the same effect but also that for otherwise. We know from this work thatproviding good nutrition and cognitive stim-the same duration would not have the same

effect at another time of life. This requires ulation can prevent developmental delays.These same children, however, still displayedstudies that systematically vary not only the

age at which deprivation begins but also the indiscriminate friendliness and some difficul-ties in attachment, which seem attributable toduration of deprivation at each of those ages,

something that does not occur in experiments the limitation of not having had a close per-sonal relationship with an adult caregiver.in nature.

In spite of the challenges of interpretation Presently we simply do not know enoughabout conditions in orphanages. Careful ob-and the methodological differences among stud-

ies of previously institutionalized children, the servational studies of children’s lives in dif-ferent orphanage settings are sorely needed inresults across studies are consistent in show-

ing that institutionalization has a powerful im- order to identify more clearly the particularfactors in the orphanage environment thatpact on all aspects of children’s development.

When compared to either other adopted chil- have an impact on developmental outcomes.Future research studying samples of childrendren or children home-reared since birth, or-

phanage children have lower IQs, are shorter from orphanages in other countries whereconditions differ in nutrition, access to chil-and weigh less, and have more behavior prob-

lems and attention difficulties. They are also dren of different ages, child to caregiver ra-tios, attitudes of caregivers toward children,more indiscriminately friendly and have more

insecure attachments. There is not an area in and number of toys available, may be betterable to isolate particular antecedents that ex-which orphanage children remain unscathed.

What is yet to be specified are the antecedent plain specific post institutionalization outcomes.At the same time it is important for currentfactors inherent in an institutional upbringing

that explain these powerful outcomes. There longitudinal studies to continue so that thelong-term effects of early institutionalizationis some evidence that the quality of the insti-

tution makes a difference to developmental can be examined. Current studies are pres-ently reporting findings 10 to 11 years afteroutcomes. Morison and colleagues (1995) found

K. MacLean880

institutionalization. This work will help us to dren still housed in institutions around theworld. For example, future research must fo-differentiate developmental delay from per-

manent damage and thus extend our knowl- cus on examining any possible interventionsthat put human interaction back in the lives ofedge concerning long term prognoses for

postinstitutionalized children. orphanage children. Improving child to care-giver ratios in orphanages is often a financialA second focus for future research lies in

intervention studies. Research efforts should impossibility, but such improvement might berealized by either the careful use of volunteersfocus on identifying the kinds of interventions

that could be implemented in the orphanage from the community or by providing servicelearning experiences for students who are in-context to ameliorate negative developmental

outcomes. There are presently two interven- terested in child development and education.This could provide a practical solution to thetion studies ongoing in Eastern Europe. The

Bucharest Early Intervention Project (Koga, problem of high child to caregiver ratios ininstitutions, but it would have to be imple-Smyke, Zeanah, 2003; Zeanah, Smyke, & Koga,

2003) has begun providing a foster care inter- mented with care to ensure that such volunteerswere committed and somewhat stable figuresvention in Bucharest, Romania, in which they

are following the development of children re- in children’s lives. Children in Eastern Euro-pean orphanages are typically housed in agemoved from orphanage to foster care and com-

paring their developmental progress to both segregated groups, a policy that hinders cog-nitive growth. More than 50 years ago Skodakchildren who remain in orphanage and a com-

munity comparison group. The St. Petersburg– and Skeels (1945, 1949) showed that placinginstitutionalized infants as “house guests” withU.S.A. Orphanage Project (McCall, Muha-

medrahimov, Groark, Palmov, & Nikiforova, older residents in the institution improved in-fants’ cognitive competence, so the idea of2003), operating in three baby homes in St.

Petersburg, is providing different interven- age integration is not new but is a change thatcould be implemented fairly easily and costtions to examine which are most effective in

reducing the developmental impact of institu- effectively. This is one aspect of the interven-tion being conducted by the St. Petersburg–tional rearing. In one baby home, orphanage

staff are being trained in child development U.S.A. Orphanage Project. If young childrenwere housed with other children who wereand sensitive responsiveness. In a second,

both caregiver training and structural changes slightly above their own developmental level,this would offer them a zone of proximal de-that reduce the number of different caregivers

and increase their stability in the lives of the velopment that could promote positive devel-opmental outcomes (Vygotsky, 1978).children are being implemented. A third baby

home is serving as a “no intervention” com- Piaget’s constructivist theory emphasizesthat interacting with both objects and peopleparison group. Preliminary reports have shown

that these interventions have been successful stimulates cognitive development. Both kindsof interaction are sorely lacking in an orphan-in improving both caregivers’ attitudes and

behavior toward the children in their care and age environment. Future interventions promot-ing cognitive development could provide or-children’s scores on standardized measures of

personal–social, communication, and cogni- phanage children with toys and/or computergames that would allow children to make some-tive skills.

These projects hold great promise for spec- thing happen in the environment. This wouldprovide them with a sense of personal effect-ifying the kinds of interventions that may be

most effective at ameliorating the develop- ance and stimulate cognitive growth. Peer in-teraction in orphanages might be increasedmental delays so common in orphanage chil-

dren. Given their high cost, however, future through the use of social interactive toys thatwould require two or more children workingresearch should also examine whether there

are less expensive interventions that might be together to operate them. If researchers coulddemonstrate that toys that required such socialimplemented on a wider scale as a partial so-

lution for the hundreds of thousands of chil- interaction actually improved developmental

Institutionalization and child development 881

outcomes then they could be implemented on with family and parent characteristics in theadoptive home. A stimulating and supportivea wider scale than more expensive interven-

tions. home environment was associated with higherIQs in orphanage children (Morison et al.,Research on institutionalized children has

shown that similar experiences early in life may 1995), and children’s insecure attachment pat-terns were associated with parents having lowerresult in a variety of outcomes, a phenomenon

that Cicchetti (1996) has termed multifinality. socioeconomic status and more stress (Chis-holm, 1998). Institutionalization is clearly aWe know that orphanage life and the intellec-

tual, physical, social, and emotional depriva- risk factor for compromised development, butit is not possible to predict developmental out-tion that it entails is clearly a risk factor for

less than optimal development. What we have come with any certainty knowing only that aparticular child has been institutionalized earlylearned from studies of institutionalized chil-

dren, however, is that having experienced in- in life. When institutionalization is combinedwith other risk factors (e.g., low IQ, behaviorstitutionalization does not necessarily doom a

child to developmental insult. It also matters problems, parenting stress, low socioeconomicstatus), it becomes easier to predict poor de-what happens after leaving institution. On some

measures poorer outcomes are associated not velopmental outcomes.only with early institutional rearing but also

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