case study on abandoned child

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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The lasting impact of neglect

Psychologists are studying how early deprivation harms children — and how best to help those who have suffered from neglect.

By Kirsten Weir

June 2014, Vol 45, No. 6

Print version: page 36

10 min read

The babies laid in cribs all day, except when being fed, diapered or bathed on a set schedule. They weren't rocked or sung to. Many stared at their own hands, trying to derive whatever stimulation they could from the world around them. "Basically these kids were left on their own," Fox says.

Fox, along with colleagues Charles Nelson, PhD, at Harvard Medical School and Children's Hospital Boston, and Charles Zeanah, MD, at Tulane University, have followed those children for 14 years. They describe their Bucharest Early Intervention Project in a new book, "Romania's Abandoned Children: Deprivation, Brain Development, and the Struggle for Recovery" (2014).

Neglect isn't just a Romanian problem, of course. UNICEF estimates that as many as 8 million children are growing up in institutional settings around the world. In the United States, neglect is a less obvious — though very real — concern. According to a report by the U.S. Department of Health and Human Services, 676,569 U.S. children were reported to have experienced maltreatment in 2011. Of those, more than 78 percent suffered from neglect.

The list of problems that stem from neglect reads like the index of the DSM: poor impulse control, social withdrawal, problems with coping and regulating emotions, low self-esteem, pathological behaviors such as tics, tantrums, stealing and self-punishment, poor intellectual functioning and low academic achievement. Those are just some of the problems that David A. Wolfe, PhD, a psychologist at the University of Toronto, and his former student Kathryn L. Hildyard, PhD, detailed in a 2002 review ( Child Abuse & Neglect , 2002).

"Across the board, these are kids who have severe problems throughout their lifetime," says Wolfe, recent past editor-in-chief of Child Abuse & Neglect .

Now, researchers are beginning to understand some of the ways that early deprivation alters a person's brain and behavior — and whether that damage can be undone.

The Bucharest project

In 1989 Romanian dictator Nicolae Ceauşescu was overthrown, and the world discovered that 170,000 children were being raised in Romania's impoverished institutions. As the children's plight became public, Fox, Nelson and Zeanah realized they had a unique opportunity to study the effects of early institutionalization.

The trio launched their project in 2000 and began by assessing 136 children who had been living in Bucharest's institutions from birth. Then they randomly assigned half of the children to move into Romanian foster families, whom the researchers recruited and assisted financially. The other half remained in care as usual. The children ranged in age from 6 months to nearly 3 years, with an average age of 22 months.

Over the subsequent months and years, the researchers returned to assess the development of the children in both settings. They also evaluated a control group of local children who had never lived in an institution.

They found many profound problems among the children who had been born into neglect. Institutionalized children had delays in cognitive function, motor development and language. They showed deficits in socio-emotional behaviors and experienced more psychiatric disorders. They also showed changes in the patterns of electrical activity in their brains, as measured by EEG.

For kids who were moved into foster care, the picture was brighter. These children showed improvements in language, IQ and social-emotional functioning. They were able to form secure attachment relationships with their caregivers and made dramatic gains in their ability to express emotions.

While foster care produced notable improvements, though, children in foster homes still lagged behind the control group of children who had never been institutionalized. And some foster children fared much better than others. Those removed from the institutions before age 2 made the biggest gains. "There's a bit of plasticity in the system," Fox says. But to reverse the effects of neglect, he adds, "the earlier, the better."

In fact, when kids were moved into foster care before their second birthdays, by age 8 their brains' electrical activity looked no different from that of community controls. The researchers also used structural MRI to further understand the brain differences among the children. They found that institutionalized children had smaller brains, with a lower volume of both gray matter (which is made primarily of the cell bodies of neurons) and white matter (which is mainly the nerve fibers that transmit signals between neurons).

"A history of institutionalization significantly affected brain growth," Fox says.

The institutionalized children who were moved into foster homes recovered some of that missing white matter volume over time. Their gray matter volume, however, stayed low, whether or not they had been moved into stable homes ( PNAS , 2012). Those brain changes, the researchers found, were associated with an increased risk of ADHD symptoms.

Many of the children remain with their foster families. (The researchers no longer support those families financially, but the Romanian government continues to provide stipends for the children's care.) Soon, Fox says, he and his colleagues will begin the 16-year assessment. They expect that to be particularly telling, since the effects of adversity in early childhood can re-emerge during adolescence.

Regardless of future findings, Fox has seen enough evidence to draw hard conclusions. "Children need to be in socially responsive situations. I personally think that there aren't good institutions for young children," he says. With millions of children growing up in similar conditions, he adds, "this is a worldwide public health issue."

Coming to America

In the United States, Megan Gunnar, PhD, director of the Institute of Child Development at the University of Minnesota, has helped fill in other pieces of the puzzle. In 1999, she and her colleagues launched the International Adoption Project, an extensive examination of children adopted from overseas. She now has nearly 6,000 names on her registry and her research is ongoing.

Gunnar has found certain brain changes are common among children who came to the United States from orphanages, including a reduction in brain volume and changes in the development of the prefrontal cortex.

"Neglect does a number on the brain. And we see behaviors that follow from that," she says.

She's found post-institutionalized kids tend to have difficulty with executive functions such as cognitive flexibility, inhibitory control and working memory. They are often delayed in the development of theory of mind, the ability to understand the mental states of others. Many struggle to regulate their emotions. Often, they suffer from high anxiety.

One of the most common behaviors she sees among post-institutionalized children is indiscriminate friendliness. "A child who doesn't know you from Adam will run up, put his arms around you and snuggle in like you're his long-lost aunt," Gunnar says. That friendliness was probably an important coping technique in their socially starved early lives, she says. "What's interesting is it just doesn't go away."

Fox and his colleagues had also noted such disarming friendliness in the Romanian orphanages. Initially, children with indiscriminate friendliness were thought to have an attachment disorder that prevented them from forming healthy connections with adult caregivers. But findings from the Bucharest Project as well as Gunnar's own research have demonstrated otherwise, she says.

In a study of 65 toddlers who had been adopted from institutions, Gunnar found that most attached to their new parents relatively quickly, and by nine months post-adoption, 90 percent of the children had formed strong attachments to their adoptive parents. Yet that attachment was often "disorganized," marked by contradictory behaviors ( Development and Psychopathology , in press). A child might appear confused in the presence of a caregiver, for instance, sometimes approaching the caregiver for comfort, and other times showing resistance.

