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Attachment relationships of adolescents who spent their infancy in residential group care: The Greek Metera study a
a
b
Panayiota Vorria , Maria Ntouma , Maria Vairami & Michael c
Rutter a
Department of Psychology, Aristotle University of Thessaloniki, Thessaloniki, Greece b
M.H.C of Western Thessaloniki, Thessaloniki, Greece
c
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MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK Published online: 10 Apr 2015.
To cite this article: Panayiota Vorria, Maria Ntouma, Maria Vairami & Michael Rutter (2015): Attachment relationships of adolescents who spent their infancy in residential group care: The Greek Metera study, Attachment & Human Development, DOI: 10.1080/14616734.2015.1028947 To link to this article: http://dx.doi.org/10.1080/14616734.2015.1028947
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Attachment & Human Development, 2015 http://dx.doi.org/10.1080/14616734.2015.1028947
Attachment relationships of adolescents who spent their infancy in residential group care: The Greek Metera study Panayiota Vorriaa*, Maria Ntoumaa, Maria Vairamib and Michael Rutterc
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a
Department of Psychology, Aristotle University of Thessaloniki, Thessaloniki, Greece; bM.H.C of Western Thessaloniki, Thessaloniki, Greece; cMRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK (Received 2 March 2015; accepted 9 March 2015) A prospective longitudinal study beginning whilst the infants were living in the Metera Babies Centre showed that the great majority showed a disorganized attachment during the period of residential care, even though neither abuse/neglect nor subnutrition were involved. There was an initial follow-up post-adoption age at four years. This paper concerns a further follow-up of the 52 adopted adolescents aged 13 years who had spent their first two years of life in Metera Babies Centre. They were compared to 36 adolescents reared in their biological families who, during their infancy, attended fulltime public day care. The key aim was to examine continuities and discontinuities between early and contemporary relationships. The Child Attachment Interview was employed in adolescence. The main findings were a significant decrease in the rate of disorganization and a lack of a significant difference between the previously institutionalized group and the family care comparison group on attachment qualities in adolescence. There was not sufficient statistical power, however, to detect a small difference. Keywords: attachment disorganization; adoption; attachment security; adolescence; residential care
Introduction From Burlingham and Freud (1944) onwards, most reviews have emphasized the frequency of anomalous attachment patterns following early institutional care, with persistence continuing even after adoption into generally well-functioning families (Bakermans-Kranenburg et al., 2011). Nevertheless, it is seriously misleading to view the anomalous attachment patterns as necessarily reflecting attachment insecurity (Rutter, Kreppner, & Sonuga-Barke, 2009). Thus, the English and Romanian Adoption (ERA) study (O’Connor, Marvin, Rutter, Olrick, & Britner, 2003), following Goldberg’s (1997) study in Canada, used the recommended Cassidy-Marvin modification of the Strange Situation Procedure (SSP) for 5–7-year-old children. The most characteristic pattern was a non-normative, affectively dysregulated “other” pattern, rather than insecurity as usually conceptualized. The evidence that this “other” pattern reflected interactions with a stranger rather than a caregiver, and the association with a disinhibited pattern cast doubt on it being an “attachment” disorder. There are good reasons for expecting that early institutional care might involve impaired social relationships but these might not take the form of insecure attachments. *Corresponding author. Email: [email protected] © 2015 Taylor & Francis
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Another important issue concerned the question of whether all institutions should be regarded as similar in both their qualities and their effects. This study of the later development of young people who spent their early life in the Metera Babies Centre in Athens, Greece, was designed to focus on institutional rearing that had not been preceded by adverse experiences prior to institutional care. Ninety-five percent were admitted before six months, and 40% during the first month of life, because the babies were placed in Metera at, or soon after, birth (on the grounds that the mother was unable to care for her child). Metera was chosen for the study on the basis that it involved a lack of individualized personal care, but nevertheless involved neither gross general deprivation nor subnutrition (Vorria et al., 2003). The study was distinctive (probably unique) in that there was a detailed study of the institutional rearing in Metera and a follow-up after adoption – initially at age four years and now at age 13 years. This means that it was possible to investigate changes within individuals, as well as make between-group comparisons. The babies were initially housed in a unit that meant that each new-born was in a separate small room in which social contacts and interactions were severely restricted making it the most depriving period of their time in Metera. At about the age of five months the infants moved to a different pavilion where care was less depriving. Earlier discussions of Metera conditions (e.g. van IJzendoorn et al., 2011) tended to focus on the baby circumstances in the first five months and were, because of that, highly critical. Subsequent research involving much worse Romanian institutions (e.g. Rutter, Kumsta, Schlotz, & Sonuga-Barke, 2012) has shown (surprisingly) that adverse sequelae were minimal, or even absent, provided that the depriving care did not persist beyond the age of six to 12 months. Accordingly, here we focus on the quality of care provided in the pavilion for infants aged over five or six months. Detailed standardized measures were obtained on the children’s attachment behavior (with 77% for both the forced A, B and C classifications and the D versus non-D classification, giving rise to kappa values of .65 and .58, respectively). The quality of childcare was evaluated using the Early Childhood Environmental Rating Scale (ECERS; Harms & Clifford, 1980). The findings for Metera were compared with those in a day care environment. The quality of caregiver/maternal sensitivity was assessed using the Parent/ Caregiver Involvement Scale (PCIS; Farran, Kasari, Comfort, & Jay, 1986). Inter-rater reliability showed an intra-class correlation of .89. When infants move to a pavilion, each caregiver in Metera is expected to facilitate a special relationship with at least one infant who then considers her as his/her mother (Vorria et al., 2003). Earlier studies of Metera (Dontas, Maratos, Fafoutis, & Karangeli, 1985; Stevens, 1975) found that, even in this polymatric institution, most children developed selective attachments (but these early studies did not assess attachment security). We did do so, finding that a quarter of Metera infants showed a secure attachment (compared with 41% of those in the comparison family care group). The caregivers in Metera did not differ from mothers using day care, on amount of interaction or caregivers’ sensitivity but they did show a significantly lower quality and appropriateness of interactions with the children. There was a relatively low caregiver turnover at Metera but shift work meant that the effective caregiver child ratio ranged from 1:4 up to 1:6. In summary, the choice of Metera meant that the overall quality of care was relatively good but that, nevertheless, there was a marked limitation in personalized caregiving of individual infants. In this paper we present the findings on attachment relationships as assessed at 13 years of age; other papers report the findings on cognitive development and scholastic achievement (Vorria, Ntouma, & Rutter, 2014a) and on behavior (Vorria, Ntouma, &
