Concerned About Unconventional Mental Health Interventions?

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

Tuesday, January 14, 2014

Orphanages, CHIFF, and UNICEF Recommendations: Is There Science Behind Anti-Orphanage Positions?

When care for children without functional families has been discussed recently, a single perspective has been paramount. This is the belief that group care in institutions (orphanages) is “toxic” to good development, and that individualized foster care and adoption are the only acceptable choices. The proposed Children In Families First (CHIFF) legislation in the U.S., and the recommendations made by UNICEF about shifting from orphanages to foster homes, are both based on the claim that scientific evidence strongly supports the idea that institutional care is in and of itself harmful to children’s development.

However, the existing evidence is not nearly as strong as some proponents argue. Today, I want to present some sources of relevant information, including both older and more recent studies, and to look at their conclusions and the evidence that supports them.

Historically, it has been fairly common for children, even infants, to be cared for in groups. Valerie Fildes, in her fascinating book Wet Nursing, looked at the practice in France of sending infants to be breastfed in the countryside for the first two years of their lives. The mothers, who were usually skilled textile workers, could continue to contribute substantially to the family’s earnings, while the wet nurse did well for herself and her family by caring for multiple infants. The mothers might or might not visit their babies, and the children were badly distressed when suddenly transferred back to their family’s care and separated from the only caregiver they knew. This does not seem to us post-Bowlby readers as a very good idea, but in fact (as James Robertson was to point out much later), when the children were then cared for sympathetically, most of them did very well. A somewhat similar situation existed in World War II Britain, when quite young children were evacuated from London to unfamiliar places and multiple caregivers   ( see Churchill’s Children, by John Welshman), or were cared for in group homes like Anna Freud’s Hampstead Nurseries. Again, good developmental outcomes were the rule, rather than  a “toxic” effect lasting through the children’s lifetimes.
No one would claim that wet nursing or evacuation were interventions that we would expect to be beneficial to development, but they seem to have done very little harm, and along with ethnographic data suggest that human beings do not require a single, restricted set of experiences in order to thrive in early life.

Like other wars, World War II created many orphans, and institutions for their care were established. Even when the war orphans were close to adulthood, institutions continued to exist to help unmarried mothers to deal with pregnancy and to care for children after birth. As these institutions were in existence contemporaneously with John Bowlby’s formulation of attachment theory, and because their arrangements were in conflict with Bowlby’s (now discarded) tenet of monotropy (the need for an infant to form an attachment to a single caregiver), many questions were asked about the effects of institutionalization on early development.

One institution that received much early attention was the Metera, a Greek foundation for unmarried mothers and their babies. According to a 1960 article in a popular magazine (possibly not very accurate), an infant born in the Metera  was assigned, along with two other young infants, to two caregivers who lived in the institution, and who moved along with their three infants to a different ward if a transfer was made. Family members could visit the children, but the emphasis was on the relationships with the caregivers; adoptions were to be arranged within a few months if possible. However, by 1979, practices in the Metera seem to have changed—or perhaps they were never as positive as previously indicated. Berry Brazelton and two colleagues examined neonatal behavior of Metera infants, as compared to other groups (Pediatrics, 63(2)), and found worse performance on the part of the Metera children at birth. They attributed these difficulties to the extreme disapproval of unmarried pregnancy in Greece, and the attempts of the mothers to starve themselves before they arrived at the Metera--  but also mentioned that the infants were in unstimulating white cubicles and fed on a strict 4-hour schedule. More recently, Vorria et al (“Early experiences and attachment relationships of Greek infants raised in residential group care”, Journal of Child Psychology and Psychiatry, 2003, 43 ,pp. 1208-1220) looked at the development of children who remained in the Metera for many months, and found that an unusually high number of them showed disorganized attachment (that is, atypical behavior when a caregiver returns after a separation in a strange place, for example, freezing in place or backing toward the adult). However, some showed secure attachment. The children, who had incidentally had much lower birth weights than a control group, were less advanced cognitively than home-reared controls. Vorria et al noted that although there were claims that the Metera babies had plenty of interaction with a small number of caregivers, in fact they had little interaction in the early months, and were later moved to a pavilion where the ratio of babies to caregivers was 4-6:1, a situation where the best-trained and best-motivated caregiver would have difficulty in being sensitive and responsive to all infant signals.

