The long road home
2007
The long road home
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| Abandoned in a Romanian orphanage, Florin now lives with his adoptive mother, Clara. |
While helping place Romanian orphans in foster homes, American researchers are learning valuable lessons about what impact deprivation has on the brain—and whether its effects can be reversed.
Florin lives with his adoptive family in a Bucharest apartment building where trellised grape vines arch the front path and white lace curtains filter the morning sun. A portfolio of his drawings sits by his bed; the aroma of fresh coffee fills the hall.
Lazing in PJs, this dark-haired, almond-eyed 6-year-old rests a cheek on his mother's shoulder as he watches cartoons. He wants to create them one day. "I will make my drawings more beautiful and more beautiful," he says, "and the best ones will be shown on TV." He is confident his teacher will find the best station to broadcast his pictures.
The ordinariness of Florin's life couldn't have been imagined based on where he started. Abandoned at birth in a maternity ward, he spent his first 11 months in one of Romania's infamous orphanages. Babies weren't held when crying, fed when hungry or changed when wet. Rarely did someone hum a lullaby to quiet the infants to sleep or delight them with peek-a-boo. They were left lying on their backs in cribs for hours, staring up at bare white ceilings.
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| Photographer Michael Carroll first visited Romania in the days after Communist dictator Nicolae Ceausescu was overthrown in 1989. His intention was to chronicle the country's AIDS crisis, but he became so consumed with the plight of the country's orphans that he founded the Romanian Children's Relief Foundation. "It was impossible to see the conditions these children were living in and not do something about it," he says. In the 18 years since that visit, Carroll has been back to Romania dozens of times, taking photos of not just the orphans and the aftermath of the Communist regime, but also the country's beautiful countryside and striking people.
Audio Slide Show This slide show, which is narrated by Carroll and features photos he took during his many visits to Romania, offers a description of the country and the story of Romania's orphans. | |
| Many media outlets have produced other kinds of stories about the Bucharest Early Intervention Project and the doctors helping the Romanian orphans. Below are a few of them: The Boston Globe, November 11, 2006 NPR's "All Things Considered" September 16, 2006 The Guardian (London) February 18, 2006 |
Older children fared no better. They were fed and clothed, their medical needs addressed, but they sat alone while caregivers watched TV. They ate from bowls with their hands. They slept two to a short, narrow bed, many sitting up. Boys and girls wore the same clothes, the same haircuts, the same sorrowful eyes. These were children who had rarely seen a crayon, let alone drawn cartoons.
Florin could well have been one of them. But in 2001, he became part of the Bucharest Early Intervention Project (BEIP)—the first randomized study in the world to investigate whether foster care could heal the emotional and behavioral wounds of severe early childhood deprivation. Funded by the MacArthur Foundation'sResearch Network on Early Experience and Brain Development, BEIP has not only delivered Florin to normalcy, it has fueled a massive overhaul of Romanian child protective services. Its findings back with hard, cold numbers the common-sense observation that children fail when deprived of normal emotional and social interaction: dismal IQ scores, high percentages of mental illness and abnormally low heights and weights.
More importantly, BEIP's initial findings suggest that consistent, high-quality foster care, begun early enough, may reverse many of these losses and salvage young lives. These hopeful findings have implications for the services developed not just for children abandoned in Romania, but for the millions orphaned by AIDS in Africa, displaced by war in Afghanistan or shunted from one inadequate foster home to another in the United States. They may deepen our understanding of normal development, too, shedding light on "sensitive periods" during which language, emotional attachment and other vital capacities must form or be lost forever.
Heartrending opportunity
BEIP brought three prominent American researchers to Bucharest: Charles Nelson, PhD, director of research for Children's Hospital Boston's Developmental Medicine Center; Charles Zeanah, MD, chief of Child and Adolescent Psychiatry at Tulane University; and Nathan Fox, PhD, professor of Human Development at the University of Maryland. Zeanah is an expert on emotional attachment, Nelson and Fox on how early experience molds the developing brain.