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Rutter, 2014b). A fourth paper puts the findings together (Vorria, Ntouma, & Rutter, 2015) to investigate possible influences on individual differences in overall vulnerability and resilience. The third concern was whether use of the SSP functioned in the same way as it did in non-institutional family settings (Bakermans-Kranenburg et al., 2011). This applied particularly to the coding of disorganized attachment which has been found to be the predominate pattern in institutional settings. We tested that by comparing the predictive validity of that pattern in the family-reared and adoptive groups. The number of familyreared children was too low for the use of statistics but, in both groups, the rate of disorganization at the first follow-up at age four years was much lower and the proportion proceeding to move from disorganization to security was much the same (about onethird). We conclude therefore that, at least in Metera, the rating probably had much the same meaning as in the family setting. However, in the first follow-up report when the children were aged four years (Vorria et al., 2006) it was tentatively suggested that, contrary to expectations, a rating of disorganization might predict security post-adoption. This paradoxical finding arose because the instrument used was the Attachment Q Sort (AQS; Waters & Deane, 1985) which included no coding for “disorganization”. When, instead, the Attachment Story Completion Task (ASCT; Bretherton & Ridgeway, 1990) was used at age four years, disorganization no longer predicted security because it sometimes led to disorganization when the AQS had indicated security (see online appendix for details). Accordingly, the misleading earlier paradoxical suggestion is hereby unreservedly withdrawn and, throughout this paper, the ASCT is used for all attachment codings at age four years. It is also relevant that, in the Vorria et al. (2006) paper, it was noted that paradoxical finding applied in much the same way to the family-reared comparison group as to the adopted group – suggesting that it was likely to reflect a general instrument artifact. Indeed the paper concluded that “no safe conclusions can be drawn”. The only other systematic, prospective follow-up studies of adopted children who had experienced institutional care in infancy that did not involve either profound deprivation or substantial subnutrition were the Hodges and Tizard’s study (1989) of adopted adolescents who spent the first two years of their life in institutions in Great Britain and the Feast, Grant, Rushton, and Simmonds (2013) follow-up in mid-adult life of girls who experienced residential care in China/Hong Kong. Personal follow-up was undertaken at a mean age of 48 years. However, there is a larger number of studies with some relevant data (see Bakermans-Kranenburg et al., 2011; Feast et al., 2013 for details). Feast et al. (2013) did not measure attachment relationships specifically but they did find that, on the whole, the women developed good functional, committed, intimate relationships. A total of 82% of the women had married, with an average length of partnership of 18 years; 71% had at least one child and most had confiding friendships. This mostly good social outcome contrasts markedly with the much higher rate of adverse outcomes found with young people adopted from profoundly depriving institutions (Chisholm, 1998; Howe, 2003; Rutter & Sonuga-Barke, 2010; Rutter et al., 2007). The Feast et al. (2013) sample of 72 women began with placement in one of four orphanages in Hong Kong. They were not studied directly by the researchers but there was access to detailed orphanage records. Most of the children had been “abandoned” in infancy, but left in a place where it could be expected that they would be found. The orphanages generally provided reasonable physical and medical care but the staff:child ratio varied between 1:8 and 1:22 with a lack of personalized caregiving. On average, the children spent 20 months in orphanage care before adoption.
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Children adopted in China in the Cohen and Farnia (2011) study at a mean age of 13.5 months were able to be attached to their adoptive parents within six months after the placement in their adoptive family but compared with controls the growth of attachments then slowed down, with growth greatest in those of higher cognitive ability. The Hodges and Tizard (1989) study began when the children were in a residential nursery. By the age of two years the children had been cared for by 24 different adults and by the age of 4½ years the figure was 50. Twenty-four children were adopted between the ages of two and four years. All were reassessed at 4½ years. A comparison was made between the 15 who had been restored to their natural parents and the 24 who had been adopted (see Tizard, 1977). Both groups tended to show attention-seeking “over-friendly” behavior, and this was still apparent at age eight. However, most seemed appropriately closely attached to their adoptive parents. The key question addressed in this paper is whether the initially greater level of disorganized attachment in the adopted individuals (as compared with the daycare children) would persist into adolescence in the form of some type of impaired attachment relationships with parents.
Hypothesis The experience of institutional care would lead to some continuing impairment in attachment relationships in adolescence, which would be associated with a difference from that found in the comparison group.
Methods The study investigates the attachment of adopted adolescents who have spent their first two years of life in residential group care and then were adopted. The results were compared with those for a group of adolescents who were reared in their own biological families and who, as infants, attended full-time public care. All adolescents were seen for the first time in infancy, and again at the age of four, and then once more at age 13 years.