"There were things that happened in terms of early development, when they lacked that responsive caregiver, that they're carrying forward," Gunnar says.

One of those things may be a disrupted cortisol pattern. Cortisol, commonly known as the "stress hormone," typically peaks shortly after waking, then drops throughout the day to a low point at bedtime. But Gunnar found that children with a history of neglect typically have a less marked cortisol rhythm over the course of the day. Those abnormal cortisol patterns were correlated with both stunted physical growth and with indiscriminate friendliness ( Development and Psychopathology , 2011).

Indiscriminate friendliness may also be tied to the amygdala. In a study using fMRI, Aviva Olsavsky, MD, at the University of California, Los Angeles, and colleagues found that when typical children viewed photos of their mothers versus photos of strangers, the amygdala showed distinctly different responses. In children who had been institutionalized, however, the amygdala responded similarly whether the children viewed mothers or strangers. That response was particularly notable among kids who exhibited more friendliness toward strangers ( Biological Psychiatry , 2013).

Closer to home

Other researchers are also exploring physiological differences in children who have experienced neglect. Around the time Gunnar was launching her adoption study, Philip Fisher, PhD, a psychologist and research scientist at the University of Oregon, was working with American foster children. Initially, he suspected the behavioral and developmental difficulties they experienced stemmed from physical abuse. But as he shared data with Gunnar and others, he realized they looked a lot like post-institutionalized children.

Though cortisol tends to follow a daily cycle, it also spikes during times of stress. Fisher expected that his foster children, who had clearly experienced stressful situations, might show high levels, too. Instead, he discovered something quite different. "Their levels were low in the morning and stayed low throughout the day," he says.

Combing through the case records of the children in his sample, he discovered that disregulated cortisol was not associated with physical or sexual abuse, but with early neglect. "This blunted daily pattern with low morning cortisol seemed to be a hallmark of neglect," he says. "That was a pretty powerful picture."

In fact, abnormal cortisol cycles have previously been noted in a variety of psychological disorders, Fisher says, including anxiety, mood disorders, behavior problems and post-traumatic stress disorder. But the good news: Cortisol patterns appear to be changeable.

Fisher found that foster kids living with more responsive caregivers were more likely to develop more normal cortisol patterns over time. Kids living with caregivers who were stressed out themselves didn't show that recovery ( Psychoneuroendocrinology , 2007). "We're more likely to see that blunted pattern when they don't get that support, and there's a lot of stress in the family," he says.

Helping caregivers manage their own stress and develop more positive interactions with their children may help reset the kids' stress responses. Fisher is now developing and testing video coaching programs that aim to identify and reinforce the positive interactions foster parents are already having with their young children. "We can show people very precisely the things we know are at the core of promoting healthy development," he says.

Meanwhile, he's also looking for other physiological systems affected by early adverse experience — particularly those that are malleable. "If we can impact those systems, especially without pharmacology, we have great tools we can leverage," he says.

For instance, kids with a history of neglect are known to have trouble with executive functioning. One way that presents itself is that the kids don't show much brain response to corrective feedback; instead, they often make the same mistakes over and over. Targeted interventions may help those children learn to tune in to the important cues they're missing, Fisher says. Though more research is needed, he adds, computer-based brain-training games and other novel interventions might prove to be useful complements to more traditional therapy.

Despite progress, child neglect remains underfunded and understudied, says Wolfe. Politically, it's a prickly subject. "Neglect is not a disease. It's entwined with the delivery of proper social and medical services. It's embedded in socioeconomic disadvantage," he says.

Politics aside, science is making strides toward erasing the stamp that early neglect leaves on a child. New understanding of the ways that neglect changes a person's physiology is helping to push the field forward, Wolfe says.

That progress is sorely needed, but the most important first step is to remove neglected children to a safe, loving environment, he adds. "The brain will often recover, if it's allowed to."

Kirsten Weir is a journalist in Minneapolis.

Further reading

• Bruce, J., Gunnar, M. R., Pears, K. C., and Fisher, P. A. (2013). Early adverse care, stress neurobiology, and prevention science: Lessons learned. Prevention Science, 14 (3), 247–256.
• Nelson, C. A., Fox, N. A., and Zeanah, C. H. (2014). Romania's abandoned children: Deprivation, brain development, and the struggle for recovery . Cambridge, MA, and London, England: Harvard University Press.
• Nelson III, C. A., Zeanah, C. H., Fox, N. A., Marshall, P. J., Smyke, A. T., and Guthrie, D. (2007). Cognitive recovery in socially deprived young children: the Bucharest Early Intervention Project. Science, 318 (5858), 1937–2940.

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The Long-Term Effects of Abandonment

by Shirley Davis | Feb 25, 2021 | Abandonment and CPTSD | 14 comments

One of the most egregious behaviors a parent or other caregiver can do to a child is to abandon them, allowing them to suffer alone. The damages done to the child when grown are significant and should not be ignored.

In this article, we shall examine together what childhood abandonment is, how it affects adults, and ways to mitigate the power it has over our lives.

What is Abandonment?

All children are entirely dependent upon parents or caregivers for their safety in their environment. When these caretakers fail to offer support and meet the child’s needs, emotionally and physically, they are said to have abandoned their child.

When parents abandon their children, their kids grow up feeling unsafe in the world and feeling people cannot be trusted. These unsafe feelings lead to the child experiencing emotions where they feel they do not deserve positive attention or adequate care.

For many children, abandonment is physical and may include:

• Lack of supervision
• Physical or sexual abuse
• Narcissistic abuse
• The inappropriate offering of nutrition
• Inadequate clothes, heat, shelter, or housing

For other children, abandonment takes the form of emotional neglect and abuse when parents do not give to their children emotional conditions and environments that are necessary for their healthy development.

The child is left feeling inadequate, rejected, and damaged, needing to hide themselves away from others knowing who they are on the inside. Abandoned children are left believing it is not okay to make mistakes, that it is not okay to show their genuine emotions, that they should not have needs, and that it is not okay to be successful.

