VII. PHYSICAL GROWTH AND MATURATION FOLLOWING EARLY SEVERE INSTITUTIONAL DEPRIVATION: DO THEY MEDIATE SPECIFIC PSYCHOPATHOLOGICAL EFFECTS?

Earlier pubertal timing, not tempo, links time-limited early adversity with psychopathology

Evolutionary-developmental theories propose that early adverse experiences adaptively shift the timing (i.e., onset) and tempo (i.e., rate) of pubertal maturation. Empirical evidence of links between early life adversity and pubertal maturation is mixed, potentially in part because isolating the unique impacts of early environments is challenging. The current accelerated longitudinal study used a quasi-experimental design to examine pubertal maturation among 132 previously-institutionalized (PI), internationally adopted children who experienced a time-limited form of severe early life adversity, compared to 169 non-adopted (NA) children. Based on prior literature, we also assessed whether pubertal timing and/or tempo are pathways by which early adversity relates to later symptoms of psychopathology. At each of three annual sessions, Tanner pubertal staging was determined by nurse exam, and symptoms of psychopathology were captured in a composite of child self-reported internalizing and parent-reported externalizing symptoms. Findings revealed that, only among children at Tanner pubertal stages 3 or below, PI children were more likely to have reached stage 3 compared to NA children, reflective of earlier pubertal timing. No group differences were found for pubertal tempo. In the subsample of children at Tanner stage 3 or lower, earlier pubertal timing was an indirect pathway by which early adversity related to both higher levels and greater longitudinal declines in internalizing and externalizing symptoms of psychopathology, accounting for a small proportion of the total effect of early adversity on psychopathology. Results from this quasi-experimental study add to existing research on associations between early adversity, early pubertal timing, and psychopathology, further suggesting that links may be specific to timing but not tempo. While findings broadly align with recent calls to consider early pubertal maturation as a transdiagnostic risk marker with utility for identifying children who could benefit from early mental health intervention, they also suggest that pubertal timing is unlikely to be a robust target for reducing psychopathology risk in these children.

Pubertal timing mediates the association between threat adversity and psychopathology

BACKGROUND

Exposure to adversity in childhood is a risk factor for lifetime mental health problems. Altered pace of biological aging, as measured through pubertal timing, is one potential explanatory pathway for this risk. This study examined whether pubertal timing mediated the association between adversity (threat and deprivation) and adolescent mental health problems (internalizing and externalizing), and whether this was moderated by sex.

METHODS

Aims were examined using the Adolescent Brain and Cognitive Development study, a large community sample from the United States. Data were used from three timepoints across the ages of 9-14 years. Latent scores from confirmatory factor analysis operationalized exposure to threat and deprivation. Bayesian mixed-effects regression models tested whether pubertal timing in early adolescence mediated the relationship between adversity exposure and later internalizing and externalizing problems. Sex was examined as a potential moderator of this pathway.

RESULTS

Both threat and deprivation were associated with later internalizing and externalizing symptoms. Threat, but not deprivation, was associated with earlier pubertal timing, which mediated the association of threat with internalizing and externalizing problems. Sex differences were only observed in the direct association between adversity and internalizing problems, but no such differences were present for mediating pathways.

CONCLUSIONS

Adversity exposure had similar associations with the pace of biological aging (as indexed by pubertal timing) and mental health problems in males and females. However, the association of adversity on pubertal timing appears to depend on the dimension of adversity experienced, with only threat conferring risk of earlier pubertal timing.

Parent-child border separation and the road to repair: addressing a global refugee phenomenon

As a result of the Department of Homeland Security's zero-tolerance policy (ZTP), over 5,000 children were separated from their parents at the U.S. southern border from 2017-2021, with over 1,000 still lacking confirmed reunifications. Separations also occur daily due to immigration raids, chaotic processing, and changing immigration policies. This article addresses the most fundamental question faced by families enduring such separations; how to mend attachment bonds that have been suddenly severed, especially within a population likely already traumatized. The paper begins by updating readers about separation in the United States and offers a concise summary of the consequences of child-parent separation. The paper then introduces Child-Parent Psychotherapy (CPP) as an intervention for affected families. This paper also uniquely applies CPP to older children and provides three case examples of its use in treating separated families. Finally, the paper offers general suggestions for supporting these families.

