No Evidence for Orphanages Being ‘Not So Bad’

Comments to Whetten K, Ostermann J, Whetten RA, Pence BW, O’Donnell K, et al. (2009). A Comparison of the Wellbeing of Orphans and Abandoned Children Ages
6–12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations. PLoS ONE 4(12): e8169. doi:10.1371/journal.pone.0008169






Marian J. Bakermans-Kranenburg, Marinus H. van IJzendoorn
Centre for Child and Family Studies,
Leiden University, The Netherlands

December 24, 2009











MJBK and MHvIJ were supported by awards from the Netherlands Organization for Scientific Research (MJBK: VIDI grant no. 452-04-306; MHvIJ: SPINOZA prize). The authors declare that no competing interests exist.

Correspondence: Marian J. Bakermans-Kranenburg or Marinus H. van IJzendoorn, Centre for Child and Family Studies, Leiden University, PO Box 9555, 2300 RB Leiden, The Netherlands (email: Bakermans@fsw.leidenuniv.nl or vanijzen@fsw.leidenuniv.nl).


“Institutions are not so bad” according to Dr. Kathryn Whetten in her interview in the New York Times of December 18, 2009. In her recent PLoS ONE paper on the Positive Outcomes for Orphans (POFO) survey in 6 sites across 5 ‘low-resource’ countries including 1,357 institution-living and 1,480 community-living orphans and abandoned children (ages 6–12 years), she and her co-authors conclude that health, emotional and cognitive functioning, and physical growth are no worse for institution-living than community-living children. In fact, in most domains institution-living children seem to fare better.

We take issue with this provocative claim that is not supported by the data collected in the POFO study. The first issue concerns the comparability of the institution-living and community-living children. The quasi-experimental design of the survey does not protect against the influence of pre-existing differences between the institution-reared and community-raised children. The second issue pertains to the generalizability of the findings. We argue that any conclusion from the POFO study is limited to a specific age range, a specific set of countries and institutions, and a restricted set of measures on certain developmental domains.

Comparability of the institution-living and community-living groups. The POFO study uses a cross-sectional and quasi-experimental design. Without randomized assignment of subjects to conditions there is always the risk of groups being systematically different (pre-, peri-, and postnatally) in crucial areas of development before they entered orphanages or community-based child rearing settings. In the POFO study there is cause for concern regarding the composition of the community-based care group.
First, almost 65% of the community-living children have a biological mother who still is alive, in contrast to 43% of the institution group. Consequently, a remarkably high percentage of community-living children are raised by their biological parents (55%). It makes no sense to compare this group of home-reared children with institutionalized children to answer the central question of where abandoned and orphaned children should be placed as placement of these children with their biological parent is no option.
The comparisons should be based on three groups: (1) institution-reared children, (2) orphaned or abandoned children not living with their biological parent or grandparent, and (3) a comparison group of children living with (one) biological parent or grandparent. The ‘sensitivity analyses’ conducted by the authors excluding several groups (e.g., non-orphaned children) is an insufficient surrogate for these analyses.
Looking at the data on children residing in institutions for less than one year (Appendix 1B), we have reason to believe that the institution- and community-living children did differ before entrance into their respective settings. Children residing in an orphanage for only a brief period of time (less than a year) show better health, less problem behaviors, and better cognitive development than their community-living peers. These differences might easily have been present before entrance into institutional care, and thus would give the institution-reared children a head start. The large variation in child outcomes within settings may be ascribed to variations in these settings, as suggested by the authors, but might also be due to genetic or perinatal differences among the children – without random assignment we simply do not know.
Of course, a randomized control trial to compare the effectiveness of institutional versus family-type care arrangements for orphans and abandoned children is difficult to imagine. Nevertheless, it did happen. In the unique randomized control Bucharest Early Intervention Project [1] young children living in institutions were randomly assigned to continued institutional care or placement in foster care, and their development was tracked through 54 months of age. Three main findings emerged from the project. First, children reared in institutions showed greatly diminished intellectual performance (borderline mental retardation) relative to children reared in their families of origin. Second, children randomly assigned to foster care experienced significant gains in cognitive function. Lastly, the younger a child was when placed in foster care, the better the cognitive outcome. Indeed, there was a continuing "cost" to children who remained in the institution for longer periods of time. Similar findings have been reported on physical growth parameters and socio-emotional development [2,3].