Fear of Abandonment in Adulthood

Because they were neglected and abused as children, many adults grow up having internalized all the messages they received from their parents when they were young.  Also, because they craved attention from their abusive parents, many adults grow up fearing losing the love of those they have in their lives.

Fear of abandonment is not a mental illness by itself but rather a form of anxiety that can negatively affect those who experience it. Adults experiencing abandonment issues often experience problems in their relationships because they fear the other person will leave them.

It is vital to recognize the signs of abandonment issues so that these issues may be tackled head-on. They include:

• They fear giving too much in a relationship.
• They push people away to avoid rejection.
• They are often people pleasers.
• They experience codependency.
• They feel insecure in intimate relationships and friendships.
• They require repeated reassurances that they are loved.
• They feel the need to control others.
• They jump from one relationship to another.
• They often will sabotage their relationships.

Other symptoms that may challenge a survivor of abandonment’s life include the following:

• Constant worry
• Panic or anxiety
• Fear of being alone
• Frequent physical illnesses
• Low self-esteem
• Disordered eating

Knowing the signs and symptoms can help you fight abandonment issues.

The Long-Term Effects of Abandonment and Neglect

People who have experienced abandonment might be more likely to have long-term mental health disorders, often based on the fear the abandonment will happen again in their adult relationships. Mood swings and anger issues later in life can often be traced to abandonment in infancy due to the lack of emotional and other support from parents.

Some of the mental health conditions thought to be heavily influenced by abandonment include:

• Codependency
• Attachment anxiety
• Borderline personality disorder

For someone who lacks self-esteem due to childhood abandonment, the fear of being abandoned again becomes a self-fulfilling prophecy as their clinginess, and other negative behaviors tend to push away potential life partners and friends.

Other long-term consequences affect future generations of those who experienced abandonment as a child. A recent study , published in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging found that the offspring of the abandoned and neglected inherit brain abnormalities from their mothers show up as functional dysconnectivity between the amygdala and medial prefrontal regions of their children’s brains shortly after birth.

  The Treatments for Childhood Abandonment in Adults

The treatment of abandonment issues focuses mainly on establishing healthy emotional boundaries and building a plethora of new responses when old thought patterns of fear begin to emerge or reemerge.

There are two primary treatments for abandonment that work tightly together to treat abandonment and neglect issues, including the following.

Psychotherapy . While psychotherapy is not for everyone, seeking out a mental health professional’s help can help those who were the victims of childhood abandonment and neglect. They can learn to overcome their fears of being abandoned again. Therapists work with their clients to understand where the fear originates and how it affects their relationships.

Self-Care. Self-care includes making sure the survivor healthily meets their emotional needs by forming friendships and relationships and allowing themselves to trust.

Should you love someone who has abandonment issues, there are ways you can support them while they heal.

Validate their fears. This means that you should acknowledge their feelings of abandonment without judgment. This move is vital to maintaining open communication. Validating a loved one’s fears doesn’t mean agreeing with them, but instead, supporting their feelings to further build on trust and compassion.

You can do this by following the six-level approach mentioned in Psychology Today. 

• Be present and actively listen to their concerns.
• Reflect and summarize your loved one’s feelings verbally and without judgment.
• Become a mind-reader, and by listening to what they say help them identify their emotions.
• Understand their history so you can openly state that you understand when circumstances trigger their past history of abandonment.
• “Normalize” their fears by acknowledging the fact that others with their history have fears of abandonment and that their feelings are understandable.
• Use radical genuineness to deeply validate your loved one and share your loved one’s fears as your own.

The treatment of abandonment anxiety can be very successful, but it requires commitment and self-care. Many people with abandonment issues do not see how destructive their behaviors have been to their relationships until it is pointed out to them and they begin to heal.

However, treatment can teach new ways of thinking and coping to end the overarching and debilitating power of abandonment in childhood.

“A friend is someone who knows all about you and still loves you.” ~Elbert Hubbard

“Being deeply loved by someone gives you strength while loving someone deeply gives you courage.” ~ Lao Tzu

20 signs someone has abandonment issues. (2017, September 8). Retrieved from https://www.aconsciousrethink.com/6064/signs-abandonment-issues

Abandonment & attachment-related trauma treatment & rehab center. (n.d.). Retrieved from http://www.therefuge-ahealingplace.com/ptsd-treatment/abandonment

Hendrix, C. L., Dilks, D. D., McKenna, B. G., Dunlop, A. L., Corwin, E. J., & Brennan, P. A. (2020). Maternal childhood adversity associates with frontalamygdala connectivity in neonates. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging .

Megase, K. (2016, March 3). How fear of abandonment affects relationships. Retrieved from https://www.counselling-directory.org.uk/counsellor-articles/how-fear-of-abandonment-affects-relationships

Schoenfelder, E. N., Sandler, I. N., Wolchik, S., & MacKinnon, D. (2011). Quality of social relationships and the development of depression in parentally-bereaved youth.  Journal of Youth and Adolescence, 40 (1), 85-96. Retrieved from http://search.proquest.com/docview/821697890?accountid=1229

Wade, B. (1995, 04). Fear of abandonment.  Essence, 25 (79). Retrieved from http://search.proquest.com/docview/223174140?accountid=1229

Rescuing My Inner Child

A Compassionate Guide to Talking about LBGTQ Issues

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My name is Shirley Davis and I am a freelance writer with over 40-years- experience writing short stories and poetry. Living as I do among the corn and bean fields of Illinois (USA), working from home using the Internet has become the best way to communicate with the world. My interests are wide and varied. I love any kind of science and read several research papers per week to satisfy my curiosity. I have earned an Associate Degree in Psychology and enjoy writing books on the subjects that most interest me.

14 Comments

Excellent article, Shirley Davis, and very interesting. Tugs at my heartstrings, and I can identify with some of that. I think about alot of kids myself; still, after all these years, and it continues to be ongoing.

Thank you Shirley. As someone that is currently working through this in therapy I appreciate reading this, it makes me feel less alone. What a fight it is to work through this type of trauma. Thank you for sharing as you do!

Thank you for taking the time to write on this topic. The information is very descriptive of the realities of many persons. Please continue the work of ‘enlightening’ the world about the truths of the Psychology of Humanity.

Thank you for your kind comment. Shirley

I’ve known this was my main issue in my life, so I looked it up online. I’m glad I did. The symptoms showing up in real life match perfectly.