Early-life stress and current stress predict BMI and height growth trajectories in puberty

In cross-sectional analyses, early institutional care is associated with shorter stature but not obesity during puberty in children adopted into US families. We examined whether shorter stature and leaner body composition in youth adopted internationally from institutions would continue as puberty progressed. We also examined whether current psychosocial stress would moderate the association between early institutional deprivation and growth during adolescence. Using an accelerated longitudinal design and linear mixed-effects models, we examined the height and body mass index (BMI) of 132 previously institutionalized (PI) and 176 nonadopted (NA) youth. We examined youth aged 7-15 at the beginning of the study three times across 2 years. Nurses assessed anthropometrics and pubertal status. Current psychosocial stress was measured using the Youth Life Stress Interview. Our results indicated that PI youth remained shorter and leaner across three assessments than NA youth. However, age-and-sex-adjusted BMI increased faster in PI youth. Psychosocial stress during puberty predicted greater age-and-sex-adjusted BMI, but this effect did not differ by group. The gap in BMI but not height appears to close between PI and NA youth. Higher psychosocial stress was associated with higher BMI during puberty.

The Magnitude of Hidden Hunger and Cognitive Deficits among Children Living in Orphanages in Kumasi, Ghana

This study assessed the magnitude of hidden hunger (micronutrient deficiencies) and cognitive deficits of 130 school-aged children (6–13 years old) living in three selected orphanages in Kumasi, Ghana. Sociodemographic data assessment, anthropometric assessment (BMI for age and height for age), dietary assessment (3-day repeated 24-hour dietary recall), urinary iodine level assessment, and cognitive performance assessment (Raven’s Coloured Progressive Matrices) were performed. Boys formed 50.8% of the study population, while girls formed 49.2%. The median age of participants was 10.50 years. About 12.3%, 7%, and 10.0% of participants were stunted, thin, and overweight/obese, respectively. The prevalence of mild iodine deficiency (i.e., 50–99 μg/L) was 16.2%. Iodine deficiency was significantly higher (23.6%) in participants who had lived for at least 7 years in the orphanage compared to those who had lived less than 7 years (10.7%) ( $p=0.047$ ). About 17% of the participants performed poorly (<50%) on the cognition test. Mean cognition test scores were significantly different among the orphanages ( $p=0.027$ ). The majority of participants, 89.2%, 54.6%, 76.9%, and 77.7%, had adequate intake of iron, zinc, vitamin C, and folate, respectively, whereas intake of vitamins A and B12 was inadequate for the majority of participants (90.8% and 50.8%, respectively). There was no significant correlation between micronutrient intake and cognitive performance. However, mean cognition test scores were significantly different between participants with adequate and inadequate iron and vitamin A intake ( $p=0.007$ and $p<0.001$ , respectively). The findings of this study warrant a closer look at nutritional intakes in orphanages to improve hidden hunger and cognitive performance.

Severe deprivation in early childhood leads to permanent growth stunting: Longitudinal analysis of height trajectories from childhood-to-adulthood

BACKGROUND

Childhood institutional deprivation is associated with growth stunting in childhood but long-term effects in adulthood remain uncertain.

OBJECTIVE

To examine the impact of global institutional deprivation experienced in early childhood on subsequent growth with a special focus on final adult height and puberty timing.

PARTICIPANTS & SETTING

The study was originally set in the UK, though some adoptive families lived abroad by the time of the adult follow up. 165 individuals adopted by UK families before 43 months of age from Romanian orphanages after the fall of the Ceaușescu regime in the early 1990's were compared to 51 non-deprived UK adoptees, adopted before the age of 6 months.

