A group of academics from the University of Southampton and King's College London recently published research conducted with former children from Romania who were adopted in the wake of the fall of the Romanian communist regime led by the now infamous President Nicolae Ceauşescu. This longitudinal study has endeavoured to elucidate how early experiences in life shape individual development (Mackes et al, 2020).
Background
After years of austerity, the people of Romania rebelled against the communist government. Ceauşescu and his wife were put on trial and executed on Christmas day 1989, paving the way for the country's reform and eventual membership of the European Union.
In the aftermath of this revolution, it quickly became apparent that Romania had a major child health crisis to resolve. This crisis had arisen because Ceauşescu had tried to emulate the philosophy of Stalin to increase the population of the country by outlawing abortion and contraception (Steavenson, 2014).
As the country sank deeper and deeper into financial crises throughout the 1980s, a consequence was child abandonment where increasing numbers of parents put their children into state-run institutions. At the end of the Ceauşescu regime it was estimated that more than 100 000 children were institutionalised in state-run orphanages (Steavenson, 2014). By the end of the regime the economy of Romania was broken and the children suffered extreme hardship—nutrition, warmth and caring deteriorated. Staff shortages ensured that, although the physical needs of the children may have been met, their emotional needs were not.
Romanian health professionals were academically isolated from their international peers, with little access to evidence-based literature. Nurses in Romania then, and today, are known as medical assistants and practise under the supervision and responsibility of a doctor. During the Ceauşescu regime the status of nurses was not comparable to that in western countries. Lacking leadership and with a disenfranchised medical profession, the medical assistants were powerless to alleviate the suffering of the children (Steavenson, 2014).
Human Rights Watch (2006) published an account of what happened in the final years of the Ceauşescu government. This report revealed that more than 7200 Romanian children and young people aged between 15 and 19 were living with HIV, more than in any country in Europe. These so-called miracle children were the survivors among the more than 10 000 children infected with HIV between 1986 and 1991 in hospitals and orphanages as a direct result of the Ceauşescu government's policies. They were exposed to contaminated needles and so-called microtransfusions of unscreened blood, which were used by the medical profession to allegedly boost the immune systems of these abandoned children. Care staff, in failing to use sterile needles, exacerbated the spread of HIV infection among these vulnerable children (Flaitz et al, 2001).
Shortly after the fall of Ceauşescu the new government invited a range of non-governmental organisations (NGOs) into the country to help alleviate the looming child healthcare crisis. Many of these NGOs were charities that sought to help deal with the catastrophic warehousing of thousands of abandoned children. Early visitors to these orphanages were shocked at the conditions children were living in. The institutions were overcrowded with too few staff to care for the children, with some tied to their beds with no access to recreational play, toys or a stimulating environment. This impoverished environment left lasting and sometimes permanent psychological scars. One of these charities, Health Aid UK, set about acquiring houses where abandoned children, many with HIV, could be taken from the orphanages to live in a more normal home environment. But, for many, this help came too late.
Sensory deprivation in early childhood
There is a large body of literature on the effects of sensory deprivation in early life. As far back as the early 1950s John Bowlby articulated the crucial role that an attachment figure (normally the mother) had for normal development (Bowlby, 1952). He argued that disruption to the mother–child relationship in early life could lead to irreparable and irreversible consequences for the individual child's development. Similarly, Tomalski and Johnson (2010) highlighted the importance of the child's socioeconomic background on brain development, with early sensory deprivation, an impoverished environment and institutionalised care having negative sequelae, especially related to mental health.
Longitudinal research over a 20-year period from Israel indicates that preterm or low-birthweight babies being nursed in incubators and deprived of their mother's touch during the early weeks of their lives may suffer long-term and enduring emotional problems. This study compared outcomes from a cohort of 146 babies, where half were allocated to a ‘kangaroo care’ group receiving chest-to-chest and skin-to-skin contact with their mother outside the incubator. The babies who did not receive kangaroo care fared less well emotionally when compared with babies who benefited from this intervention. Many NHS trusts facilitate kangaroo care in neonatal units (Knapton, 2020).