Participants From the initial sample of the 86 infants from the Metera Babies Centre, 67 (78%) were adopted, 14 (16%) children returned to their biological parents, three (4%) were fostered, and two (2%) were still in the Metera Babies Center. From those children who were adopted, six (9%) adopted children declined to participate in the first follow-up study. Thus, 61 adopted children participated in the first follow-up study. In the present, second follow-up study, nine years later, seven (11%) of the adopted adolescents declined to participate and two (3%) adopted girls could not be traced. The comparison adolescents reared in their biological families were also followed longitudinally. In the original study in infancy, the comparison group had been chosen on the basis of their parents’ being married and living together, with both parents working and the infants attending full time at a public day care center in Athens, for which the costs were quite low. From the initial sample of 41 infants, two (5%) declined to participate in the first follow-up study and three (7%) adolescents declined to participate in the second follow-up. Thus, in the present second follow-up study, the participants were 52 adopted adolescents (mean age = 13.1 years, SD = 0.5 years, range = 12.2–13.8;
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27 boys and 25 girls) and 36 comparison adolescents (mean age = 13 years, SD = 0.5 years, range = 12.3–13.8; 18 boys and 18 girls). The participation rate from the first follow-up study to the second follow-up study was 85% in the adopted group and 92% in the comparison group. We examined whether there were any differences between the 52 adopted adolescents who participated in all three stages of the study and the 15 adolescents who declined to participate in the two follow-up studies, by looking at the attachment with their caregiver when they were infants in the Metera Babies Center. No significant association was found between security of attachment in infancy and participation in the follow-up studies. Twenty two (43%) adopted adolescents were living in Athens and 30 (57%) in the country; 89% of the adolescents in the comparison adolescents lived in Athens.
Measures Attachment in infancy The quality of attachment of the infants was assessed, using the Infants Strange Situation Procedure (ISSP; Ainsworth, Blehar, Waters, & Wall, 1978), with the primary caregiver in the institution and with the mother for the family-reared infants. The videotapes of the behavior in the Strange Situation were coded by two experts who were blind to the group membership of the infants (77% agreement for the D vs non-D classification; Vorria et al., 2003).
Attachment in preschool years The follow-up was undertaken at approximately four years of age, some two years (on average) after adoption. Because of the change in age, the ASCT (Bretherton, Ridgeway, & Cassidy, 1990) was used in order to assess children’s representations of relationships with attachment figures. The ASCT is a semi-projective measure in which the child is asked what happens next following a variety of attachment-related story beginnings. These give rise to codings of secure, insecure and disorganized attachments. The reliability of the disorganization coding (the key one for the study) was examined by M.N. independently coding 30 children. Her ratings agreed with those of P.V. in 28 out of 30 cases – giving rise to a kappa value of .84. It has been usual with representational codings to give more weight to validity determined by assessing contemporaneous or retrospective agreement with the SSP (Bretherton, 2005; Bretherton & Munholland, 2008; Solomon & George, 2008). We did the same by comparing disorganization and no disorganization on the ASCT at age four with the ISSP ratings in Metera. Of the seven cases showing disorganization on the ASCT, all showed disorganization on the ISSP in Metera – compared with 0 out of 54 of those without disorganization on the ASCT. A 2-tailed exact test showed a value of less than .0001. We may conclude that the disorganization coding on the ASCT is both reliable and valid. The ASCT also has the advantage of there being several successful translations into other languages.
Attachment in adolescence Attachment in adolescence was assessed using the Child Attachment Interview (CAI; Target, Fonagy, & Shmueli-Goetz, 2003). The CAI is a 19-question, semi-structured interview that assesses the child’s mental representations of attachment figures. Each
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adolescent’s interview was videotaped and then transcribed. The CAI is coded using eight different scales: Emotional Openness, Balance of Positive/Negative References to Attachment Figures, Use of Examples, Preoccupied Anger, Idealization, Dismissing/ Avoidance, Resolution of Conflicts, and Overall Coherence. Each dimension is rated on a 9-point scale from 1, showing a low score, to 9, showing a high score. Scores on the eight scales enable classification of each child in one of the four main attachment classifications: Secure, Dismissing, Preoccupied and Disorganized.
Internal consistency for CAI scales Target and colleagues (2003) reported that the five “state of mind” scales (emotional openness, balance, use of examples, conflict resolution, and coherence) were highly intercorrelated. In the present study, the alpha coefficient for the above five scales was .97, and the standardized item alpha for the state of mind representations of mother and father was .79.
Inter-rater reliability for CAI main classifications and for CAI scales In the present study, the CAI was administered and rated by M.N., who had been trained on scoring by Yael Shmueli-Goetz at the Anna Freud Centre. A second rater, M.V., who had also been trained by Yael Shmueli-Goetz, independently coded, randomly, 20 (23%) of the cases. The agreement between the coders on security/insecurity was kappa = .89, with similarly high intra-class correlations (ranging from .72 to .95) for the subscales.
Data collection procedures All families were contacted by phone by P.V., who was the main investigator in the previous stages of the study and the families knew her. Parents were informed about the purpose of the present study and the data collection procedures. Parents and adolescents who agreed to participate were visited at their home; the appointment time was set by the parents. Parents and adolescents who participated in the study signed a consent form, which informed the participants, voluntarily agreeing to participate in the research study, that they had a right to withdraw from the study at any time without adverse consequences. Ethical approval was obtained from the Research Committee of the Aristotle University of Thessaloniki, in order to ensure that the research conformed to ethical principles and standards. Families who had moved were traced through the telephone directory. In seven (13%) cases where we could not trace them, the families were contacted by the social workers of Metera Babies Center and they agreed to participate in the study. The families were visited by the two investigators, P.V. and M.N. M.N was blind as to which group each adolescent belonged to. M.N. gathered the data from the adolescents and P.V. from the mothers. Each home visit lasted 2–3 hours.
Results Factors affecting between-group differences Because the outcome findings might be influenced (a) by differences from the general population in Greece, (b) by between-group differences in parental education and social
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class and (c) by selective placement, it was necessary to consider these possibilities before turning to substantive findings on the adolescent follow-up.
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Differences between the education of participating parents and the general population in Greece According to the data from the National Statistical Service of Greece for people aged 50–54 years, 49% of the general population (44% males and 53% females) had primary education only; 32% had secondary education (35% males and 29% females); and 12% had tertiary education (15% males and 10% females) (see Vorria et al., 2014a for further details). A chi square for trends analysis showed that both groups differed from the general population [adoptive parents: χ2 (2, 52) = 26.95, p < .001, and comparison group: χ2 (2, 36) = 32.85, p < .001] in being better educated. This difference mainly arose from the smaller proportion of the two groups who had received primary education only.