METHODS

The English and Romanian Adoptees (ERA) study is a 20-year longitudinal natural experiment on the effects of institutional deprivation on development. Key growth milestones were extracted from growth curve modelling of height data collected at ages 4, 6, 11, 15 and 23 years using a Bayesian approach to fit the JPA2 model.

RESULTS

Deprivation effects on height were present at the take-off point of accelerating adolescent growth and persisted into adulthood - the largest effects being for individuals who experienced over six months of deprivation. Deprivation was associated with earlier take-off and achievement of peak height velocity of adolescent growth acceleration - an effect driven largely by females' data and correlated with parent ratings of pubertal development.

CONCLUSIONS

Early deprivation appears to reset tempo of growth early in development leading to permanent growth stunting in adulthood and accelerated onset of puberty, specifically in females.

Anthropometrics of Estonian children in relation to family disruption: Thrifty phenotype and Trivers-Willard effects

Background and objectives

The thrifty phenotype hypothesis proposes that at resource limitation, the growth of some organs/tissues is selectively spared to preserve more critical ones, such as the brain or lungs. The Trivers–Willard hypothesis (TWH) predicts that boys are more vulnerable in the case of resource limitation than girls. Both hypotheses were tested in children from disrupted families, differing in the extent of deprivation/adversities imposed on them.

Methodology

In a retrospective cohort study in the mid-20th century Estonia (Juhan Aul’s database), different types of orphans and children of divorced parents (treatment groups; n = 106–1401) were compared with children from bi-parental families (control groups; n = 2548–8648) so that children from treatment groups were matched with control children on the basis of sex, age, year of birth, urban versus rural origin and socioeconomic position.

Results

Children in orphanages suffered strong growth suppression, best explained by psychosocial deprivation. Their feet were on average 0.5 SD shorter than the feet of the controls, followed by height, leg/torso ratio and cranial volume that differed from controls by ca 0.4 SD. Weight difference was 0.2 SD units, while body mass index did not differ from controls. The growth of boys and girls in orphanages was suppressed to the same extent. Boys whose mothers were dead were relatively smaller and less masculine than girls from such families. Fathers’ absence was unrelated to growth suppression. Sons of divorced parents had broader shoulders than boys whose fathers were dead.

Conclusions and implications

Prediction of TWH about the greater vulnerability of male growth may hold under some conditions but not universally. Predictions of the thrifty phenotype hypothesis were partly supported: trunk growth was spared at the expense of leg growth; however, no evidence for brain sparing was found. Comparison of children of divorced versus dead fathers may appear useful for indirect assessment of sexual selection on offspring quality.

Lay Summary: Boys and girls in orphanages suffered similarly strong growth suppression, best explained by psychosocial deprivation. Boys whose mothers were dead were relatively smaller and less masculine than girls from such families. The occurrence of sex-specific associations between family structure and children’s growth depends on the type of family disruption.

Biological aging in childhood and adolescence following experiences of threat and deprivation: A systematic review and meta-analysis

Life history theory argues that exposure to early life adversity (ELA) accelerates development, although existing evidence for this varies. We present a meta-analysis and systematic review testing the hypothesis that ELA involving threat (e.g., violence exposure) will be associated with accelerated biological aging across multiple metrics, whereas exposure to deprivation (e.g., neglect, institutional rearing) and low-socioeconomic status (SES) will not. We meta-analyze 54 studies (n = 116,010) examining associations of ELA with pubertal timing and cellular aging (telomere length and DNA methylation age), systematically review 25 studies (n = 3,253) examining ELA and neural markers of accelerated development (cortical thickness and amygdala-prefrontal cortex functional connectivity) and evaluate whether associations of ELA with biological aging vary according to the nature of adversity experienced. ELA overall was associated with accelerated pubertal timing (d = -0.10) and cellular aging (d = -0.21), but these associations varied by adversity type. Moderator analysis revealed that ELA characterized by threat was associated with accelerated pubertal development (d = -0.26) and accelerated cellular aging (d = -0.43), but deprivation and SES were unrelated to accelerated development. Systematic review revealed associations between ELA and accelerated cortical thinning, with threat-related ELA consistently associated with thinning in ventromedial prefrontal cortex, and deprivation and SES associated with thinning in frontoparietal, default, and visual networks. There was no consistent association of ELA with amygdala-PFC connectivity. These findings suggest specificity in the types of early environmental experiences associated with accelerated biological aging and highlight the importance of evaluating how accelerated aging contributes to health disparities and whether this process can be mitigated through early intervention. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The psychobiological consequences of child separation at the border: lessons from research on attachment and emotion regulation