BEIP brought three prominent American researchers to Bucharest: Charles Nelson, PhD, director of research for Children's Hospital Boston's Developmental Medicine Center; Charles Zeanah, MD, chief of Child and Adolescent Psychiatry at Tulane University; and Nathan Fox, PhD, professor of Human Development at the University of Maryland. Zeanah is an expert on emotional attachment, Nelson and Fox on how early experience molds the developing brain.
"For the brain to wire correctly, it needs input," explains Nelson, a psychologist and neuroscientist. "Children living in institutions lack stimulation on a grand scale, so we expect them to experience a range of problems due to 'errors' in brain development."
When the researchers first visited Romania in the late 1990s, they saw teenagers the size of 8-year-olds, not because of poor nutrition, but because emotional and social deprivation inhibit growth. They witnessed rows of toddlers who, lying alone for hours, waved hands repetitively in front of their faces in an effort at self-stimulation. Language and attachment, learning and attention, emotion, behavior, IQ—all can be damaged when infants are denied the coos, smiles, and consistent, one-on-one care of a normal childhood.
Such problems had been reported in the literature, but when the BEIP began, research was sparse and no study had rigorously investigated one of the most critical questions: Could foster care provide an effective antidote to early deprivation? Could institutionalized children placed with families catch up verbally? Cognitively? Emotionally? Could they thrive? Romania is providing a heartbreaking but rich environment to find answers.
Tragic legacy
In the 1960s, Romania's Communist dictator Nicolae Ceausescu decreed that the nation would be self-sufficient. Romania was to make its own bread, shoes, steel, missiles—nothing would be imported. But the state needed workers. Ceausescu mandated that all families have five children. He banned birth control and abortion and forced women to undergo gynecological exams at work to assess their fertility. He financially rewarded families for having two or more children and taxed them for every child shy of five. When families began having children they could not afford, Ceausescu built child placement centers.
In the 1960s, Romania's Communist dictator Nicolae Ceausescu decreed that the nation would be self-sufficient. Romania was to make its own bread, shoes, steel, missiles—nothing would be imported. But the state needed workers. Ceausescu mandated that all families have five children. He banned birth control and abortion and forced women to undergo gynecological exams at work to assess their fertility. He financially rewarded families for having two or more children and taxed them for every child shy of five. When families began having children they could not afford, Ceausescu built child placement centers.
By 1989, when Ceausescu's government fell, more than 100,000 Romanian children were living in state-run institutions. As images of the children's stunted bodies, blank eyes and disturbed behavior began flooding the media, Romanians were as stunned and appalled as the rest of the world. The post-Communist government began improving conditions in the placement centers.
Saving the children
By the time Nelson and his colleagues arrived a decade later, the government had begun reuniting children with their birth families, cutting Romania's institutionalized population in half. But the country had only the beginnings of a foster-care system and no tradition of adoption. Indeed, anyone who took in another person's child was assumed to have only the darkest intentions. But a passionately committed Minister of Child Protection, Cristian Tabacaru, understood the value of family-based care and was determined to move children out of institutions and into the community. When the American researchers outlined their ideas for the BEIP, he recognized that their study could provide scientific data to convince local officials and professionals of the value of family-based care. Tabacaru offered enthusiastic support, including space for offices and a lab.
By the time Nelson and his colleagues arrived a decade later, the government had begun reuniting children with their birth families, cutting Romania's institutionalized population in half. But the country had only the beginnings of a foster-care system and no tradition of adoption. Indeed, anyone who took in another person's child was assumed to have only the darkest intentions. But a passionately committed Minister of Child Protection, Cristian Tabacaru, understood the value of family-based care and was determined to move children out of institutions and into the community. When the American researchers outlined their ideas for the BEIP, he recognized that their study could provide scientific data to convince local officials and professionals of the value of family-based care. Tabacaru offered enthusiastic support, including space for offices and a lab.
The researchers decided to follow three groups of children: those institutionalized, those moved from an institution to foster care and a control group of children who had always lived at home. The idea was to evaluate them on every conceivable developmental dimension: brain activity; emotional, intellectual, behavioral and language development; attachment to caregivers; and mental health.
