Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, September 25, 2013

An Orphanage Study: High Tech, Perhaps Not So Much Science

There’s been a good deal of discussion recently about the possible effects of neglectful orphanage experiences on children’s development, with some claims made about damage to brain development in the proposed “Children in Families First” legislation. A recent publication is bound to be made grist for this legislative mill, and I would like to go over some aspects of the study before this happens. The paper is by Jamie L. Hanson et al (“Early neglect is associated with alterations in white matter integrity and cognitive functioning”) and was published in Child Development, Vol. 84(5), pp. 1566-1578.

Before I address the Hanson et al paper, let me point out that I am far from claiming that neglectful care, whether in an institution, a foster home, or the birth family, can possibly do infants and toddlers any good! Nor am I about to say that Hanson et al are wrong in their conclusions, and I will note that the paper’s discussion carefully lays out cautions about the results. However, I am concerned that this paper’s technical pizzazz and use of neuroimaging have the potential for convincing readers that a clear statement about the relationship between experiences of neglect and brain development has been made, whereas it seems to me for various reasons that it has not.

Hanson et al looked at a measure of white matter organization in the brain and compared 25 adolescents who had been adopted from orphanages to 38 individuals in the same age range who apparently had not been adopted (at least I don’t see a statement about this) and were growing up in homes of about the same SES as the post-institutional adolescents. There were 15 males and 13 females in the post-institutional group and 23 males and 12 females in the comparison group. Nineteen of the post-institutional children had been adopted from Romania and Russia, 3 from China, and 2 from Bulgaria, while one family did not report the country of origin. The groups were not different on measures of pubertal status. Neurological measures mapped brain connectivity, not brain volume, and found associations between experience of neglect, decreased white matter in the prefrontal and temporal cortex, and increased problems on a spatial planning task and on a visual learning and memory task. There were also developmental problems in other brain areas that did not appear to be related to the behaviors measured.

This paper reported an enormous amount of difficult work aimed at answering a question of real practical import. So, why do I think it’s a problem if anyone rushes to make use of this study for political purposes? It’s because I have a number of questions about the whole thing.

Most of my questions turn on the fact that adoptive parents were the source of information about experiences of neglect. As far as I can see, the paper fails to state how these parents were brought into the study. Were newspaper advertisements used, or were there contacts with organizations of adoptive parents? Or, is it possible that Hanson et al had a list of nearby foreign-adopted children in the right age range and were able to contact parents and find a reasonable number who were interested? In any of these cases, it is likely that the parents’ own interests and beliefs determined their participation in the study, and those interests and beliefs could also have determined their recollection and reporting of details about the children’s early experiences.

Hanson et al noted that “there was variability in the duration and exact timing of the neglect suffered” as it was reported by the parents, and that the parents’ reports were not correlated with brain or behavioral findings. In other words, the expected dose-response relationship--  more neglect, more problems of brain and behavior--  was not demonstrated. The range of ages at which children had been adopted was from 3 months to 92 months, but the range of time spent in institutional care was 3 to 64 months, suggesting that one or more children had not been placed in the orphanage in the first months of life.

In the adoptive parents’ reports, they “consistently reported [that in the orphanages children had] few one-to-one interactions with caregivers, lack of toys or stimulation, and very little linguistic stimulation before 2 years of age”. Objective reports about orphanages in the past suggest that these are probably correct statements, but one wonders how the parents were able to make such reports. How long did they spend at the orphanage, and how much were they actually able to see of institutional life when no visitors were present? Could it be that their descriptions of their children’s early experiences were determined by what they had heard and expected about these institutions, rather than their own experiences? The highly technical side of the study gives us great detail about neurological and cognitive events, but without clear evidence about experiences of neglect, it’s not possible to conclude that neglect caused the problems.

What else could have caused the adopted children’s developmental problems? Hanson et al point out that there was no information available about prenatal history or about possible malnutrition. (Relevant to this, I searched the paper for references to head size or weight and stature, all measures potentially reduced by malnutrition, and did not find any—although pubertal status ia also a useful measure.)