Thank you for writing this. Looking internally, I couldn’t see clearly. Your writing helped.

(just realized I was trying to people-please in my writing. The shoe fits)

Thank you for your comment, I’m glad I could help. Shirley

I was abandoned, and now abandoned others without a thought. I don’t know how to love or find happiness, but hope your writings will help me.

Just realized I have this issue. Sucks… And its come at a point where I have already lost everything. So no money, means no therapy. I have isolated myself so much. when I look back over the years, I was the problem. Now i just hate being. Every minute I spend at my friends place is torture. So I am waiting for a little money to leave and hit the streets where I cannot hurt anyone anymore. Im 44 now. If you can go get help while you can. I am hoping to die as quickly as possible without doing it to myself. I see 2 possibilities. starvation or freezing in the UK when this coming winter. I was abandoned several times, abused as a child. And now people expect me to just shrug it off. Careful who you tell. I tried to open up to my best friend of 34 years. He told me so what. Suck it up and move on. I wish I could. I wish so much. Most of my life I have not felt love. My belief is that people do not even like me. Why do they put up with me. The friend I am staying with tries to help. He told me to see a therapist and then the next day will say suck it up. This just confuses my mind more. Which is it? And how? I have no job and no money. The little I have buys me some food. When your friends talk to you like this, its of no help and further confirms my uselessness in this world. Wish you all the best. Hopefully with 3 weeks, i get to walk out and never have to love or look for it. And yes my parents have died. And my younger brother ripped me off and my elder brother wont even return $400 to me even if he can afford holidays, lavish parties. I’m eating instant noodles 3 times a day and he has the nerve to call me his brother. why was I born?

I have a friend struggling psychologically because of abandonment, and I know how hard it is to overcome, so I always give a talk to all my friends when they are emotional. A simple word and showing them that you care for them are simple, yet essential to them. Thanks for sharing this excellent article. Great post!

This is so sad, heartbreaking. Some parents are so selfish. They only think about their needs

Yeah! That is the sad reality. Not all kids are blessed to have completely loving family.

my father abandoned me and ruined my life and till this day he has nothing to his name but living off a woman.

Thank you so much for your article, finally I managed understand myself. I was denying this for so long, finally I’m on a path of healing. Naming what happend to me helps a lot.

How about instead of giving everyone else a chance to understand and be there for you, you give yourself a chance? What you went through does not define who you are nor whom you will be. I know it is easier said than done, but if you can find a tiny glimpse of hope within you, I am sure that is all you need.

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• 3 Things You Need to Know About Dating Someone with Abandonment Issues | by Stacey Herrera | Feb, 2022 – Women Theme - […] https://cptsdfoundation.org/2021/02/25/the-long-term-effects-of-abandonment/ […]
• How Childhood Trauma Impacts Adult Relationships, According to Psychology | Pangjia - […] so if the adults in their lives behave in unhealthy ways, the child will, too. Additionally, abandonment during stages…
• How Childhood Trauma Impacts Adult Relationships, According to Psychology – ThankSoMuch - […] so if the adults in their lives behave in unhealthy ways, the child will, too. Additionally, abandonment during stages…
• How Childhood Trauma Impacts Adult Relationships, According to Psychology | Leland Baptist - […] so if the adults in their lives behave in unhealthy ways, the child will, too. Additionally, abandonment during stages…
• How Childhood Trauma Impacts Adult Relationships, According to Psychology | Our Furry Fandom - […] so if the adults in their lives behave in unhealthy ways, the child will, too. Additionally, abandonment during stages…
• How Childhood Trauma Impacts Adult Relationships, According to Psychology - MANIFESTATION EXPOSED - […] so if the adults in their lives behave in unhealthy ways, the child will, too. Additionally, abandonment during stages…
• Angoasa de abandon - cauze, implicații psihologice | Clinica Aproape - […] https://cptsdfoundation.org/2021/02/25/the-long-term-effects-of-abandonment/ […]
• are abandonment issues a mental illness - logindataworld - […] The Long-Term Effects of Abandonment | CPTSDfoundation.org […]
• 13 Ways That Narcissists Damage Their Children - […] According to Shirley Davis of the CPTSD Foundation, these are some of the effects of abandonment trauma… […]
• Abandonment Issues: 14 Clear Signs & Tips to Deal With Them - […] Abandonment issues stem from your life experiences when you felt alone and could not rely on your loved ones…
• How to Enjoy Being Alone - […] CPTSD Foundation suggests that abandoned kids “grow up feeling unsafe in the world and feeling people cannot […]
• Why Do I Always Feel Left Out? | Uncover Counseling - […] Impact of the Abandonment Wound: […]
• The Long-Term Effects of Abandonment | CPTSDfoundation.org – critical diary - […] The Long-Term Effects of Abandonment | CPTSDfoundation.org — Read on cptsdfoundation.org/2021/02/25/the-long-term-effects-of-abandonment/ […]

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The Painful, Long-Term Effects of Parental Abandonment

A trauma with lifelong impact few others understand..

Posted October 2, 2022 | Reviewed by Jessica Schrader

• Caregiver abandonment affects us long into adulthood, often manifesting as dysfunctional traits in and outside of relationships.
• Caregiver neglect or abandonment can be a significant source of trauma but is often overlooked in older teens.
• Those who experience parental abandonment may struggle with self-image and self-esteem as adults.

Cassie was 14 when her father left her mother, moving into an apartment across town. She dealt with the trauma of their separation by skipping school, experimenting with drugs, and staying out late with boys, and she was even caught shoplifting.

But she was 18 when he left her . Reporting to mutual family members that he "couldn't handle" Cassie's behavior anymore, he stopped answering the phone and moved in with a new woman. As he began a completely new family, it was clear that Cassie was no longer welcome.

He still sent Christmas and birthday cards for the next couple of years (which were clearly written in his new wife's handwriting), but then stopped contact altogether. He refused to come to her college graduation, brushing off her attempts to reach out. "You're an adult now," he told her, "let me live my life and be happy for me."

She felt that the rug had been ripped out from under her. She blamed herself for him leaving. Not knowing where to turn to self-soothe the pain and confusion, she plunged into 10 years of drug addiction , compulsive eating, and other self-destructive behavior before landing on my couch in a desperate attempt to change her life. She was about to be 33, divorced , and had just had her first child. She felt like it was time to process the abandonment she had experienced so she did not pass the pain onto her child.