Generalizability of the findings. The age range of the current study is 6-12 years. It appears from longitudinal studies of institutionalized children that most significant delays are found in the first years of life, and that institutionalized children tend to catch up after their fourth birthday (see e.g. [4], for growth parameters, and the Bucharest Early Intervention Project [1] for cognitive development). A meta-analysis of cognitive development of institutionalized children (including 75 study outcomes) showed a difference of almost 20 IQ-points between institutionalized and family-reared children [5]. But children who were younger at assessment and those who were younger at placement in the orphanage showed more delays than their older peers. The focus on the age range 6-12 years may obscure substantial differences in the years before.
Second, differences may be less visible in the specific outcomes that were included in the current study. The authors are to be commended for the inclusion of a large sample in their survey, but this necessarily goes at the cost of more time-consuming and at the same time more valid observational assessments. As has been documented in a number of studies, the formation of selective and stable attachment relationships is seriously compromised in all institutionalized care settings studied thus far [2, 6-9], and the Strengths and Difficulties Questionnaire is a meager operationalization of the children’s emotional development. Furthermore, long-term effects of institutionalization may have gone “under the skin” and be visible in, e.g., deviant stress regulation, as documented by Gunnar and her team [10] in a study on HPA axis functioning of children adopted from Romanian orphanages; for children residing in Ukrainian orphanages see [11].
Third, the selected regions and countries constitute a small and specific selection of countries where institutionalized care is present to a large extent, and this selection favors the ‘no difference’ outcome. To call countries like Cambodia, Ethiopia, Tanzania, and Kenya ‘less wealthy nations’ is a crude understatement. The aforementioned meta-analysis on cognitive development showed that in countries with extremely low Human Development Index scores there was no difference between family-reared and institutionalized children [5]. The extremely poor living conditions for institutionalized as well as community-care children in these countries may result in a floor effect without any differential effects of rearing condition. To call the well-being of the children living under these conditions ‘not so bad’ is an ethnocentric euphemism.
Fourth, and related, from various studies on institutional care [12] damage appears to be largest when caregiver arrangements are characterized by instability of caregivers and frequent shifts of arrangements during a care schedule of 24 hours, 7 days per week. Precisely that aspect of institutions appears to be less prevalent in the institutions included in the POFO study, where institutional caregivers worked on average more than 100 hours per week, and 37% of the caregivers were present continuously (168 hours per week). This is –alas– not the case in the majority of institutional care settings [1-2, 6-7], and in fact may come closer to a family-type environment but with heavier financial burdens and larger costs for the private life of the caregivers than in more common institutionalized care settings.

The Positive Outcomes for Orphans study (POFO) –nomen est omen- still has some way to go to fulfill its mission. In the meantime, we should devote our resources to the extension foster and adoptive care, and to the improvement of institutional care, which will unfortunately remain a last resort for millions of children for years to come [13].

References

1. Nelson CA, Zeanah CH, Fox, NA, Marshall PJ, Smyke AT et al. (2007) Cognitive recovery in socially deprived young children: The Bucharest Early Intervention Project. Science 318: 1937-1940.
2. Zeanah CH, Smyke AT, Koga S, Carlson E, The BEIP Core Group (2005) Attachment in institutionalized and community children in Romania. Child Development 76: 1015-1028.
3. Smyke AT, Zeanah CH, Fox NA, Nelson CA, Guthrie D Placement in foster care enhances quality of attachment among young institutionalized children. Child Development. In press.
4. Van IJzendoorn MH Bakermans-Kraneburg MJ Juffer F (2007) Plasticity of growth in height, weight and head circumference: Meta-analytic evidence of massive catch-up of children’s physical growth after adoption. J Dev Behav Pediatr 28: 334-343.
5. Van IJzendoorn MH, Luijk M, Juffer F (2008) IQ of children growing up in children’s homes: A meta-analysis on IQ delays in orphanages. Merrill-Palmer Quarterly 54: 341-366.
6. The St. Petersburg – USA Orphanage Research Team (2008) The effects of early socialemotional and relationship experience on the development of young orphanage children. Monographs of the Society for Research in Child Development 73: 1–262.
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11. Dobrova-Krol N, Van IJzendoorn MH, Bakermans-Kranenburg MJ, Cyr C, Juffer F (2008) Physical growth delays and stress dysregulation in stunted and nonstunted Ukrainian institution-reared children. Infant Behavior and Development 31: 539-553.
12. Dobrova-Krol NA, Van IJzendoorn MH, Bakermans-Kranenburg MJ, Juffer F. Effects of perinatal HIV infection and early institutional rearing on social cognitive development of children in Ukraine. Child Development. In press.
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