The interesting point about these studies of the Metera is that although there was little question that the institutional babies fared less well than home-reared babies did, the authors did not attribute the problems to any single factor, particularly not to institutionalization in and of itself. On the contrary, they looked at characteristics of the infants’ pre-birth experiences and at specific characteristics of the institution as possible causes of poor development.

The recent research on which CHIFF and the UNICEF recommendations depend is the Bucharest Early Intervention Project (BEIP), conducted by the eminent child psychiatrist Charles Zeanah and many collaborators, and reported in a growing number of publications. The BEIP research is unique among investigations of  institutional effects on children in that it involved a randomized controlled trial (RTC), the highest level of research design, and one which does much to assure that outcomes are caused by the treatments the children experience, rather than by other unknown factors. As described by C.H. Zeanah, N.A. Fox, and C.A. Nelson in 2012 (“The Bucharest Early Intervention Project…”, Journal of Nervous and Mental Disease, 200, pp. 243-247), this project worked with 136 children 6-31 months old who were being cared for in Romanian orphanages. Children were assigned at random to remain in the institution where they already were or to go to a foster home.

BEIP authors have given clear descriptions of the resources poured into the foster homes. The work included establishment of a foster care network, as well as training of social workers who would oversee and encourage the development of relationships between the foster children and their caregivers. The social workers also received weekly consultations with expert psychologists in the U.S. It is notable, by the way, that the training and resources involved here were probably a good deal greater than those available to foster parents in the U.S. or the U.K.

Publications on the BEIP have given much less detail about the experiences of the children who were randomized to institutional care. It would be of much interest to know details of these experiences such as the ratio of infants to caregivers or the sizes of groups (these factors generally being considered to have strong effects on the outcomes of day care). The 2012 article by Zeanah et al references the well-publicized appalling conditions in Romanian institutions for children following the fall of the Ceasescu regime in 1989, but does not provide much information about ways in which orphanages might have changed (for better or worse) in the ensuing period. This lack of information about the experiences of the children randomized to the institutional treatment arm makes it difficult to know what factors actually differed between the two groups, and to what extent they were different.

An additional difficulty of design has been pointed out by Douglas Wassenaar, writing in Infant Mental Health Journal in 2006. Wassenaar noted a problem of scientific validity in the BEIP study: the fact that evaluators should have been, but were not, “blinded” to (unaware of) the treatment being received by each child, for “both the ‘soft’ psychosocial evaluations, which are notoriously subject to rater bias, and some of the more ‘objective’ physical evaluations”. Wassenaar also pointed out that this matter should have been discussed by Zeanah and other BEIP authors, as an important issue with respect to confidence in the conclusions, “particularly in view of their expressly stated bias favoring deinstitutionalization”.  

In spite of these difficulties and criticisms, BEIP participants (and many others) have continued to state general conclusions that the project has shown the advantages of foster care over institutional care for young children. Fox et al, in the Journal of Child Psychology and Psychiatry in 2011, stated that children raised in institutions exhibit lower IQ scores than those raised in family settings.

However, even setting Wassenaar’s concern about blinding aside, it’s necessary to question what the BEIP data actually show. Is it not that children who were in high-quality, resource-rich foster care did better than children who were in institutions whose quality was not clearly described but may have been abysmal? Is the conclusion not that a particular group of children, in one set of conditions, did better than another group, in a specific other set of conditions? Those conclusions are a far cry from saying that institutions are “toxic”, and that all possible institutional variants are harmful in comparison to all possible variants of adoption or foster care (including, perhaps, “mega-families”). The latter statements smell strongly of the “expressly stated bias favoring deinstitutionalization” mentioned by Wassenaar and evident in CHIFF and other proposals.


What would have happened if the training and resources lavished on the foster homes were also provided for the  Romanian institutions? That’s the question that must be answered as a step toward understanding whether institutions are “toxic” (and I would like to see that sensational “toxicity” metaphor abandoned, as it distracts from rational discussion). Until we have further information, it will not be time to say that science supports one view or another of care for children without parental care. When such statements are made, they should be recognized as the ideological positions they actually are.

