Out of a barren cradle

Romanian orphans adopted by UK families have made remarkable progress, despite an appalling start in life. Michael Rutter argues that this sheds new light on child development and raises questions about adoption policy.

Since the early 1950s the question of whether children starved of loving family care in their first few years would be irrevocably damaged for life has been hotly debated. At first it was thought that such deprivation would have irreversible effects on a growing child, but it rapidly became clear that this is not so.

Biological studies have shown that, under some circumstances, a child's experiences can have an effect into adulthood. Equally, however, the same evidence has shown that people are very resilient and capable of considerable change. The 64 million dollar question for researchers is: what are the qualities that make some children resilient, able to catch up with their more fortunate peers both intellectually and emotionally, and what are the circumstances that militate against recovery?

The problem for those trying to answer this question is that few children who suffer dreadful experiences in early life then move to a home where they are surrounded by love and attention, giving them the chance to emerge from the effects of their early privations.

When the communist regime under the dictator Nicholas Ceaucescu collapsed in Romania in 1989, however, exposing to view dozens of bleak orphanages where children were being brought up in the most barren environments imaginable - and which led to some of the children being adopted by British families - it gave researchers in the West just the kind of "natural experiment'' needed. A study of these adopted children gave us the chance to monitor whether and how they made intellectual and social progress once in the bosom of a loving family. Of course, their suffering is not something one would ever want but, given that it happened, it seemed important to seize the opportunity to investigate the effects on children's psychological development.

Our research, at the Medical Research Council child psychiatry unit, had two other, equally important aims. We wanted to look at the challenges faced by parents adopting children who suffered very traumatic circumstances when young. How did the successful families cope? What help did they need from professionals? Also, because the adopting parents included some who were older than is usually regarded acceptable for UK adoptions and who already had biological children of their own, we wanted to examine the extent to which traditional British guidelines for the approval of adopting parents are justified in terms of how the child fares in later life.

The conditions in Romanian institutions varied from poor to utterly appalling. In most, the children were confined to cots without toys or playthings, carers scarcely talked to them and feeding time was usually a bottle full of gruel with a large teat (often just left propped up in the child's mouth). Washing often consisted of being hosed down with cold water, and sometimes drugs were used to keep the children calm. There was physical or sexual abuse (Romanian records do not allow any estimate of how often abuse took place). In most cases the children entered the orphanage as babies (the average age was about ten days old) and only a handful had any form of upbringing in a family setting. So far as we could tell, very few children returned to their families and none was adopted before the Ceaucescu regime fell.

As might have been expected, given these conditions, the children were in a bad way when they entered Britain. Just over half were severely malnourished. Similarly, over half were severely retarded developmentally. Chronic and recurrent respiratory infections were rife, intestinal infections were also common, and many had skin disorders.

As part of a broader study of adoption we compared the development of 165 adoptees from Romania with that of 52 children adopted within the UK before they were six months old. None of the latter had experienced gross privation or abuse. First, we considered the extent to which, by the age of four, the Romanian children had caught up with the British adoptees. The results were spectacular. Their weight was as expected for normal UK children, their height was only just a little below normal, and their mental level approximately average (representing, overall, a gain of some 40 IQ points since coming to the UK). It is a striking demonstration of the remarkable resilience of children - even after deprivation of a degree rarely, if ever, seen in this country.

Can the catch-up be viewed as complete recovery? Unfortunately not, because the children are still too young for us to know what they will be like as adults, and because the mental scores of the Romanian adoptees are, on average, still some dozen points below those of the British adoptees. However, we discovered no significant difference between the IQ scores of the UK adoptees and those of the adoptees from Romania who arrived in Britain before they were six months old. The implication is that complete intellectual recovery may be possible if deprivation does not last beyond the first six months of life.