When we discuss parental abandonment, we often think of vulnerability. Images of small children or babies in foster care come to mind.

However, the effects of caregiver abandonment can be detrimental at any age. While it can be argued that smaller children are more at risk for lasting impact due to their stage of development, many people struggle with parental abandonment that happened during their adolescent or teen years—or even well into young adulthood.

Cassie's father wrongly assumed that because she had reached her teenage years, she was responsible for her own behavior and therefore did not need him anymore. He wanted to live his life without the responsibility of having to be a parent, and simply cut her off.

To most of us, this act seems abusive and wrong. How can a parent turn off their love like a light switch? While it can be assumed that her father was undoubtedly struggling with his own mental health concerns, the impact on the young woman Cassie was becoming was lasting.

Her pain was real, but it was ignored by many due to her age. "You're an adult now, it doesn't matter," her mother said to her, dismissing her feelings. "Well, you two never did get along," her uncle said, excusing the inexcusable behavior of an adult caregiver and projecting the blame onto the child.

Cassie's father blamed her behavior as his reason for leaving, and others in her life reinforced this cruel message, setting her up for a life of self-blame and loathing. When a caregiver abandons a toddler, few would think to blame the child. But for some reason, when a teenager or young adult is abandoned, society often assigns them the blame. "Their behavior was so bad, who could blame them?" Or, "There must have been something they did." This is the common whisper among unknowing onlookers who wrongly assume their behavior had to contribute to the caregiver throwing their hands up and leaving. In reality, there is no excuse: It is abandonment.

In our culture, we assume that older children need us less than they did when they were babies, when they were helpless and dependent on their caregivers for every need. And of course, this is true in a physical sense.

However, teenagers and young adults often need their parents a lot more than they are able to articulate. Just because they can feed and clothe themselves somewhat appropriately does not mean that they cease to benefit from parental guidance. Yes, that angry teenager or college student who tells you he hates you, and acts annoyed by your very presence, actually needs you.

Children in dysfunctional families are often put in age-inappropriate emotional and physical situations. And they are often treated as either older or younger than they are, developing personality characteristics that reflect that mistreatment, such as ultra-independence, learned helplessness , or codependency.

However, these personality traits are then held against them in the family unit. For example, Cassie was used as the emotional caregiver of her parents, often expected to handle the psychological stress of the family—but she was then punished for staying out late, talking back, and having many sexual relationships as a teenager. She was allowed to act like an adult, but only when it benefitted the family.

Her father " couldn't handle it anymore," and resigned from his job as a parent. This places an unfair and age-inappropriate burden on a young child who is then punished for acting in other adult ways. It's hypocritical and sends mixed messages to a developing brain. Children of all ages already blame themselves for traumas in their life. They do not need society pushing that self-blame further. Nothing tells a young person that they are less worthy of love than their own parent leaving them. Cassie felt scarred for life. Who wouldn't?

In therapy , Cassie worked on her feelings of abandonment that manifested as depression , anxiety , poor self-esteem , and chronic unhappiness. She reported an inability to leave unsafe or toxic relationships until the other person eventually just left her. She drank heavily, stuffed her feelings with food, and was scared to raise her child alone—even considering going back to her abusive ex-husband. She was so scared of repeating the abandonment she had suffered as a teen that she was willing to stay in an unsafe relationship. It took years of diving into the pain that she had experienced before she started to feel like she was worthy of love and healthy relationships.

Most parents will agree that their love for their children is unconditional and never-ending, but what happens when some caregivers do not feel the same? When someone is able to turn away from a child, no matter the age, this seems foreign and cruel—as it should. To another adult, the behavior often speaks to the pathology and mental health of the offending parent. But to the emerging adult, who does not yet have the tools to compartmentalize the situation, it has lasting effects on their very sense of self, with the trauma often manifesting for many years after.

Facebook /LinkedIn image: Lopolo/Shutterstock

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking. Read in entirety in 2021.

Shirley, D. (2021).The Long-Term Effects of Abandonment. https://cptsdfoundation.org/2021/02/25/the-long-term-effects-of-abandon… Accessed 10/1/2022.

Wang ZY, Hu M, Yu TL, Yang J. The Relationship between Childhood Maltreatment and Risky Sexual Behaviors: A Meta-Analysis. Int J Environ Res Public Health. 2019 Sep 29;16(19):3666. doi: 10.3390/ijerph16193666. PMID: 31569567; PMCID: PMC6801672. Accessed 10/1/2022.

Kaytee Gillis, LCSW-BACS, is a psychotherapist and the author of three books, including Breaking the Cycle and It's Not High Conflict, It's Post-Separation Abuse.

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Why and How do Parents Secretly Abandon their Children? The psychosocial burden they went through: Qualitative case study in Gondar City, Ethiopia

Globally, studies on parents who secretly abandoned their children scarce and were unavailable in Ethiopia. This study, therefore, explored the lived experiences of mothers/fathers who secretly abandoned their children.

Qualitative case study design was employed. Semi-structured interviews were conducted with purposefully selected parents in Gondar city. Thematic content analysis was employed to analyse the data.

In the present study, three core themes emerged: parents’ situation before delivery, parents’ child abandoning experiences, and parents’ psychosocial conditions after abandonment. Contextual factors before and after the child is born (e.g. challenging life situation, unwanted pregnancy, rape/abuse, etc.) played important roles in later child abandonment. Child abandonment is a process that includes contemplation, preparations and taking actions. Economic hardships, exacerbated by sociocultural factors pushed parents to abandon their children. Psychological sufferings begin before abandonment and continued after the abandonment.

Conclusions:

Child abandonment, as one form of avoiding parental responsibilities, is not a onetime act and sociocultural factors exacerbated the economic push factors. Therefore, it is recommended that extensive participatory studies, psychosocial support for vulnerable parents, and awareness creation campaigns need to be in place to mitigate child abandonment.

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The Effects of Early Neglect: Addressing the Emotional Needs of Abandoned Children

In various societies, the effects of neglect in the early stages of a child’s life are often overlooked. The consequences of neglect in the future could cause potential harm to the physical and emotional well-being of the neglected child as they grow older. Every child who has ever been neglected or abandoned has their own way of handling their traumatic experience.