But could they succeed? The team would be running this complex, multi-year project from 4,000 miles away. They needed a project coordinator, preferably bicultural, who could manage the local research staff. They needed to train that staff: Most psychologists and social workers in Romania have only undergraduate degrees and no research training. The American researchers also needed to negotiate the legal, cultural and ethical issues of studying the abandoned children, and establish a foster care network. They didn't even know if the children would cooperate or if the electrical power would be sufficient to run their equipment.
Nelson, Fox and Zeanah had visited the placement centers, however, and had seen children lying in their cots—often crying—unattended for hours. They had witnessed the consequences. As scientists, they recognized a unique opportunity to study a phenomenon that had received little attention. As men, as fathers, they were drawn to help. "I kept thinking, things happened to these children that were entirely preventable," says Nelson. "It was a conscious decision to rear them like that."
"It was impossible to go into those orphanages and not have rescue fantasies," adds Fox. "The first time there I saw a little girl with black curly hair. The parents who had abandoned her were visiting, then they just left her, abandoning her again. I wanted to put her in my suitcase and get her out of there."
A program launched
Thanks to the cooperation of the Romanian government and the child welfare agency SERA Romania, plus the political and organizational savvy of BEIP's first director, Sebastian Koga, MD, the project completed a successful pilot study in 2000 and began work in earnest in 2001. The researchers had identified 69 qualified foster families, so were able to enroll 136 institutionalized children in the study. Another 68 children from the community served as controls. All were between 5 and 30 months old.
Thanks to the cooperation of the Romanian government and the child welfare agency SERA Romania, plus the political and organizational savvy of BEIP's first director, Sebastian Koga, MD, the project completed a successful pilot study in 2000 and began work in earnest in 2001. The researchers had identified 69 qualified foster families, so were able to enroll 136 institutionalized children in the study. Another 68 children from the community served as controls. All were between 5 and 30 months old.
The institutionalized children were randomly assigned to either remain in the placement center or to enter foster care. Florin was one of the lucky ones placed in foster care. His foster mother remembers when he first arrived. At 11 months, he could not sit up. He didn't smile. This little boy who now avidly describes each detail of his paintings did not babble as an 11-month-old baby should. "He would only say 'na, na, na' when I changed his diaper," recalls his mother. "He didn't like being touched."
Yet Florin was in better shape than many. Nelson and his colleagues assessed all the children before any were placed in foster care. Compared to typically developing children in the community, those in the orphanage had dramatically lower IQs (an average of 65 compared to 103) and substantially higher rates of mental illness (43 percent versus 14 percent). They smiled less, laughed less and were less likely to initiate or respond to social interaction. Their language skills were blunted, as was their ability to form healthy relationships with caregivers. Their brains reflected this paucity of development, showing significant reductions in electrical activity.
The consequences of living in the emotionally sterile institutional environment were not surprising. But the findings gave urgency to the researchers' most important question: Could foster care reverse the damage? The answer has been emerging over the past five years.
Signs of success
The BEIP provided what Nelson dubs "super-duper foster care." The project gave each family a stipend and paid for diapers and toys. A pediatrician was on call 24/7, and a social worker was sent to each home every seven to 10 days. Weekly videoconferences with the researchers back in the States let the Romanian team troubleshoot problems beyond their expertise.
The BEIP provided what Nelson dubs "super-duper foster care." The project gave each family a stipend and paid for diapers and toys. A pediatrician was on call 24/7, and a social worker was sent to each home every seven to 10 days. Weekly videoconferences with the researchers back in the States let the Romanian team troubleshoot problems beyond their expertise.
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| Children's researcher Charles Nelson, PhD, and colleagues first went to Bucharest, Romania, in the late 1990s. Their goal was to see what effect extreme social, emotional and physical deprivation had on the country's orphans. |
When the children turned 9 months old, then 18, 30, 42 and 54 months, the researchers repeated the initial assessments. They are still analyzing data (and planning a follow-up study when the children turn 7 to 8 years old), but the results so far are encouraging. The foster-care children show huge gains in intelligence, with jumps as great as 10 to 12 IQ points. They've also shown improvements in language development; the ability to form healthy relationships, even if they were withdrawn in the institutions; and improved mental health, with rates of anxiety and depression having plummeted.