30 comments:

  1. You should read Mother Nature by Dr. Sarah Blaffer Hrdy. She did actual research on that French practice (and other types of allo-parenting), and the death statistics were actually pretty grim.

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    1. Actually, Hrdy cited Valerie Fildes' two books, and Fildes was the original researcher. That's why I cited Fildes.

      Certainly infant mortality was high among children who were "at nurse", but it was also far higher than we can really imagine today, for all babies at the time. The reasons for the death rate for children in the care of wet nurses are pretty obvious in terms of our present understanding of contagious disease and of the potential dangers of feeding methods other than the breast, in the absence of pasteurization and sterilization (wet nurses often did not have sufficient milk for all their charges and supplemented feedings in ways that caused serious disease).

      In any case, my point was not that we would do well to go back to the old wet nurse routine, but that there have been many ways humans have cared for babies in groups, and information about those can be useful to us.

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  2. Yes, there is a problem with the CHIFF bill stating these assumption in its "Findings":

    "Science now proves conclusively that children suffer immediate, lasting, and in many cases irreversible damage from time spent living in institutions or outside of families, including reduced brain activity, reduced IQ, smaller brain size, and inability to form emotional bonds with others."

    This study, actually with a bias against orphanages, that found outcomes for children in the orphanages of six countries to be quite good:

    "Orphanages Rival Foster Homes for Quality Child Care"

    http://www.scientificamerican.com/article.cfm?id=orphanages-rival-homes

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    1. It's sometimes hard to figure out what's the difference between a small orphanage and a large foster home. A lot of this may boil down to the well-known issue on day care quality, that small groups work better than large groups-- although of course, with consideration of this, you can have small self-contained groups in a large institution.

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    2. Orphanages - open not for experimentation over nature, but to save children from hunger, cold and neglect .. In Russia, the number of children's homes increased after the wars and revolutions. These orphanages saved the lives of millions of orphans. It is difficult to understand for people who have long had not wars on its territory. Adoptive families? If you have nothing to feed their children ..... these families do not adopt someone else's child. We must be realistic and understand the situation in a foreign country. Does not make sense to shout about irreversible changes in a child's brain if there are many thousands of successful graduates of children's homes and hundreds of famous alumni. You can not destroy the last haven for poor children if not a real possibility arrange all orphans in good foster homes. Bad foster family ... is repeated trauma to the child and the loss of faith in the goodness and justice ..

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    3. Thank you, Mihail,you make some very good points!

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    4. Thanks , Jean Mercer ,

      Increased funding orphanages already yielded positive results. In Псковском region has increased the number of orphanage graduates wishing to pursue higher education ..... There was a need to create a charitable foundation to support students - orphans. Where have "irreversible changes" in the brain of these orphans? I think more research is needed to be based not only on the experience of Romanian orphans in 1990.

      http://www.rcws.org/programs_scholarship.htm

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  3. Imperial Orphanage. St. Petersburg
    Was opened in 1772
    As conceived by the founders, the Foundling Hospital was supposed to be a place of formation of a new type of people, the so-called Third Estate "merchants, artists, amanufacturers and traders"; But infants had a high mortality. . Nurses tried to save the children. . They tied the weakest children to his body and wore them like African women are African children. Only in this way managed to save some children. FINALLY orphanage became distribute infants toddlers in peasant families. Children stopped dying. . Older children had no such problems and they received good education and a chance at a successful life .

    http://www.encspb.ru/image/2837863719/1

    http://www.kvartira78.ru/public/images/galleryblock/145/b_1f4f729a6bd5a28e01f86ba51d6834e4.jpg

    http://www.encspb.ru/object/2855755026?dv=2853951676&lc=ru

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    1. I'm not sure what you mean to conclude, Mihail. Do you understand why there would have been high infant mortality in groups in those days?

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  4. Yes. This is a different infektsii.Siroty have little immunity to infectious diseases. Different women breastfeed these children .... This did not allow the child to develop a defense against various infektsiy.V then there was Arem vaccinations and antibiotics ... so the babies died.