In the spring of 2018, the Attorney General of the United States issued a memorandum declaring a "zero tolerance policy" under which all adults entering the United States illegally would be criminally prosecuted, and, if traveling with minor children, forcibly separated from their children. Although the government was ordered to reunite the children with their parents it is still unclear how many children have been or remain separated. Given the high risk of permanent harm to a vulnerable population, and the fact that this risk may continue into the near future, we present a review of what nearly eight decades of scholarly research has taught us about the damaging impact of deprivation and separation from parents. The article briefly reviews the origins of attachment theory as well as empirical studies that examine the psychobiological impact on children who experienced parental deprivation or separation. The paper concludes with recommendations, for future research.

Caregiving Disruptions Affect Growth and Pubertal Development in Early Adolescence in Institutionalized and Fostered Romanian Children: A Randomized Clinical Trial

OBJECTIVES

To determine the effects of foster care vs institutional care, as well as disruptions in the caregiving environment on physical development through early adolescence.

STUDY DESIGN

This was a randomized controlled trial of 114 institutionalized, though otherwise healthy, children from 6 orphanages and 51 never institutionalized control children living in birth families (family care group) in Bucharest, Romania. Children were followed from baseline (21 months, range 5-31) through age 12 years for caregiving disruptions and growth trajectories and through age 14 years for pubertal development.

RESULTS

Children randomized to the foster care group showed greater rates of growth in height, weight, and body mass index (BMI) through age 12 years than institutionalized group. Tanner development was delayed in institutionalized group boys compared with foster care group and family care group boys at 12 but not 14 years. There were no differences in Tanner development and age of menarche among foster care group, institutionalized group, and family care group girls at ages 12 and 14 years. More disruptions in caregiving between 30 months and 12 years moderated decreases in growth rates of height in foster care group and weight in foster care group and institutionalized group across age. institutionalized group boys with ≥2 disruptions showed lower Tanner scores at age 12 vs institutionalized group and foster care group boys with <2 disruptions. foster care group girls with ≥2 disruptions had higher Tanner scores at age 14 vs foster care group girls with <2 disruptions. Age of menarche was not affected by caregiving disruptions.

CONCLUSIONS

For children who experienced early institutionalization, stable placement within family care is essential to ensuring the best outcomes for physical developmental.

TRIAL REGISTRATION

clinicaltrials.gov: NCT00747396.

Catch-up growth, metabolic, and cardiovascular risk in post-institutionalized Romanian adolescents

BACKGROUND

Reduced prenatal growth followed by rapid postnatal weight gain are risk factors for developing metabolic and cardiovascular disease. Children reared in institutions experience a similar pattern of growth restriction followed by catch-up growth after removal. We explored whether patterns of catch-up growth affect metabolic and cardiovascular outcomes in previously institutionalized adolescents.

METHOD

A longitudinal study of institutionalized infants randomized to care as usual (n = 68) or foster care intervention (n = 68), and never institutionalized controls (n = 127). Body mass index (BMI) was measured at baseline (20 months), 30, 42 months, and ages 8, 12, 16. At age 16, metabolic and pro-inflammatory markers were derived from blood samples.

RESULTS

Four BMI trajectories were derived (i.e., average-stable, low-stable, elevated, and accelerated). The accelerated trajectory was comprised predominately of children randomized to foster care, who also exhibited higher levels of glycosylated hemoglobin and C-reactive protein than the other three trajectories. Also, children placed in foster care at younger ages were more likely to be on the accelerated rather than the average-stable trajectory.

