Today´s Oliver Twist

By Charles A. Nelson

Have you heard about this poor boy Oliver Twist who endured a miserable existence in a child institution in the early 19^th century and decided to escape to lead a better life? Well, it’s just a story the famous author Charles Dickens wrote in 1838, but child institutions are more than just a story. For many children they are a reality they have to live with every day. An estimated 8 million children worldwide (2 million in low-and middle income countries) are being raised in institutions. According to Red Latinoamericana de Acogimiento Familiar, approximately 347, 308 children in Latin America grow up in public or privately run institutions.

Despite the millions of children cared for in institutions over the centuries, until the past decade or so, studies of institutional rearing were quite limited. In the middle of the 20^th century, small descriptive studies comparing children in foster care to children in institutions appeared. These studies uniformly found that children in foster care developed more favorably than children in institutions. The British Psychoanalyst John Bowlby authored a report to the World Health Organization in 1952 describing the plight of children being raised in institutions and advocating for their removal into family or foster homes.

More recently, studies have tracked children´s development post adoption. They have reported significant gains for most children once they were in adoptive homes. The limitation of these studies – both of which suggest that being raised in families is better for children’s development – is that it is unclear why some children were institutionalized and others were not, and why some were adopted and others were not. In other words, the possibility of systematic bias in both types of studies exists. In the older studies, children may have been assigned to institutions because they had problems, and in the more recent studies, children may not have been adopted because they had problems. Importantly, these biases both favor children reared in families. Though the consistency of their findings is notable, the number of studies is limited, and the possibility of bias cannot be ruled out.

This is what motivated researchers from Tulane University, University of Maryland, and Children´s Hospital in Boston in 2000 to launch the Bucharest Early Intervention Project (BEIP) (of which I am a member), to fill the knowledge gap and address limitations of previous studies. The main objective of the BEIP is to understand how institutional care affects both brain and behavioral development, and whether removing abandoned children from institutions and placing them in families helped reversing many of the negative effects of institutional rearing on the child’s development.

For the study we selected 136 young children from 6 institutions in Bucharest, Romania. These children had been abandoned to institutions in the first weeks or months of life. Half of the children were randomly assigned to a foster care intervention that our team developed, maintained and financed, and the other half were assigned to remain in the institution. A third group of children was included in the study; these children have always lived with their families and have never been institutionalized.

We are studying these three groups of children for more than a decade now. Today, the children are between 12 and 13 years of age and findings regarding the effect of child rearing in institutions are both remarkable and distressing. First, we have found that the development of institutionalized children lags far behind children who have never been institutionalized. Second, institutionalized children show dramatic reductions in their IQs, language performance and the brain’s electrical activity (EEG); they also show a very high prevalence of attachment problems and mental health problems. However, we have also observed powerful intervention effects. Regarding the former, we have consistently observed that previously institutionalized children placed in foster care show increases in IQ, language, and attachment (to name but three), particularly if they were placed before 2 years of age. 

It is worth noting that there are a few domains where children did not benefit from the foster care intervention; for example, the prevalence of attention deficit hyperactivity disorder is very high (approximately 20%) among both institutionalized children and children in foster care. Similarly, both groups show impairments in executive functions (so-called higher cognitive functions, such as planning ability).

The BEIP provides solid scientific evidence for raising children in families and against raising children in institutions. There are therefore powerful lessons here for the millions of institutionalized children in Latin America and around the world.

Prof. Nelson holds the Richard David Scott Chair in Pediatric Developmental Medicine Research at Children’s Hospital, and is also a professor of pediatrics, neuroscience, and psychology at Harvard Medical School and a professor in the department of society, health, and human development in the Harvard School of Public Health Medical School and Harvard Center on the Developing Child. He studies the brain and behavioral development of young children, focusing in particular on those children for whom early development has somehow gone awry (or is at risk for going awry), either as a consequence of adversity early in life or because of biologically based injury.