One question we tried to answer is whether the slight intellectual deficit displayed by some of the Romanian children was due to the extreme deprivation they endured rather than, for example, their genetic endowment. The fact that the degree of deficit is strongly related to the age at which the children entered the UK suggests that it was a consequence of some aspect of their early experiences. By the time they reached six, the average IQ of those who entered the country after the age of two was about two dozen points less than that of the UK adoptees. In other words the length of time they spent in squalid and deprived conditions was the crucial factor - the longer their early suffering the worse the effect on later IQ. Nevertheless, it should not be thought that lower IQ is inevitable even with those children adopted late; the scores for these six-year-olds ranged from below 50 to above 130 - a very wide range indeed.

Another issue is whether the main early damage was caused by a lack of food or a lack of play, conversation, toys and loving relationships. From our research we concluded that although the duration of malnutrition is important, it is likely that the prolonged lack of meaningful psychological experiences of almost all kinds is even more influential.

Very little was known, before our study started, on the effect of neglect on children's subsequent social development. We found that, in some respects, the social results parallel the intellectual ones. Although most of the Romanian adoptees were functioning well by the time they were four, there were some problems, most marked in the children who were oldest when they joined their adoptive families. For example, the Romanian children were less inclined to play make-believe games and were less sociable in their play than the British adoptees. Among those who were oldest on coming to the UK, there was also a tendency to show indiscriminate friendliness; the risk was that they might go off with a stranger. They were more likely than other children to touch people they did not know. We also found slight social problems even in some of those who left Romania before the age of six months. This was unexpected and needs to be regarded as tentative but it is provocative in its suggestion of possible slight effects from even very early experiences - though some of the children grew out of these difficulties. The combination of social and scholastic difficulties in some children made their initial transition to school quite difficult.

The other unusual pattern we found in about one in 16 of the children from Romania, and in none of the British adoptees, involved autistic-like behaviour (such as poor social reciprocity, a difficulty in picking up social cues and a lack of conversational flow). This was surprising but it seems clear that it did derive from their early experiences. In the adoptees, substantial improvement was seen between four and six years, in contrast to the worsening at this age that is usually seen in autism.

Our research findings are thus a fascinating mixture of the expected and the unexpected. Some results, such as the spectacular intellectual catch-up seen in the Romanian children, provide grounds for great optimism about the ability of children to recover even from the most horrific experiences. Others, such as the social sequelae seen in a minority, make for greater caution about the possibility of problems persisting into later life. But persistent is not the same as permanent. Our findings do not indicate a clear-cut critical period beyond which it is too late to provide remedies. There are remaining questions requiring follow-up and we hope to begin to see the children again near the end of their time at primary school when their pattern of friendships and scholastic success should be clearer.

Michael Rutter is honorary director of the MRC child psychiatry unit, London. A fuller version of this research can be found in May's Journal of Child Psychology and Psychiatry.

DARREN AND JUSTINE

Darren was abandoned at birth and left in a Romanian orphanage. He was adopted by parents who kept a shop and came to Britain at 23 months, developmentally retarded. He rocked a lot, made sounds but had no words and was always hungry. He seemed not to need people and, although he cried a lot, did not like to be cuddled.

A very determined little boy, however, he progressed rapidly. Soon he was beginning to pick up words and play. By the time he was four he enjoyed playing with other children and occasionally asked his parents for a cuddle.

By the time he was six he was in mainstream school where his work was above average. He had a group of friends, with whom he got on well so long as he was in charge. Darren was still a strong-willed and independent child. His mum accepted the fact that he did not come easily for cuddles but would come when he wanted.

Having been reared in a Romanian orphanage since birth, Justine was adopted by a professional family and came to the UK when she was 18 months old. She was podgy and had intestinal, respiratory and skin infections and was developmentally retarded. She threw tremendous tantrums, screaming and banging her head on the floor.

Justine was preoccupied with eating, lacked interest in other people, would not be cuddled and was only consolable with food.

Her behaviour showed little improvement in the first year and her parents sought professional advice. They were encouraged to draw firm boundaries and gradually Justine responded. Her tantrums became less frequent, she began to play with other children and occasionally showed affection to her parents.

By the time she was six she was coping in a mainstream school but only with daily help from a special needs teacher. Her desire to be popular meant that peer pressure began to restrain her temper.