CONCLUSIONS

Although catch-up growth is viewed as a positive improvement among post-institutionalized children, rapid/continuous increases in body size pose a health concern. Attention should be given to monitoring weight gain, diet, and physical activity.

Biological embedding: evaluation and analysis of an emerging concept for nursing scholarship

AIM

The purpose of this paper was to report the analysis of the concept of biological embedding.

BACKGROUND

Research that incorporates a life course perspective is becoming increasingly prominent in the health sciences. Biological embedding is a central concept in life course theory and may be important for nursing theories to enhance our understanding of health states in individuals and populations. Before the concept of biological embedding can be used in nursing theory and research, an analysis of the concept is required to advance it towards full maturity.

DESIGN

Concept analysis.

DATA SOURCES

PubMed, CINAHL and PsycINFO were searched for publications using the term 'biological embedding' or 'biological programming' and published through 2015.

METHODS

An evaluation of the concept was first conducted to determine the concept's level of maturity and was followed by a concept comparison, using the methods for concept evaluation and comparison described by Morse.

RESULTS

A consistent definition of biological embedding - the process by which early life experience alters biological processes to affect adult health outcomes - was found throughout the literature. The concept has been used in several theories that describe the mechanisms through which biological embedding might occur and highlight its role in the development of health trajectories. Biological embedding is a partially mature concept, requiring concept comparison with an overlapping concept - biological programming - to more clearly establish the boundaries of biological embedding.

CONCLUSIONS

Biological embedding has significant potential for theory development and application in multiple academic disciplines, including nursing.

The science of early adversity: is there a role for large institutions in the care of vulnerable children?

It has been more than 80 years since researchers in child psychiatry first documented developmental delays among children separated from family environments and placed in orphanages or other institutions. Informed by such findings, global conventions, including the 1989 UN Convention on the Rights of the Child, assert a child's right to care within a family-like environment that offers individualised support. Nevertheless, an estimated 8 million children are presently growing up in congregate care institutions. Common reasons for institutionalisation include orphaning, abandonment due to poverty, abuse in families of origin, disability, and mental illness. Although the practice remains widespread, a robust body of scientific work suggests that institutionalisation in early childhood can incur developmental damage across diverse domains. Specific deficits have been documented in areas including physical growth, cognitive function, neurodevelopment, and social-psychological health. Effects seem most pronounced when children have least access to individualised caregiving, and when deprivation coincides with early developmental sensitive periods. Offering hope, early interventions that place institutionalised children into families have afforded substantial recovery. The strength of scientific evidence imparts urgency to efforts to achieve deinstitutionalisation in global child protection sectors, and to intervene early for individual children experiencing deprivation.

Institutional care and iron deficiency increase ADHD symptomology and lower IQ 2.5-5 years post-adoption

Increased ADHD symptomology and lower IQ have been reported in internationally adopted (IA) children compared to non-adopted peers (Hostinar, Stellern, Schaefer, Carlson & Gunnar, 2012; Kreppner, O'Connor & Rutter, 2001). However, it is unclear whether these outcomes are due to institutional deprivation specifically or to co-occurring micronutrient deficiencies that disrupt brain development (Fuglestad, Rao & Georgieff, 2008b). In this study, IA children were compared to children raised in their biological families to examine differences in ADHD symptomology and IQ 2.5-5 years post-adoption and to assess the contributions of iron deficiency (ID) and duration of deprivation to these cognitive outcomes. ADHD symptoms (parent- and experimenter-reported) and IQ were evaluated in 88 IA (M = 62.1 months, SD = 2.4) and 35 non-adopted children (M = 61.4 months, SD = 1.6). IA children were assessed 29-64 months post-adoption (M = 41.9 months, SD = 10.2). ID was assessed during the initial post-adoption medical visit in 69 children, and children were classified into four groups by iron status, ranging from normal to ID anemia (most severe). IA children had greater ADHD symptomology, p < .01, and lower IQ, p = .001, than non-adopted children. Within the IA group, children with more severe ID at adoption had greater ADHD symptomology, r(69) = 0.40, p = .001, and lower IQ, r(68) = -0.28, p < .05. Duration of institutional care was positively correlated with ADHD symptoms, r(86) = .28, p < .01, but not IQ, r(85) = -.08, p = .52. Longitudinal results indicate improvement in IQ from 12 months post-adoption to age 5 for children with greater ID severity at adoption and longer duration of institutional care but no improvement in ADHD symptoms. These results signify continuing effects of early deprivation and ID on ADHD symptoms and IQ years after adoption. A video abstract of this article can be viewed at http://www.youtube.com/watch?v=vUFDAS3DD1c.