In the past, there have been several studies conducted to take a look at the impact of different types of neglect on children’s development. One of the recent studies compared children ages 3-10 years old, with a history of familial neglect (USN), children with a history of institutional rearing (IA), and children without a history of neglect (Spratt et al., 2012). After the comparison with the children that were not neglected, results showed that the children with a history of USN and IA showed lower cognitive and language scores and more behavioral problems. Most common across the USN group were both internalizing and externalizing behavior problems. Externalizing behavior problems predicted parenting stress. When comparing the two neglect groups, shorter time spent in a stable environment, lower scores on language skills, and the presence of externalizing behavior predicted lower IQ. While higher IQ could be predicted by language scores and an absence of externalizing behavior problems.

The Emotional Needs of Abandoned Children

Since early childhood is a pretty vulnerable time for children to develop cognitive, language, and emotional skills, the presence of neglect can cause catastrophic problems in a child’s life. According to Weir , the problems that stem from children being neglected include poor impulse control, social withdrawal, having problems coping and regulating their emotions, having low self-esteem issues, having pathological behaviors such as tics and tantrums, stealing and self-punishment, poor intellectual functioning and low academic achievement. These are just some of the problems that are present when children get abandoned or neglected.

Even though some children have long-lasting effects from being neglected, there are other children who are able to recover quickly from the trauma. With that being said, the emotional needs of the children still suffer because it is very difficult for a child’s brain to fully absorb and understand the enormity of abandonment (“ How To Overcome Abandonment Issues From Childhood ”). The abandoned child is left questioning their self-worth, has difficulty trusting others, and struggles with the feelings of guilt and shame.

Neglect in Developed Countries vs. Developing Countries

Although the issue of neglect is not as present in the U.S. as it is in developing countries, the topic is still a very huge concern nationwide. According to Spratt, neglect is the most prevalent form of maltreatment and is associated with negative social, behavioral, and cognitive consequences. In 2010, neglect in the U.S. accounted for 78% of all child maltreatment cases nationwide, far more than physical abuse (17%), sexual abuse (9%), and psychological abuse combined (“ Center on the Developing Child ”). Some of the reasons for the neglect among children in the U.S. were due to low-stimulation environments, inconsistent parenting (lack of rules, failure to monitor kids, inconsistent punishment and rewards), children receiving lower scores on their intelligence and language tests (Spratt et al., 2012). The children also showed development delays in IQ, language, social emotional functioning, and impaired attachment.

In addition to the physical and emotional neglect in the U.S., the effects of neglect among children can take place in developing countries where there is a lack of consistent caregivers, crowded conditions and abandoned children not having their physical, social, and emotional needs met. In Romania, after the Romanian dictator Nicolae Ceausescu was overthrown, there were 170,000 children who were being raised in Romania’s impoverished institutions (Weir, 2014). Later in 2000, a group of researchers from the Bucharest project assessed 136 children; they assigned half of the children to move into Romanian foster families and had the other half remain in the Romanian institutions.

From their study, the researchers found that the children who were neglected and lived in the institutions had many problems. The children had delays in cognitive function, motor development, language, shortages in socio-emotional behaviors, experienced psychiatric disorders and they showed changes in the patterns of the electrical activity in their brains (Weir, 2014). For the children that were moved into foster families, they showed improvement in language, IQ, social-emotional behaviors and they were able to form responsive relationships to their caregivers.

Non-Profit Organizations for Neglected Children

For more than 15 years, the World Forgotten Children Foundation (WFCF) has supported and partnered with many organizations worldwide to help tend to the emotional and physical needs of abandoned and neglected children.

Organizations such as:

Under the Same Sun

Under the Same Sun is a non-profit organization in Tanzania that promotes the well-being of people with albinism through education and advocacy.

International China Concern (ICC)

International China Concern is a non-profit organization that helps children with disabilities who are abandoned and left in desperate conditions.

Spratt, E. G., Friedenberg, S. L., Swenson, C. C., Larosa, A., De Bellis, M. D., Macias, M. M., Brady, K. T. (2012, February 01). The Effects of Early Neglect on Cognitive, Language, and Behavioral Functioning in Childhood. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652241/

Center on the Developing Child: Harvard University. (n.d.). Neglect. Retrieved from https://developingchild.harvard.edu/science/deep-dives/neglect/

Weir, K. (2014, June). The lasting impact of neglect. Retrieved from https://www.apa.org/monitor/2014/06/neglect

How To Overcome Abandonment Issues From Childhood. (n.d.). Retrieved May 31, 2019, from https://drjonicewebb.com/the-3-main-issues-of-the-abandoned-child-in-adulthood/

About Us – International China Concern. (n.d.). Retrieved May 31, 2019, from https://www.chinaconcern.org/about-us/

About Us | Under the Same Sun. (n.d.). Retrieved May 31, 2019, from https://www.underthesamesun.com/content/about-us

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Institutional Care and Child Abandonment Dynamics: A Case Study in Antananarivo, Madagascar

• Published: 27 April 2012
• Volume 5 , pages 659–683, ( 2012 )

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A “social market” for children care is growing in developing world, in a context of philanthropic support and strong demand for international adoption. Moreover, impoverishment of many urban families results in a high demand for social aid that governments have trouble to provide. We have explored the circumstances leading to the placement of 764 children using a survey conducted among 40 residential care institutions in Antananarivo, capital city of Madagascar. One third of these children have been abandoned or orphaned. Stigmatizations against some children (born to unmarried mothers) and the refusal to care for step-children in newly reconstituted families seem to be key factors for abandonment. Some two-thirds of children are not abandoned and have at least one parent alive. Families place these children for economic reasons. If residential placement is the best solution for some children, it is important to question the relevance of child placement as a response to deep poverty, which makes up the majority of cases (the two-thirds). How are responses influenced by adoption demand? What responses should be promoted? How is residential placement embedded within the national policy for child protection? Our findings highlight the need for a more in-depth understanding of the dynamics of child abandonment in view of prevention actions. This paper has also raised the need for coordinated actions based on a real dialogue and consultation among all the stakeholders.