Clearly, the lack of sensory stimulation/deprivation in early childhood can be devastating for the future wellbeing of children but it has been thought that, if these children were subsequently placed in a loving and caring environment, some of these negative effects could be ameliorated.
Addressing the plight of Romania's forgotten children
I was able to visit Romania about 18 months after the overthrow of Ceauşescu in the summer of 1992. I accompanied the vice-president of the Royal College of Nursing (RCN) in my capacity as the deputy chair of the Society of Paediatric Nursing (now configured as a range of forums) on a preliminary mission. The aim of the mission was to offer the medical assistants in the cities of Bucharest and Brasov, who were endeavouring to align themselves with the UK model of nursing, a series of lectures on recent concepts in nursing. My specific task was to make presentations on recent innovations in the care of sick children. On our return I was asked by the RCN to lead a series of charitable missions to help the plight of sick children in the country, including those infected with HIV.
My colleagues and I continued to visit Romania over the next 5 years, and on each occasion we collected toys for the children from various organisations, but especially banks, who gave us many packets of balloons (Glasper, 1999). When we first visited institutions caring for these sick children in Bucharest we were shocked at the lack of emotional stimulation offered by the medical assistants, who perceived their role to be primarily physical in nature. The children were cared for in white cots in Nightingale-type wards with plain white walls. They sat in these cots with the sides up totally devoid of toys, usually staring into space and rocking backwards and forwards. Although many were toddlers, they had little in the way of language acquisition and I remember vividly their eyes lighting up as I blew each of them a balloon to play with. The following year we ran a series of seminars in Bucharest and Brasov on the value of play for addressing sensory deprivation (Herron and Glasper, 1993).
We knew that it was important for the medical assistants to fully understand the importance of play. This is because it is the language of children, an essential tool through which they attain knowledge about themselves and the world around them. Play is a rich learning medium, and the ability to play develops earlier in children than the ability to communicate through language, making it a valuable communication tool for children of all ages. Play is essential for all aspects of ‘normal’ growth and development, enabling the child to develop emotionally, socially, physically and intellectually (Weaver and Groves, 2010).
However, altering the environment of care to incorporate play was never going to be the sole answer for these children. They needed to be cared for in more normal, homely environments where play provision and one-to-one communication between the child and the carer was facilitated, such as in the houses set up by Health Aid UK, where small groups of abandoned orphans with HIV were cared for. In the intervening years my colleagues and I were able to visit several of these, where there were ‘house mothers’ who acted in loco parentis and many of the children thrived. I have remained in touch with one of these children, who is now married and a mother of two children herself. Although this little girl survived her early life ordeals, others were not so fortunate.
The long-term effects of early life deprivation
Despite the commendable efforts of individuals and organisations to mitigate the effects of early life sensory deprivation on these children in Romania, it appears, at least for some, that these may be irreversible.
The research by Mackes et al (2020) endeavoured to investigate the impact on adult brain structure of severe but time-limited institutional deprivation in early life experienced by a group of Romanian children who were subsequently adopted into nurturing families. The Romanian young adults who participated in the research had been placed in institutions in the first few weeks of life. These babies were subsequently malnourished and received minimal social contact and little stimulation. The time spent in institutions before adoption into families in the UK varied between 3 and 41 months. The researchers found that there were changes in brain volume linked to their early life deprivation, which were statistically associated with lower IQ and greater attention deficit hyperactivity disorder (ADHD) symptoms. This research has shown that structural brain changes in adulthood can be associated with the duration of deprivation experienced at a very young age.
Conclusion
Millions of children worldwide live in non-familial institutions where they can be deprived of sensory stimulation. The evidence base now suggests that, despite subsequent positive experiences, many children continue to be negatively affected by early life sensory deprivation. The Romanian Health Authority has acknowledged the HIV medical catastrophe, and each HIV infected person from that era now receives free antiviral therapy and a disability pension for life.