Beyond stimulus deprivation: iron deficiency and cognitive deficits in postinstitutionalized children

Children adopted from institutions have been studied as models of the impact of stimulus deprivation on cognitive development (Nelson, Bos, Gunnar, & Sonuga-Barke, 2011), but these children may also suffer from micronutrient deficiencies (Fuglestad et al., 2008). The contributions of iron deficiency (ID) and duration of deprivation on cognitive functioning in children adopted from institutions between 17 and 36 months of age were examined. ID was assessed in 55 children soon after adoption, and cognitive functioning was evaluated 11-14.6 months postadoption when the children averaged 37.4 months old (SD = 4.9). ID at adoption and longer duration of institutional care independently predicted lower IQ scores and executive function (EF) performance. IQ did not mediate the association between ID and EF.

Iron deficiency after arrival is associated with general cognitive and behavioral impairment in post-institutionalized children adopted from Eastern Europe

To investigate the role of iron deficiency in general cognitive and behavioral development in post-institutionalized (PI) children during the early post-adoption period. PI children (N = 57) adopted from Eastern Europe or Central Asia (9-46 months of age) were seen at baseline around 1 month after arrival into the US and at follow-up 6 months later. Measures included anthropometry, iron status, the Toddler Behavior Assessment Questionnaire-R (TBAQ-R), the Mullen Scales of Early Learning, and examiner-rated behaviors during testing. 26 % were iron deficient at baseline; 18 % were iron deficient at follow-up. There was a trend for those with iron deficiency at baseline to be more fearful on the TBAQ-R. Those with iron deficiency at follow-up displayed more hyperactivity on both the TBAQ-R and the examiner-rated behaviors. Those with iron deficiency at follow-up were more likely to score below average on the Mullen Early Learning Composite (iron deficient: 80 %; good iron status: 32 %). The association between iron status at follow-up and the Mullen Early Learning Composite was mediated by inattention and hyperactivity behaviors during testing. Iron deficiency is associated with neurobehavioral alterations months after arrival, mediated by the effect on attention and activity levels. Iron status needs to be monitored at least through the first half-year post-adoption, particularly in children exhibiting rapid catch-up growth. Additionally, developmental evaluation is recommended in those with iron deficiency, even in children with good iron status at arrival.

Adoption: biological and social processes linked to adaptation

Children join adoptive families through domestic adoption from the public child welfare system, infant adoption through private agencies, and international adoption. Each pathway presents distinctive developmental opportunities and challenges. Adopted children are at higher risk than the general population for problems with adaptation, especially externalizing, internalizing, and attention problems. This review moves beyond the field's emphasis on adoptee-nonadoptee differences to highlight biological and social processes that affect adaptation of adoptees across time. The experience of stress, whether prenatal, postnatal/preadoption, or during the adoption transition, can have significant impacts on the developing neuroendocrine system. These effects can contribute to problems with physical growth, brain development, and sleep, activating cascading effects on social, emotional, and cognitive development. Family processes involving contact between adoptive and birth family members, co-parenting in gay and lesbian adoptive families, and racial socialization in transracially adoptive families affect social development of adopted children into adulthood.