 Hanson et al noted that malnutrition and social neglect could play separate or interactive roles in shaping development, but I would suggest that elements of social neglect often cause malnutrition even though enough food is available. Most family babies probably have occasional experiences of poor feeding because of maternal distraction (I am thinking of a mother at a party who couldn’t get her 6-week-old to take a bottle as they stood in the middle of a crowded, noisy room), and babies in medical care may be fed insensitively (I am thinking of a NICU nurse who cleaned and diapered a preterm baby with terrible diaper rash, then perched the screaming baby on the end of her knee and pushed a bottle into the child’s mouth). But these events are probably intermittent and temporary for most babies outside of institutions, whereas in an institution it may be a consistent experience to have food spooned in too rapidly or a bottle that is too hard to suck, when overworked and undertrained staff just try to get through the task. A study of the feeding patterns that had been in place at the children’s orphanages might give some very useful information, combining an index of neglect with a view of nutrition.

One of my concerns about this paper is the ease with which proponents of some system changes may jump to the conclusion that effects of neglect on brain connectivity have actually been shown, rather than that a method for looking at this issue has been created.  A second concern is that readers will equate “orphanage” with “neglect”. Given sufficient funding and well-trained staff, there is no reason why group care has to be neglectful. And, if caregivers have few resources and poor information, there is no reason to think that foster care or adoption  never involves neglect--  or even abuse.




8 comments:

  1. I am not an adoptive parent, but I have spent much time volunteering with two NGOs that support orphanages in two very different countries (one a communist country with institutionalized orphanages, and one with privately funded relief orphanages in an African country). I have visited these orphanages with and without others present, and one thing has been common: the children are not cared for as they would be in a family. There are too many children for the amount of workers present, not enough resources, and not enough stimulation for the children. The children appear to actually be more cared for in the private African orphanages, but there they struggle to provide basic nutrition and medical care. In the communist institutional orphanage, they are well funded but the staff appear to just be doing their "job", and don't have a lot of affection or care for the children. Either way, it is a sad, sad thing and I believe that it has to affect the way that young children grow and develop. As a parent, I want to see all children passionately loved and cared for, not treated as a job or a burden.

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    1. Dear Anon-- thanks for these thoughtful comments. It's always helpful to have some direct observations.

      I think there are two points to be considered:

      The first is that the great majority of these institutions are as you say, understaffed with undertrained and poorly motivated people. The children are not cared for as they would be in a GOOD family, but may be as well cared for as they would be in a poorly-functioning "mega" foster or adoptive family.

      The second point is that there are ways to improve the functioning of these institutions, orphanages, foster, and adoptive families alike. But to do so requires money, political will, and understanding of children's real needs.

      It is extremely sad, but I don't think we improve things when the focus is a simplistic one: Family Good, Institution Bad.

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  2. I found your blog while searching for Nancy and Beth Thomas, and just wanted you to know that I love it! You have provided such interesting reads. Thank you.

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    1. Dear Danielle P.-- I am completely flummoxed. I'd really like to know how anyone who is looking for N. and B.Thomas could possibly like what I write. Could you be one of the people who contacts Advocates for Children in Therapy looking for Beth Thomas to be your keynote speaker? If so, there is some confusion.

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  3. http://harpers.org/archive/2013/10/cold-war-kids/
    I wonder if you've read this article in Harper's. I was shocked by how little the journalist knew or cared to find out about the problems with international adoptions or the controversy about the RAD diagnoses. She even contacted Federici who manifestly demonized adopted children, then went on a paranoid, not to mention homophobic, rant about his enemies who he claims are scientologists. There are numerous other red flags raised and not pursued in the article. I'm apalled because I really expect better of Harper's magazine. I am hoping that you will write to them. Perhaps they would publish a letter from you that would undo some of the damage of the article.
    You're a great person!

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    1. Thanks so much for calling my attention to this. I see Harper's wants $21 for it on line, so I'll try my public library. It certainly sounds worth a response. No doubt the reporter Googled the topic and found that Federici has stated his own importance on a number of sites.

      As for great people, aw shucks! I am hoping not to leave the world worse off than I found it, though, and I expect you feel the same for yourself.

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  4. i want to became a doc , soone of my my future palns is to build an orphanage little hightech ,my family is not so wealthy ,is it possible for me to build an orphanage when i became a doctor..............

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  5. I think you need to ask someone else! But the point is that you need to know a lot about children, not so much about technology/

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