Between-group differences in parental education and social class In order to compare the two groups followed into adolescence, the parental education findings were converted into a composite score as follows. A score of 1 was allocated if either parent had only primary education, a score of 3 if either parent had tertiary education, and a score of 2 for the remainder. The adoptive parents had a mean of 2.06, SD = .75; and the comparison group parents had a mean of 2.22, SD = .65. There was no significant difference between these means, t(1, 86) = −1.07, p = .286. No national statistics are available for social class classification in Greece. However, between-group comparisons were possible. Social class was classified on the basis of a three-point scale with “low” for farm workers and laborers, “middle” for traders and craftsmen, and “high” for doctors, teachers and other professionals. The distribution did not differ significantly between the two groups.
Selective placement considering biological and adoptive mother’s education Table 1 shows the distribution of adopted adolescents according to the educational level of biological and adoptive mothers. Only 16% (6 out of 37) of the children were born to a biological mother with primary education only (or education not known, as analyses showed that this functioned similarly with respect to children’s cognitive level) had been placed with an adoptive mother with tertiary education, as compared with 53% (8 out of 15) of those born to a biological mother with secondary schooling or technological Table 1.
Maternal educational levels. Adoptive mother’s educational level
Biological mother’s education Illiterate or primary education or missing info (n = 37) Secondary school or technological training (n = 15) Total
Primary
Secondary
Tertiary
8 2 10
23 5 28
6 8 14
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training. This difference was significant at the 2% level, χ2 (2, 52) = 5.70, p = .017, indicating some tendency for selective placement.
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Differences between the adopted and the comparison adolescents Due to the high concordance between attachment classifications of mother and father [in the adopted group: χ2 (9, 50) = 132.97, p < .001, in the comparison group: χ2 (4, 35) = 70.00, p = .000], we used attachment classifications with respect to mothers only for the analyses. There were no significant differences between the adopted and the comparison adolescents in the security of attachment with the mother, χ2 (1, 88) = 1.66, p = .275 (Table 2). There were scarcely any children in the adopted group (only three adolescents) who showed disorganized attachment at age 13 and none at all in the comparison group. The overall coherence showed no significant difference between the adopted and the comparison adolescents, but the adopted showed significantly less emotional openness, F(1, 86) = 5.48, p = .022, η2 = .06. Multivariate analysis of variance (MANOVA) for the group effect on the five “state of mind” scales CAI subscales showed non-significant results, Pillai’s = .17, F(11, 73) = 1.39, p = .196. Nevertheless, this result should be treated with caution in view of the non-significant multivariate findings. In order to explore further the quality of attachment relationships in the two groups, the attachment measure and the emotional openness measure (using a cut-off score of 6) were combined to create three groups: secure and emotionally open; not secure or emotionally open; and a group that showed either security or emotional openness but not both. Table 3 shows the between-group comparisons. There were no significant differences in the quality of attachment relationships between the adopted and the comparison adolescents, χ2 for trends (2, 88) = 1.86, p = .172. Twenty-three (44%) of the adoptees were neither secure nor emotionally open, as compared with nine (25%) of the comparison adolescents. The groups did not differ on the proportion that were both secure and emotionally open (about half in both groups). Table 2. Distribution of main attachment classifications with respect to mother and group differences in CAI scales. Adopted (n = 52)* Attachment classification with respect to Mother
Comparison (n = 36)
n
(%)
n
(%)
χ2
p
26 26
(50) (50)
23 13
(64) (36)
1.66
.275
CAI scales
Mean
(SD)
Mean
(SD)
F
p
Emotional openness Balance of positive/negative references to AF Use of examples Resolution of conflicts Overall coherence
5.41 4.56
(2.06) (1.60)
6.38 5.15
(1.61) (1.36)
5.48 3.31
.022 .072
5.14 4.80 5.15
(1.90) (1.67) (1.86)
5.68 5.13 5.69
(1.51) (1.49) (1.58)
2.06 .86 2.03
.155 .349 .158
Secure Insecure (Dismissing, Preoccupied, & Disorganized)
*Missing cases: Two adoptive mothers had died so the CAI coding was done for the child’s adoptive father in one case and for child’s stepmother in the other case. AF = Attachment Figures.
Attachment & Human Development Table 3.
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Quality of attachment relationships in the two groups. Adopted adolescents n (%) Comparison adolescents n (%)
Secure & emotionally open Intermediate Neither secure nor emotionally open
26 (50) 3 (6) 23 (44)
21 (58) 6 (17) 9 (25)
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*χ2 (2, 88) = 1.86, p = .172.
The justification for combining the two measures is that attachment is a multifaceted phenomenon and that putting together two different approaches might better pick up between-group differences. Of the five main CAI scales, openness was the only one to show a statistically significant between-group difference.
Attachment classification in the three stages of development Table 4 presents the attachment classifications of the adolescents who participated in infancy, in preschool and in adolescence. Attachment classifications were divided into secure, insecure and disorganized. There were significant differences in security of attachment between the institutional and the comparison in infancy, χ2 for trends (2, 75) = 5.17, p = .002. The between-group differences were also significant in the first follow-up, χ2 for trends (2, 86) = 13.12, p = .001. However, the between-group differences were not significant in the last follow-up, χ2 for trends (2, 88) = 2.59, p = .108. It was already noted that, while they were in the institution, the adopted group showed a high rate of disorganization as compared with the comparison group. By sharp contrast, at the time of the adolescent follow-up, there were no significant differences in attachment between the two groups. Accordingly, it was necessary to look in more detail at the ways in which attachment security varied from infancy to adolescence. Figure 1 shows the findings from infancy to adolescence. Table 4.