The hypothalamic-pituitary-gonadal axis: a switch-controlled, condition-sensitive system in the regulation of life history strategies

This article is part of a Special Issue "Puberty and Adolescence". Life history theory provides an overarching framework for explaining the development of individual differences in reproductive strategies and highlights the role of familial and ecological conditions in regulating pubertal timing. Parental investment and sexual selection models afford a powerful framework for explaining the emergence of sex differences in reproductive strategies and suggest that pubertal timing in males and females is differentially sensitive to psychosocial stress. The West-Eberhard's (2003) model of switch-controlled modular systems provides the foundation for a comprehensive analysis of variation in reproductive strategies at the level of mechanism and development. Applied to puberty, this model provides a framework for explaining how genes and environments interact over development, are modulated by extant phenotypic characteristics, and operate through control of regulatory switch mechanisms across multiple levels of the hypothalamic-pituitary-gonadal axis. Taken together, life history theory, parental investment and sexual selection models, and the West-Eberhard framework enable an integrated evolutionary-developmental analysis of between-sex variation and within-sex variation in pubertal processes and their role in regulating alternative life history strategies.

Unique relations of age and delinquency with cognitive control

Context processing has significant empirical support as an explanation of age- and psychopathology-related deficiencies in cognitive control. We examined whether context processing generalizes to younger individuals who are in trouble with the law. We tested whether age and delinquency might have unique relations to context processing skills in four samples of male participants: adolescent offenders (n = 43), control adolescents (n = 33), young adult offenders (n = 40), and control young adults (n = 31). We used a modified Stroop task to measure context processing (i.e., attention, memory, and response inhibition). Task performance was superior for older participants in conditions most demanding of context processing skills. Adolescent offenders and control adolescents showed difficulties engaging selective attention to filter out irrelevant information, even after controlling for the effects of age. Control adolescents made the most errors in the condition most demanding of context processing, whereas the other three samples showed slower processing but fewer errors in context processing.

Institutional Care for Young Children: Review of Literature and Policy Implications

Millions of infants and toddlers are in institutional care around the world, care that is poorly suited to meet young children's developmental needs. In this article, we briefly review the history of institutional care and surrogate care. We then discuss why institutional care is at odds with children's needs, and review the empirical evidence regarding the effects of institutional care on young children's development. Finally, we discuss alternatives to institutional care, and make recommendations for changes.

Children in Institutional Care: Delayed Development and Resilience

Children exposed to institutional care often suffer from "structural neglect" which may include minimum physical resources, unfavorable and unstable staffing patterns, and social-emotionally inadequate caregiver-child interactions. This chapter is devoted to the analysis of the ill effects of early institutional experiences on resident children's development. Delays in the important areas of physical, hormonal, cognitive, and emotional development are discussed. The evidence for and against the existence of a distinctive set of co-occurring developmental problems in institutionalized children is weighed and found to not yet convincingly demonstrate a "post-institutional syndrome". Finally, shared and non-shared features of the institutional environment and specific genetic, temperamental, and physical characteristics of the individual child are examined that might make a crucial difference in whether early institutional rearing leaves irreversible scars.

Growth delay as an index of allostatic load in young children: predictions to disinhibited social approach and diurnal cortisol activity

The goal of this study was to examine whether growth delay can serve as an index of allostatic load during early development, as it is well known that the activity of stress-mediating systems inhibits growth. The participants were children adopted internationally from institutional care (n = 36), children adopted internationally from foster care (n = 26), and nonadopted children (n = 35). For the adopted children, height for age and weight for height were assessed at adoption; for all children, disinhibited social approach (DSA; termed elsewhere as "indiscriminate friendliness") and diurnal cortisol were assessed at 6-8 years (M = 6.9 years). For internationally adopted children in general, and postinstitutionalized children specifically, linear growth delay assessed at the time of adoption was associated with more dysregulated behavior in response to an unfamiliar adult (i.e., greater DSA) and a more dysregulated diurnal cortisol rhythm (i.e., higher late afternoon and evening values). Further, among the most growth-delayed children, higher cortisol levels later in the day were correlated with DSA. The potential for using growth delay as an allostatic load indicator and the possible problems and limitations in its use in child populations are discussed.