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    1. I don't think that it would make a difference that more than one woman nursed a baby. My guess would be that there was also supplementary artificial feeding, and in the absence of understanding about infectious disease that would be an important source of infection and mortality.

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  5. That's what I wanted to write. Infectious diseases were the main cause of the high mortality rate of infants orphans. But bad translation. But I keep thinking that different women were also contribute to infectious diseases. I know that peasant sometimes used goat milk for feeding infants, but if they could not find a woman breastfeeding for the baby. Cow's milk is not used for feeding infants in Russian peasant families. I think at that time was not a big problem find lactating women for the child. All Russian aristocrats in those days used peasant women for feeding noble children .. This does not create any problems with distortion attachment but were literary works in which adult noble children thanked peasant women.

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    1. Sorry I misunderstood the translation! Yes, I think it was common for peasant women to be "wet nurses". Were you thinking that perhaps the intimate contact with more than one woman exposed a baby to more contagious diseases?

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    2. Yes.The intimate contact with more than one woman and the lack of antibiotics. exposed a baby to more contagious diseases .

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    3. I was not mistaken. Many different women were fed breast milk these orphans.
      ".... In 1797 the Empress ordered annually allocate 9,000 rubles for content in an orphanage lactating women."
      (Categories / Charity in St. Petersburg / History / child care)

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  6. Breast milk promotes emergence of immunity. Arises of the child's ability to resist certain infections. If a woman has immunity against some infections then the child will also have immunity from these infections. But if women are different .... the child's body does not have time to create a defense. Vaccination is also a small infection but if vaccinations every day ..... the body can not cope and the child dies. I think so.

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  7. Excellent article and certainly a good place to start a debate. My experiences in Uganda working for Government reviewing standards in orphanages and developing alternative care led me to visit many orphanages. The subsequent comprehensive baseline study was clear though that the standards in the majority of these places were appalling, abusive and damaging for children in nearly every way. Saying that the few who upheld the high standards by the Government were very good and had more of a foster-based approach. Truth is that when care systems are good they can be very good but when bad can be very bad and damaging. CHIFF though only ever concentrate on the bad in order to push their IA agenda. What is not in dispute in Uganda is something that people behind CHIFF does not want to hear.... that nearly ALL children do not need to be in an orphanage (however good or bad the standards) or in alternative care. Most could and should be home in their own communities. The push and pull factors are often made by orphanages themselves and one telling comment that was repeated throughout a series of 10 workshops across the country was that when asked why children ended up in orphanages was "Because they exist"... So for me a major focus should be regulating and implementing better gatekeeping and child protection systems to stop children being placed into orphanages in the first place. If they do end up there we believe we can find Ugandan solutions. And for many children where resettlement or community placements are not an option high quality institutions are a good option. But the damaging orphanages where children are abused, malnourished, forced into a religion, beaten and have little or no care from caregivers absolutely need to close.

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    1. Dear Mark-- thanks so much for giving this important perspective! Unfortunately, the IA advocates do not seem to be aware that in Uganda, in Russia, and in many other places, the children in "orphanages" are often not technically "orphans", and there are many better solutions to their problems than adoption.

      I would like to see institutions (when they are needed) take advice from what is known about nonparental day care: that outcomes are much improved when children are in small, consistent groups, and especially when they have assigned caregivers, each of whom deals exclusively with a small number of children except in emergencies. These characteristics may be what you call a foster-based approach, and I would speculate that the advantages reported for foster care have to do with the characteristics I've just mentioned, not with being in a "home" rather than a large institution.

      Your reference to forced religion is an important one, and I want to point out that in my state, New Jersey, there has recently been a case where a foster parent insisted on re-naming the child of a Muslim family and taking him to church, in spite of the protests of the birth family. Orphanages are not alone in this practice, and it would seem that one of the goals of IA is to have adoptive parents do the same thing.

      I don't know whether you see the journal "Zero to Three", but there was an article in the last issue that restated the firm conclusions drawn from the Bucharest Early Intervention Project about foster homes. The next issue will include a letter to the editor from me, questioning these conclusions, as well as a reply from the original authors.

      Thanks again for your comments.