Attachment classifications in the three stages of the study.
Infancy (ISS)
Secure Insecure Disorganized
First follow-up Preschool years (ASCT)
Second follow-up Adolescence (CAI)
Group care infants (n = 48)
Family care infants (n = 27)
Adopted (n = 52)
Comparison (n = 34)
Adopted (n = 52)
Comparison (n = 36)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
14 (29) 4 (8) 30 (63)
10 (37) 11 (41) 6 (22)
5 (10) 41 (79) 6 (11)
15 (44) 18 (53) 1 (3)
26 (50) 23 (44) 3 (6)
23 (64) 13 (36)
Missing cases: Infancy: four group care and nine family care infants were unclassified, therefore missing. Preschool: in two comparison children the ASCT could not administered. Adolescence: two adoptive mothers had died. In one case we used the CAI father, since the father did not have a partner; in the other case the adolescent’s stepmother was used. Infancy: χ2 for trends (2, 75) = 5.17, p = .002. First follow-up: χ2 for trends (2, 86) = 13.12, p = .001. Second follow-up: χ2 for trends (2, 88) = 2.59, p = .108.
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P. Vorria et al. Secure Group Care Infants & Adopted Adolescents Attachment type in Adolescence
Secure Infants n = 14 (29%)
Secure Family Care Infants Attachment type in Adolescence
8 (57%) Secure
7 (70%) Secure Secure Infants n = 10 (37%)
6 (43%) Insecure
Insecure Group care Infants & Adopted Adolescents
3 (30%) Insecure
Insecure Family care Infants
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Attachment type in Adolescence
Insecure Infants n = 4 (8%)
4 (100%) Secure
Disorganized Group care Infants & Adopted Adolescents
Attachment type in Adolescence
Insecure Infants n = 11 (30%)
Disorganized Family care Infants
Attachment type in Adolescence
Attachment type in Adolescence
11 (37%) Secure Disorganized Infants n = 30 (63%)
16 (53%) Insecure
6 (55%) Secure 5 (45%) Insecure
2 (33%) Secure Disorganized Infants n = 6 (17%)
4 (67%) Insecure
3 (10%) Disorganised
Figure 1. Attachment type of adopted and comparison adolescents who were secure, insecure or disorganized in infancy. Difference between infancy and adolescence in rate of security was not statistically significant in either group. Adoptees χ2 (1,33) = .01 p = .915 and comparison group χ2 (1,25) = .27 p = .601 The fall in rate of disorganization between infancy and adolescence was significant χ2 (1,75) = 31.03 p < .001. The proportion of adolescents who showed insecurity at the follow-up did not differ significantly according to the attachment rating in infancy. A binary logistic regression analysis of adoptees showed a just significant effect at the 5% level of disorganization in infancy in increasing the likelihood of insecurity (including disorganization); B = 1.24. Wald = 3.91, p = .048.
Stability of attachment security from infancy to adolescence Figure 1 shows the attachment type of adopted and comparison adolescents who were secure, insecure or disorganized in infancy. Only the children who participated in the original study, in infancy, and in the second follow-up in adolescence are included in the figure. One key finding is that the overall rate of security was greater in adolescence than it had been in infancy and that this change applied to both groups, not just one. Thus, there were overall 24 (32%) infants with security at the beginning [14 (29%) in the adoptees and 10 (37%) in the comparison group] whereas there were 38 (51%) in adolescence [23 (48%) in the adoptees and 15 (56%) in the comparison group]. The difference in the proportions between infancy (32%) and adolescence (51%) was not significant at p < .05 level, χ2 (1, 75) = 1.46, p = .228. The same applies for the adopted, χ2 (1, 37) = .01, p = .915, and the comparison group, χ2 (1, 25) = .27, p = .601. The majority of those with security in infancy continued to show security in adolescence (15 out of 24, 63%) and this tendency did not differ between the two groups, χ2 (1, 15) = .00, p = .988.
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Conversely, there was a statistically significant massive drop in the rate of disorganization from 36 (48%) in infancy to just three (4%) in adolescence, all of them adopted, χ2 (1, 75) = 31.03, p < .001. The proportion of disorganized infants who showed insecurity at the second follow-up (20 out of 36, 56%) was slightly higher than the proportion with either secure infants (9 out of 24, 38%), χ2 (1, 29) = .25, p = .620, or insecure infants (5 out of 15, 33%), χ2 (1, 25) = .18, p = .674. Although the proportion of insecure adolescents who were disorganized as infants was lower in the adopted group, this general tendency applied to both groups, χ2 (1, 25) = .18, p = .674. The majority of infants showing insecurity were rated as secure in adolescence (10 out of 15, 67%). Although the proportion of secure adolescents who were insecure as infants was greater in the adoptees, this tendency applied to both groups, χ2 (1, 10) = .71, p = .399. Binary logistic regression analysis was conducted to examine the effect of disorganized attachment in infancy in attachment relations with parents in adolescence. The results showed that, in adopted adolescents, disorganization of attachment in infancy did have a just-significant effect (at the 5% level) in increasing the likelihood of insecurity (including disorganization) of attachment in adolescence, B = 1.24, Wald = 3.91, p = .048. Nineteen adopted adolescents (63%) who showed disorganization in institution were insecure in adolescence, whereas 11 adopted adolescents (37%) who were disorganized in institution were secure in adolescence. In the comparison group, disorganization of attachment in infancy had no effect on attachment relationships in adolescence. However, this has little meaning, since only six comparison adolescents showed disorganized attachment in infancy; the sample size was smaller, making it necessary for the differences to be larger in order to reach statistical significance. Stability of attachment security from preschool years to adolescence In both the adoptees and the comparison group, there was a tendency for insecurity to be less common in adolescence than in the preschool years. In the adoptees, the decrease was from 55.7% to 40.3%, and in the comparison group the decrease was from 52.0% to 44.0%. In other words, the trends over time were closely comparable in the two groups. Pooling the two groups, the majority (13 out of 16–81%) of those with security in the preschool years continued to show security in adolescence. Conversely, of those insecure at age four, 30 out of 50 (60%) still showed insecurity in adolescence. There were too few children showing disorganization at age four to quantify time trends up to adolescence, but there were only three adoptees and none in the comparison group showing disorganization in adolescence. The effect of age of adoption, reason of admission and gender on attachment in adolescence Age of adoption had a significant effect on emotional openness in adolescence, F(2,49) of 5.22, giving a p value of .009. An age of two years or more at the time of adoption predicted a worse score on emotional openness. The 20 children adopted at over the age of 24 months had a mean score of 4.35 (SD = 2.21), the 15 adopted between 17 and 24 months had a mean score of 6.30 (SD = 1.58), and the 17 adopted below the age of 17 months had a mean score of 5.88 (SD = 1.79). Reason of admission had no effect on emotional openness, F(1, 50) = .40, p = .529. There was also a lack of significant gender effect on either attachment, F(1, 85) = .10, p = .926, or CAI scales, Pillai’s = .12, F (8, 78) = 1.22, p = .299.