IV. Growth Failure in Institutionalized Children

Children within institutional care settings experience significant global growth suppression, which is more profound in children with a higher baseline risk of growth impairment (e.g., low birth weight [LBW] infants and children exposed to alcohol in utero). Nutritional insufficiencies as well as suppression of the growth hormone-insulin-like growth factor axis (GH-IGF-1) caused by social deprivation likely both contribute to the etiology of psychosocial growth failure within these settings. Their relative importance and the consequent clinical presentations probably relate to the age of the child. While catch-up growth in height and weight are rapid when children are placed in a more nurturing environment, many factors, particularly early progression through puberty, compromise final height. Potential for growth recovery is greatest in younger children and within more nurturing environments where catch-up in height and weight is positively correlated with caregiver sensitivity and positive regard. Growth recovery has wider implications for child well-being than size alone, because catch-up in height is a positive predictor of cognitive recovery as well. Even with growth recovery, persistent abnormalities of the hypothalamic-pituitary-adrenal system or the exacerbation of micronutrient deficiencies associated with robust catch-up growth during critical periods of development could potentially influence or be responsible for the cognitive, behavioral, and emotional sequelae of early childhood deprivation. Findings in growth-restricted infants and those children with psychosocial growth are similar, suggesting that children experiencing growth restriction within institutional settings may also share the risk of developing the metabolic syndrome in adulthood (obesity, Type 2 diabetes mellitus, hypertension, heart disease). Psychosocial deprivation within any care-giving environment during early life must be viewed with as much concern as any severely debilitating childhood disease.

Children in Institutional Care: Delayed Development and Resilience

Children exposed to institutional care often suffer from "structural neglect" which may include minimum physical resources, unfavorable and unstable staffing patterns, and social-emotionally inadequate caregiver-child interactions. This chapter is devoted to the analysis of the ill effects of early institutional experiences on resident children's development. Delays in the important areas of physical, hormonal, cognitive, and emotional development are discussed. The evidence for and against the existence of a distinctive set of co-occurring developmental problems in institutionalized children is weighed and found to not yet convincingly demonstrate a "post-institutional syndrome". Finally, shared and non-shared features of the institutional environment and specific genetic, temperamental, and physical characteristics of the individual child are examined that might make a crucial difference in whether early institutional rearing leaves irreversible scars.

IV. Growth Failure in Institutionalized Children

Children within institutional care settings experience significant global growth suppression, which is more profound in children with a higher baseline risk of growth impairment (e.g., low birth weight [LBW] infants and children exposed to alcohol in utero). Nutritional insufficiencies as well as suppression of the growth hormone-insulin-like growth factor axis (GH-IGF-1) caused by social deprivation likely both contribute to the etiology of psychosocial growth failure within these settings. Their relative importance and the consequent clinical presentations probably relate to the age of the child. While catch-up growth in height and weight are rapid when children are placed in a more nurturing environment, many factors, particularly early progression through puberty, compromise final height. Potential for growth recovery is greatest in younger children and within more nurturing environments where catch-up in height and weight is positively correlated with caregiver sensitivity and positive regard. Growth recovery has wider implications for child well-being than size alone, because catch-up in height is a positive predictor of cognitive recovery as well. Even with growth recovery, persistent abnormalities of the hypothalamic-pituitary-adrenal system or the exacerbation of micronutrient deficiencies associated with robust catch-up growth during critical periods of development could potentially influence or be responsible for the cognitive, behavioral, and emotional sequelae of early childhood deprivation. Findings in growth-restricted infants and those children with psychosocial growth are similar, suggesting that children experiencing growth restriction within institutional settings may also share the risk of developing the metabolic syndrome in adulthood (obesity, Type 2 diabetes mellitus, hypertension, heart disease). Psychosocial deprivation within any care-giving environment during early life must be viewed with as much concern as any severely debilitating childhood disease.