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Determinants and Consequences of Children Living Outside of Parental Care in Lao People’s Democratic Republic: Views and Experiences of Adults and Young People in Family and Residential Care

Child Protection and Welfare Systems in Ireland: Continuities and Discontinuities of the Present

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Acknowledgment

We would like to thank UNICEF for providing financial support for the survey on residential care institutions in Antananarivo. Our thanks also go to the Syndicat Professionnel des Diplômés du Travail Social (SPDTS) for their support in organizing data collection and entry. We extend a warm thank to C. Benge, M. Razafindratsima, P. Vatinel, E. Harang, J. Ballet and S. Delcroix for their very useful comments on this paper.

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Valérie Delaunay

Development Aid and Child Protection, Trigny, France

Lidia Galenao Germain

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Delaunay, V., Germain, L.G. Institutional Care and Child Abandonment Dynamics: A Case Study in Antananarivo, Madagascar. Child Ind Res 5 , 659–683 (2012). https://doi.org/10.1007/s12187-012-9141-y

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Accepted : 25 March 2012

Published : 27 April 2012

Issue Date : December 2012

DOI : https://doi.org/10.1007/s12187-012-9141-y

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Alternatives for Abandoned Children: Insights from the Bucharest Early Intervention Project

Charles h. zeanah.

1 Tulane University School of Medicine

Kathryn L. Humphreys

2 Stanford University

Nathan A. Fox

3 University of Maryland

Charles A. Nelson

4 Boston Children’s Hospital and Harvard Medical School

5 Harvard Graduate School of Education

The Bucharest Early Intervention Project is the first and only randomized controlled trial of foster care as an alternative to institutional care for orphaned and abandoned children. Across various domains of brain and behavioral development we demonstrated that children in families developed more favorably than children in institutions, that foster care remediates some but not all compromises associated with institutional placement and that earlier placement in foster care leads to more developmental gains in some but not all domains. In addition to early placement, higher quality of care provided and more stable placements for children all enhanced outcomes. These results have important implications for science, practice and policy.

Millions of orphaned, abandoned, and maltreated children worldwide require care that cannot be provided by their parents or families. For hundreds of years, these children have posed challenges that have led to two major societal approaches: caring for children in institutional settings (orphanages), or placing children in families, through foster care or adoption.

Prior to the study this paper describes, only a small number of descriptive studies, mostly conducted in the mid-20 th century, had compared children in foster care to children in institutional care (4–13). Results demonstrated that children in foster care developed more favorably than children in institutions. On the other hand, interpreting these results is challenging, given that it is plausible that more handicapped children might be more likely to be placed in institutions rather than foster care. More recent studies of children adopted from institutions similarly show substantial gains after family placement, but they are limited by the potential for selection bias inherent in adoption. In addition, most did not assess the children within the institutions prior to adoption.

Origins and Design of the Bucharest Early Intervention Project

Following the infamous economic policies of Nicolae Ceausescu, Romania faced an unprecedented child protection crisis at the turn of the 21 st century, with an estimated 170,000 children living in large, socially impoverished institutions [ 1 , 14 ]. Our group was invited to conduct an intervention study by the Romanian Secretary of State for Child Protection, because of a policy debate about the best approach to caring for large numbers of abandoned children [ 1 ].

To address the challenges and limitations of previous research, we decided to conduct a randomized controlled trial (RCT) of foster care as an alternative to institutional care among children who had been abandoned in infancy and were being raised in institutions. The unique and crucial advantage of randomizing infants already living in institutions is that both groups share pre-existing risk factors, and any differences in outcomes can be confidently attributed to the intervention. Thus, this was the only design that could provide definitive evidence of which form of care was preferable [ 1 , 2 ].

We also wanted to assess the children’s development comprehensively, and we determined that measures of brain and behavioral functioning could be used to address the questions of concern. We recruited 136 children 6 to 31 months of age who were living in Bucharest in institutions, following abandonment and who had neither obvious genetic syndromes or severe neurological conditions. All the children had lived at least half of their lives in institutions. We also recruited 72 typically developing children from pediatric clinics in Bucharest to serve as a comparison group, since the measures we planned to use had not been used in Romania before (see design in Figure 1 ).

Participants in BEIP

Following baseline assessments, we randomly allocated half of the sample to care as usual and half of the sample to placement with foster parents whom we recruited, managed and supported. As illustrated in Figure 1 , the original RCT was conducted from baseline through age 54 months. At that point, we turned support of the foster care network over to local governmental authorities in Bucharest. We then conducted follow-ups of the children at 8 years and 12 years.

Ethical issues

Studying a vulnerable population and conducting an RCT raises a number of concerns. We [ 1 , 15 , 16 ] and others [ 17 , 18 , 19 ] have discussed these issues in detail. Briefly, we conducted a study with a vulnerable population only because it addressed a question relevant to them. Second, we did not interfere in any decisions about changes in placement of the children since legally those decisions had to be made by Romania’s child protection officials. Third, we used only measures that posed no more than minimal risk to participants. Fourth, there were multiple levels of oversight of the study within Romania and at each principal investigator’s university.

The BEIP Intervention

We endeavored to create a foster care program in Bucharest that was culturally appropriate, feasible, replicable and informed by developmental science. We have previously described these efforts in detail [ 1 , 20 ]. The essence of the foster care intervention was to recruit, train and support foster parents willing to make a full and long-term commitment to the children in their care.

Drawing upon our experiences of intervening with young children in the U.S. [ 21 ], we recruited and trained foster parents who could understand and respond effectively to meet the needs of young children in their care. We knew from informal observations and pilot assessments [ 22 ] that these young children had serious developmental delays and deviances, and we expected that they would present challenging behaviors to parents caring for them. We also knew that resources for special needs children were not widely available at that time in Romania. Therefore, we knew that the care that foster parents provided would be the major means through which children’s developmental delays and deviant behavior would be addressed.

A particular challenge that we faced was that not only was the fledging child protection system in Bucharest overwhelmed and underfunded at the time, the entire profession of social work in Romania was inexperienced due to Ceausescu’s elimination of social work as a profession (deeming it unnecessary). Therefore, we provided expert mentoring to BEIP social workers from the United States. Mental health clinicians from Tulane University who had had many years of experience working with young maltreated children in foster care provided weekly consultation to BEIP social workers about how to support foster parents in caring for formerly institutionalized children. Social workers had frequent in person and phone contact and tried to be responsive to needs that foster parents expressed.