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Discussion Differences between the adopted and the comparison adolescents One of the main research questions was to establish whether there were differences in attachment relationships with their parents between the adopted and the family-reared comparison adolescents. In the original study, the differences between the institutional and the comparison infants were significant. The vast majority of the institutional infants had a disorganized attachment with their caregivers. In the preschool years, when the children had been adopted and had lived with their families for approximately 2½ years, the differences between adopted and comparison children in attachment relationships with their mothers were still significant (Vorria et al., 2006). In adolescence, however, the between-groups differences in attachment relationships with their parents lessened to the point of statistical non-significance (see Table 4). The findings were similar to those reported in other studies using the CAI in school-aged children (Borelli et al., 2010; Zachrisson, Røysamb, Oppedal, & Hauser, 2011). With the sample sizes we had, there was not adequate statistical power to detect a small difference. Because the sample size for the first follow-up was similar to that in adolescence (see Table 4), it is clear that the substantial difference between the groups found in the preschool period was not evident in adolescence. However, with the statistical power available, we could not determine whether there was nevertheless a residual small difference.
Attachment classification in the three stages of development Our findings on the longitudinal course of attachment security/insecurity showed an interesting mixture of stability and change. The majority of children showing security in infancy continued to show security in adolescence. On the other hand, although a smaller proportion of those showing disorganization in infancy showed security in adolescence, only a trivial proportion continued to show disorganization. Most especially, there was a huge fall in the rate of disorganized attachment between infancy and adolescence. A possibility was that the SSP findings in infancy might have greater predictive value in the comparison group (because of the lesser validity in the institutional situation). However, the findings showed no between-group difference in predictive value. It might be thought that our finding of modest stability of attachment ratings between infancy and adolescence runs counter to the general finding from other studies that infancy measures have little predictive value for social functioning in adult life (Grossmann, Grossman, & Waters, 2005). However, our findings mainly concern the difference between security and disorganization rather than security and insecurity. Also, the stability has been shown only up to adolescence so far. It remains to be seen what adult findings will show. Probably the most important finding is that, although there were a few suggestions of possibly slightly more attachment problems in the adoptee group, these fell well short of significance and the finding of no difference between the groups on a composite measure combining attachment insecurity and a lack of emotional openness indicates that attachment qualities in the adoptees were mainly satisfactory.
Strengths and limitations The first strength is that, unlike almost all previous prospective studies of children adopted after early institutional rearing, the Metera study focused on the possible long-term effects of
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rearing that lacked personalized caregiving but was not complicated by the additional adversities of either subnutrition or global deprivation involving neglect or abuse. The second strength is that the qualities of the institutional care were directly assessed using standardized measures of both the care provided and by whether or not a secure attachment was formed with the care staff. The third strength is that the design involved a starting point in infancy whilst the children were experiencing institutional care and then a prospective follow-up first at age four years after adoption and then again most recently at age 13 years. Comparable assessments at the same ages were undertaken with a family-reared sample which experienced day care but were not in institutional care. However, because the design was prospective, effects could be examined by means of the stronger test of withinindividual changes as well as between-group comparisons. As far as we are aware, there has been no other study that had all these strengths. A further strength is that the followup included standardized measurement of the quality of attachment relationships. There are four important limitations. First, age 13 years is too young to determine the ultimate quality of attachment relationships as evident in adult life. A further follow-up is planned to meet that need. Second, there is continuing uncertainty about how best to measure attachment relationships in the post-childhood years (Cassidy and Shaver, 2008). Third, in view of the findings of relationship anomalies following profound global deprivations not covered by the usual measure of attachment, it would have been desirable to use an observational measure such as that developed by Cassidy and Marvin (see Solomon & George, 2008). Unfortunately, funding constraints made that impossible. Fourth, with the sample size available we lacked the statistical power to detect small residual differences in the quality of attachment.
Conclusions Children initially placed in an institutional setting that did not involve profound deprivation and subsequently adopted mostly developed good attachment relationships with their adoptive parents. It is noteworthy that this is in keeping with the Chinese follow-up study (Feast et al., 2013) findings (which also did not involve profound deprivation) but very different from the findings with profoundly deprived institutional samples (BakermansKranenburg et al., 2011).
Acknowledgments We are extremely grateful to the young people and their parents for giving their time so generously in all three stages of the study. We are also deeply appreciative of the help throughout of the staff members of the Metera Babies Centre who made all of the work possible. We thank Professor Grigoris Kioseoglou, at the Aristotle University at Thessaloniki, for statistical advice; part of this research, concerning the CAI codings, has been co-financed by the European Union (European Social Fund – ESF) and Greek national funds through the Operational Program “Education and Lifelong Learning” of the National Strategic Reference Framework (NSRF) Research Funding Program: Heracleitus II. We express our great thanks to the Nuffield Foundation for financial support for the travel involved in the follow-up.