Researchers have also found that the age at which a child went into foster care matters: Those placed before age 2 are talking nearly as well as their community peers; those placed later are barely improving. Similarly, IQ, weight and height gains are greatest for children placed at younger ages.
Some problems remain stubbornly unchanged regardless of the child's age at placement, however. To children with a disorder called indiscriminate friendliness, for example, all adults are interchangeable. "I remember one little boy who acted like I was his father even though he'd never seen me before," recalls Nelson. "I was there, so he grabbed my hand. He needed an adult to take him somewhere." Children like this boy are not forging the trusting relationships with specific caregivers that form the basis for intimacy throughout life.
And while many children with depression and anxiety get better, those with behavioral disorders such as attention deficit hyperactivity disorder (ADHD) don't seem to be improving. This could be because the developmental window for shaping attention and behavioral control slams shut very early, before the children entered foster care, explains Nelson. But it could also be that behavioral disorders simply take longer to resolve.
The researchers are planning a new follow-up study to explore this question, among others. "Everything could change dramatically when we see the kids at 8 years," says Nelson. "Our intervention may have had a huge effect at first, but over time, the children could regress. It's equally possible, though, that they're holding their own or continuing to improve. We need to find out."
A lasting impact
For Florin, the gains have been enormous—and they've included a permanent family. His foster parents adopted him in 2004. "We loved him from the very first day," says his mother.
For Florin, the gains have been enormous—and they've included a permanent family. His foster parents adopted him in 2004. "We loved him from the very first day," says his mother.
Florin is one of 10 BEIP children who have been adopted so far. But for every Florin, another 3,000 Romanian children remain in institutions. The bleak orphanages in which teenagers the size of 8-year-olds once languished in row after row of metal-barred cribs are long gone, but the institutions that remain can still elicit rescue fantasies. A dorm in which 5- and 6-year-olds sleep is a sea of wooden bunk beds, each with a thin mattress blanketed in blue or red. No teddy bears or books, no Winnie-the-Pooh pillowcases or finger paintings proudly taped to bedposts adorn these beds. The anonymity is bearable. The gagging odor of urine and sweat is not.
The government is working vigorously to provide alternatives for these children. It continues to reunite biological families and has built a network of foster homes and small group residences. Spurred by BEIP findings, it has banned institutionalization for children younger than 2, unless they are profoundly handicapped.
The government has also initiated programs to identify and support mothers at risk of abandoning their kids. But poverty, illiteracy, homelessness and the habits of the past have left the rate of child abandonment unchanged. According to a 2005 United Nations report, 9,000 Romanian children are left in hospitals and maternity wards each year.
Thirty years of Communist rule gutted the country's capacity to cope with this problem. A staggering amount of money, research and education are needed to develop appropriate residential, educational and medical services for formerly institutionalized children and to train staff to provide them. This is where BEIP researchers hope to have their most lasting impact. They and their Romanian partners are transforming the lab and staff developed for the BEIP into the core of a permanent Romanian Institute for Child Development (ICD).
The ICD is modeled after the renowned Developmental Medicine Center (DMC) at Children's, and will import the DMC's model of integrated and collaborative clinical services, research and training. "We want to create a landmark institution that can train Romanian child development specialists, do the research and develop the services that will give these kids the best possible chance," says Nelson.
But more than that, the BEIP researchers and their Romanian colleagues want to see that the tragedy of Romania's institutionalized children is not repeated —not there, not anywhere. They are committed to making the ICD a beacon for child development specialists around the world. "In Romania, I've seen how quickly science can be translated into policy," says Nelson. "I can no longer do research without asking, how will this impact the lives of kids?"
Nelson hopes the ICD's research will translate into programs and social policy that encourage every child to flourish, transforming Romania's tragic legacy of child abandonment into one of hope.
To learn more about supporting Charles Nelson's PhD's, work in Romania,
please contact Sara Kelly in the Children's Hospital Trust
at (617) 355-2562 or sara.kelly@chtrust.org.
please contact Sara Kelly in the Children's Hospital Trust
at (617) 355-2562 or sara.kelly@chtrust.org.