Scientific questions

BEIP addressed three major questions across multiple domains of development ( Table 1 ). First, we documented developmental differences between young children living in institutions and those with no history of institutionalization living in families. Second, we determined if and how much recovery foster care might produce for young children who had been abandoned and placed in institutions, using a stringent intent to treat analysis, in which data were analyzed by original group assignment rather than subsequent placement status. This provided a conservative estimate of intervention effects. Third, we examined whether the timing of placement affected outcomes and how this varied across domains of development.

Domains of assessment

Baseline results

At baseline, there were no differences between the children later randomized to foster care or care as usual, but these children living in institutions were different from their never institutionalized counterparts in virtually every developmental domain [ 1 , 23 ].

Intervention effects: Foster care and care as usual

Results from the RCT were consistent across most developmental domains -- children in foster care developed more favorably than children who received care as usual. Selected intervention outcomes are shown in 2a, with effect sizes and confidence intervals to allow comparisons across domains. Overall, the magnitude of the effects illustrated in Table 2a are consistently in the small to medium range (all in the expected direction, FCG have better outcomes than CAUG). Because of the randomized design, these results are definitive proof that foster care placement led to enhanced functioning.

Selected Intervention Effects (CAUG > FCG)

Note. d Effect Size using Maximum Likelihood Estimator [95% Confidence Interval].

-- indicates no intent-to-treat finding or not assessed.

Perhaps more interesting, is when these same domains are examined comparing the FCG and NIG, demonstrating “catch-up” of the FCG to a (quasi-matched) comparison group of children with no history of institutionalization ( Table 2b ). Here, effect sizes vary dramatically, with some domains showing almost complete catch-up (e.g., height, weight, EEG alpha power) and others demonstrating a lack of complete catch-up despite notable difference between those children who did and did not get assigned to the intervention. For example, the magnitude of IQ differences between the FCG and NIG were large across all time points considered. Most often the FCG children, as a group, occupy a level of functioning that is intermediate to the CAUG and NIG.

Foster Care Group Catch-up (FCG > NIG)

Although IQs of FCG children were significantly higher than those CAUG children over time [ 26 , 27 ], there were few intervention effects on executive functioning skills [ 28 , 29 ], which were not assessed in early childhood. FCG children also demonstrated an attention bias to positive facial expressions of emotion at both 8 and 12 years [ 30 , 31 ]. Social behaviors, including peer relations and social skills were enhanced [ 32 , 33 ]. Externalizing signs, CU traits and attachment disorder behaviors at 12 years all were reduced for children living in foster care [ 34 – 37 ]. Brain structure and functioning at 8 and 12 years also were enhanced by the intervention [ 38 – 41 ]. Further, cortical white matter volume partially mediated the effect of institutional rearing on EEG alpha power, suggesting that reductions in circuitry were associated with reductions in brain electrical activity. Also, white matter tracts in the external capsule and corpus callosum partially explained links between institutional rearing status and internalizing symptoms in middle childhood and early adolescence [ 39 ]. Children randomized to foster care demonstrated healthier stress responses, as indexed both by cortisol levels and autonomic nervous system indices [ 42 ].

Timing of enhanced care

Because of the variability of children’s ages at the time they were randomized to foster care (7–33 months), we were able to examine the effects of age at which their placements occurred in relation to outcomes (see Table 3 ). For some, but clearly not all domains, children placed into foster care at earlier ages fared better than those placed at older ages. The ages at which differences became significant ranged from 12–24 months, but most were between 20 and 24 months of age. We have considered these results as compatible with sensitive periods in brain development [ 1 , 43 , 44 ].

Timing effects: Age of placements at which differences between earlier and later placed children became significant.

Keys to the success of the intervention

Quality of caregiving, which was objectively coded from videotaped observations, was higher in the children in BEIP foster care than children who received care as usual [ 1 ]. During naturalistic interactions at 30 months, quality of caregiving was an important predictor of early psychopathology [ 45 ]. Secure attachments at 42 months, which were significantly more likely in children in foster care, mediated the effect of caregiving quality on psychopathology at 54 months [ 46 ]. In fact, secure attachment in early childhood also predicted other subsequent outcomes, including IQ and peer relations at 8 years [ 26 , 47 ].

At age 12 years, children who had remained in a stable foster placement since original randomization were less likely to display signs of internalizing and externalizing disorders [ 34 ], as well as more likely to demonstrate an attention bias to positive emotional displays, while instability of foster care placement was related to threat bias. The magnitude of the positive bias was associated with fewer internalizing problems and better coping mechanisms [ 31 ]. Of course, children with higher levels of serious behavior problems might precipitate more disruptions, but we found no differences on multiple measures at earlier ages in children whose placements subsequently disrupted and those that did not, so it is unlikely that challenging behaviors led to the disruptions. Instead, the disruptions often resulted from decisions to reunify children with their biological families, sometimes with subsequent later returns to institutional care.

Conclusions

Implementation of a quality foster care intervention for young children who had experienced severe deprivation proved feasible and led to improved developmental outcomes across numerous domains compared to care as usual. Earlier placement into foster care, higher quality of care provided, and more stable placements all enhanced outcomes. Though early institutional rearing was associated with large deleterious effects across physical, cognitive, socioemotional and behavioral domains, the effects on cognitive development and psychopathology showed the least response to quality foster care intervention. The urgency of early family placements is underscored by others’ findings that adoption of institutionalized Romanian infants before 6 months of age in led to near complete recovery across domains [ 48 ].

From a practice and policy perspective, the lack of sustained and meaningful support to the foster care program at the trial’s conclusion was accompanied by an increase in disrupted placements and loss of some developmental and clinical gains. Given that developmental delays and deviance from deprivation seem not to be transient, sustained investments in high quality care are worth pursuing and sustaining.

• BEIP is the first ever RCT comparing foster care to institutional care for young children.
• Institutional rearing led to substantial developmental compromises across almost all domains.
• FCG children made significant gains compared to CAUG children.
• Timing of placement into families was critical for selected domains of development.
• Recovery from early deprivation was incomplete for most domains of development.
• Key recovery factors were earlier placement, and quality of care and stability of placements.

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