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    2. For readers who would like to see more discussion by Mark and others on the Uganda situation, see http://childrendeservefamilies.com/unicefs-fingerprints-hurting-orphans-in-uganda and scroll down to the comment section.

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  8. In Russia, trying to emulate the Austrian experience orphan care. SOS Children's Villages. This 10-15 houses, each house lives one family - "professional" foster mother, aunt (au pair) and 6-9 children. Russia just six such villages. 2 children's village under construction. Each family has their own financial budget .. In conventional orphanages have also begun to form small groups of different ages with one permanent caregiver. Like moving eventually all children's homes close or convert in the family's home. There is hope that will only, profile childrens scrap (music, sports, military ....) and SOS Children's Villages. Orthodox orphanages will also continue to function. . They have a positive successful experience in educating orphans.

    SOS Children's Villages.
    http://www.sibchildren.ru/articles/article_3222

    http://www.1tv.ru/news/world/195919

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    1. Mihail, do you suppose these "villages" are being considered as foster families? Or is there still consideration of sending children to foster parents in their own homes?

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    2. No. Children in villages are unlikely to be adopted. It almost never happens. These children can return to their biological family. Very strong psychological factor. mother gets used to children and children get used too. Conversion to another family ... it re-injury. Russia has a lot of orphans and primarily subject to adoption of the usual children 's homes. Children from children's villages have good support and control after release. They go into a youth hostel 16 years and have a course of socialization and preparation for independent living. They have the opportunity to visit the house in the children's village and live there if do not like the hostel. Theoretically adoption possible. but it never happens.

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    3. Yes. In the children's villages have nursing babies. It depends on the willingness of mothers-tutor. Usually kids have siblings in the family. These children receive the apartment after finishing his education. All orphans are entitled to get an apartment .. But often it is a long waiting period and the bureaucracy and judicial scandals. Children from children's villages quickly get an apartment. I guess it depends on the administration children's villages. Moms - tutors also genuinely interested in the welfare of children. Very often you can see that they are engaged with the grandchildren and help adult children ..

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    4. I wonder whether we are having a translation problem? In English, "nursing" babies usually means they are being breastfed, but I can't think you mean that. Do you mean they are bottle-fed?

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    5. translation problem))

      Of course kids have artificial feeding. Breastfeed adopted children is rare, and even extravagant phenomenon in Russia. However, there are already experimenters-amateurs. It may be fashionable in some time, but not now.

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  9. SOS Children's Villages have the status of an orphanage. But the family has its own budget. Each family has its sponsors. Children from the same family can attend different schools. Children themselves buying food ....... all as well as in an ordinary family, but it is a children's home.

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    1. Thanks for this information, Mihail. I am also wondering, are infants and young children also placed in these family-style arrangements? What would you say are the youngest children to go there? If there are young children, are there also larger numbers of caregivers?

      I think it's very important to consider the many ways human beings have found to care for parentless children. The old-fashioned Israeli kibbutz nurseries offered another model.

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    2. This Children's Village in Tomilino (near Moscow) In this village was placed. "Very aggressive and dangerous" Artem Saveliev. In this video, he draws a house trees flowers and a pram in which the baby sleeps.

      http://www.youtube.com/watch?v=_FqvPNNOt44

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  10. can not destroy all the children's home. There are success stories of public воспитания orphans. . 95 % of orphans have relatives . Sometimes it does not make sense to break off these relations roughly device for dubious foster family. Not always older children can get used to and love adopters. This does not mean that children do not know how to love . This means that the child loses the last contact with relatives is sometimes irreparable loss if inadequate action adopter . Sometimes assistance worse inactivity. One well-known charitable organization sent dog food to a starving African region . People were demoralized and humiliated . Was a terrible international scandal . But philanthropists did not want to offend people specifically . They sincerely want to provide emergency assistance and prevent the extinction of humans. But this assistance was like a blow below the belt .

    Orphanage musical development (near Moscow ) .

    http://www.youtube.com/watch?v=G6GTz8YQRsk

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    1. Your points are well taken. When help is given, it should be the help that is needed. I'm reminded of a situation where bags of dry milk were given to people who were lactose-intolerant, making them pretty sick and certainly suspicious of further "help".

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