Disclosure statement No potential conflict of interest was reported by the authors.
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Supplemental data Supplemental data for this article can be accessed here.
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References Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Erlbaum. Bakermans-Kranenburg, M. J., Steele, H., Zeanah, C. H., Muhamedrahimov, R. J., Vorria, P., Dobrova-Krol, N. A., … Gunnar, M. R. (2011). III. Attachment and emotional development in institutional care: Characteristics and catch-up. Monographs of the Society for Research in Child Development, 76, 62–91. doi:10.1111/j.1540-5834.2011.00628.x Borelli, J. L., Crowley, M. J., David, D. H., Sbarra, D. A., Anderson, G. M., & Mayes, L. C. (2010). Attachment and emotion in school-aged children. Emotion, 10(4), 475–485. doi:10.1037/ a0018490 Bretherton, I. (2005). In pursuit of the internal working model construct and its relevance to attachment relationships. In K. E. Grossmann, K. Grossmann, & E. Waters (Eds.), Attachment from infancy to adulthood: The major longitudinal studies (pp. 13–47). New York, NY: Guilford Press. Bretherton, I., & Munholland, K. A. (2008). International working models in attachment relationships: Elaborating a central construct in attachment theory. In J. Cassidy & P. E. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 102–130). London: Guilford Press. Bretherton, I., & Ridgeway, D. (1990). Story completion task to assess young children’s internal working models of child and parents in the attachment relationship. In M.T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 300–308). Chicago, IL: University of Chicago Press. Bretherton, I., Ridgeway, D., & Cassidy, J. (1990). Assessing internal working models of the attachment relationship. An attachment story completion task for 3-year-olds. In M. T. Greenberg, D. Ciccetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research and intervention (pp. 273–308). Chicago, IL: University of Chicago Press. Burlingham, D., & Freud, A. (1944). Infants without families. London: Allen & Unwin. Cassidy, J., & Shaver, P. R. (Eds.). (2008). Handbook of attachment: Theory, research, and clinical applications (2nd ed.). New York, NY: Guilford Press. Chisholm, K. (1998). A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian Orphanages. Child Development, 69(4), 1092–1106. doi:10.1111/j.1467-8624.1998.tb06162.x Cohen, N. J., & Farnia, F. (2011). Social-emotional adjustment and attachment in children adopted from China: Processes and predictors of change. International Journal of Behavioral Development, 35(1), 67–77. doi:10.1177/0165025410371602 Dontas, C., Maratos, O., Fafoutis, M., & Karangeli, A. (1985). Early social development in institutionally reared Greek infants: Attachment and peer interaction. Monographs of the Society for Research in Child Development, 50, 136–146. doi:10.2307/3333830 Farran, D., Kasari, C., Comfort, M., & Jay, S. (1986). Parent/Caregiver Interaction Scale. Chapel Hill: University of North Carolina Press. Feast, J., Grant, M., Rushton, A., & Simmonds, J. (2013). Adversity, adoption and afterwards: A mid-life follow-up study of women adopted from Hong Kong. London: British Association of Adoption and Fostering. Goldberg, S. (1997). Attachment and childhood behavior problems in normal, at-risk and clinical samples. In L. Atkinson & K. Zucker (Eds.), Attachment and psychopathology (pp. 171–195). New York, NY: Guilford Press. Grossmann, K. E., Grossman, K., & Waters, E. (Eds.). (2005). Attachment from infancy to adulthood: The major longitudinal studies. New York, NY: Guilford Press. Harms, T., & Clifford, R. M. (1980). Early childhood environment rating scale. New York, NY: Teachers’ College Press. Hodges, J., & Tizard, B. (1989). Social and family relationships of ex-institutional adolescents. Journal of Child Psychology and Psychiatry, 30(1), 77–97. doi:10.1111/j.1469-7610.1989. tb00770.x
Downloaded by [University of Nebraska, Lincoln] at 07:00 13 April 2015
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Howe, D. (2003). Attachment disorders: Disinhibited attachment behaviours and secure base distortions with special reference to adopted children. Attachment & Human Development, 5(3), 265–270. doi:10.1080/14616730310001593965 O’Connor, T. G., Marvin, R. S., Rutter, M., Olrick, J. T., & Britner, P. A. & the English and Romanian Adoptees Study Team. (2003). Child-parent attachment following early institutional deprivation. Development and Psychopathology, 15, 19–38. doi:10.1017/S0954579403000026 Rutter, M., Colvert, E., Kreppner, J., Beckett, C., Castle, J., Groothues, C., … Sonuga-Barke, E. J. S. (2007). Early adolescent outcomes for institutionally-deprived and non-deprived adoptees. I: Disinhibited attachment. Journal of Child Psychology and Psychiatry, 48(1), 17–30. doi:10.1111/j.1469-7610.2006.01688.x Rutter, M., Kreppner, J., & Sonuga-Barke, E. (2009). Emanuel Miller Lecture: Attachment insecurity, disinhibited attachment, and attachment disorders: Where do research findings leave the concepts? The Journal of Child Psychology and Psychiatry, 50, 529–543. doi:10.1111/ j.1469-7610.2009.02042.x Rutter, M., Kumsta, R., Schlotz, W., & Sonuga-Barke, E. (2012). Longitudinal studies using a “natural experiment” design: The case of adoptees from Romanian institutions. Journal of the American Academy of Child & Adolescent Psychiatry, 51, 762–770. doi:10.1016/j.jaac.2012.05.011 Rutter, M., & Sonuga-Barke, E. J. (2010). Conclusions: Overview of findings from the ERA study, inferences, and research implications. Monographs of the Society for Research in Child Development, 75, 212–229. doi:10.1111/j.1540-5834.2010.00557.x Solomon, J., & George, C. (2008). The measurement of attachment security and related constructs in infancy and childhood. In J. Cassidy & P. E. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 102–130). London: Guilford Press. Stevens, A. (1975). Attachment and polymatric rearing. A study of attachment formation, separation anxiety and fear of strangers in infants reared by multiple mothering in an institutional setting. In H.R. Schaffer (Ed.), The origins of human social relations. London: Academic Press. Target, M., Fonagy, P., & Shmueli-Goetz, Y. (2003). Attachment representations in school-age children: The development of the Child Attachment Interview (CAI). Journal of Child Psychotherapy, 29, 171–186. doi:10.1080/0075417031000138433 Tizard, B. (1977). Adoption: A second chance. London: Open Books Publishing. van IJzendoorn, M. H., Palacios, J., Sonuga-Barke, E. J. S., Gunnar, M. R., Vorria, P., McCall, R. B., … Juffer, F. (2011). Children in institutional care: Delayed development and resilience. Monographs of the Society for Research in Child Development, 76, 8–30. doi:10.1111/j.1540-5834.2011.00626.x Vorria, P., Ntouma, M., & Rutter, M. (2014a). The cognitive development and school achievement of adopted adolescents: The Greek “Metera” study. European Journal of Developmental Psychology. doi:10.1080/17405629.2014.933703 Vorria, P., Ntouma, M., & Rutter, M. (2014b). The behaviour of adopted adolescents who spent their infancy in residential group care: The Greek Metera study. Adoption & Fostering, 38, 271–283. doi:10.1177/0308575914543237 Vorria, P., Ntouma, M., & Rutter, M. (2015). Vulnerability and resilience after early institutional care: The Greek “Metera” Study. Development and Psychopathology. Advance online publication. doi:10.1017/S0954579415000243 Vorria, P., Papaligoura, Z., Dunn, J., Van IJzendoorn, M. H., Steele, H., Kontopoulou, A., & Sarafidou, Y. (2003). Early experiences and attachment relationships of Greek infants raised in residential group care. Journal of Child Psychology and Psychiatry, 44, 1208–1220. doi:10.1111/1469-7610.00202 Vorria, P., Papaligoura, Z., Sarafidou, J., Kopakaki, M., Dunn, J., Van IJzendoorn, M. H., … Kontopoulou, A. (2006). The development of adopted children after institutional care: A follow-up study. Journal of Child Psychology and Psychiatry, 47, 1246–1253. doi:10.1111/ j.1469-7610.2006.01666.x Waters, E., & Deane, K. (1985). Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research, Monographs of the Society for Research in Child Development, 50 (1–2, Serial No. 209) (pp. 41–65). Zachrisson, H. D., Røysamb, E., Oppedal, B., & Hauser, S. T. (2011). Factor structure of the child attachment interview. European Journal of Developmental Psychology, 8(6), 744–759. doi:10.1080/17405629.2011.631293
Attachment & Human Development Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rahd20
Attachment relationships of adolescents who spent their infancy in residential group care: The Greek Metera study a
a
b
Panayiota Vorria , Maria Ntouma , Maria Vairami & Michael c
Rutter a
Department of Psychology, Aristotle University of Thessaloniki, Thessaloniki, Greece b
M.H.C of Western Thessaloniki, Thessaloniki, Greece
c
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MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK Published online: 10 Apr 2015.
To cite this article: Panayiota Vorria, Maria Ntouma, Maria Vairami & Michael Rutter (2015): Attachment relationships of adolescents who spent their infancy in residential group care: The Greek Metera study, Attachment & Human Development, DOI: 10.1080/14616734.2015.1028947 To link to this article: http://dx.doi.org/10.1080/14616734.2015.1028947
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Attachment & Human Development, 2015 http://dx.doi.org/10.1080/14616734.2015.1028947
Attachment relationships of adolescents who spent their infancy in residential group care: The Greek Metera study Panayiota Vorriaa*, Maria Ntoumaa, Maria Vairamib and Michael Rutterc
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a
Department of Psychology, Aristotle University of Thessaloniki, Thessaloniki, Greece; bM.H.C of Western Thessaloniki, Thessaloniki, Greece; cMRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK (Received 2 March 2015; accepted 9 March 2015) A prospective longitudinal study beginning whilst the infants were living in the Metera Babies Centre showed that the great majority showed a disorganized attachment during the period of residential care, even though neither abuse/neglect nor subnutrition were involved. There was an initial follow-up post-adoption age at four years. This paper concerns a further follow-up of the 52 adopted adolescents aged 13 years who had spent their first two years of life in Metera Babies Centre. They were compared to 36 adolescents reared in their biological families who, during their infancy, attended fulltime public day care. The key aim was to examine continuities and discontinuities between early and contemporary relationships. The Child Attachment Interview was employed in adolescence. The main findings were a significant decrease in the rate of disorganization and a lack of a significant difference between the previously institutionalized group and the family care comparison group on attachment qualities in adolescence. There was not sufficient statistical power, however, to detect a small difference. Keywords: attachment disorganization; adoption; attachment security; adolescence; residential care
Introduction From Burlingham and Freud (1944) onwards, most reviews have emphasized the frequency of anomalous attachment patterns following early institutional care, with persistence continuing even after adoption into generally well-functioning families (Bakermans-Kranenburg et al., 2011). Nevertheless, it is seriously misleading to view the anomalous attachment patterns as necessarily reflecting attachment insecurity (Rutter, Kreppner, & Sonuga-Barke, 2009). Thus, the English and Romanian Adoption (ERA) study (O’Connor, Marvin, Rutter, Olrick, & Britner, 2003), following Goldberg’s (1997) study in Canada, used the recommended Cassidy-Marvin modification of the Strange Situation Procedure (SSP) for 5–7-year-old children. The most characteristic pattern was a non-normative, affectively dysregulated “other” pattern, rather than insecurity as usually conceptualized. The evidence that this “other” pattern reflected interactions with a stranger rather than a caregiver, and the association with a disinhibited pattern cast doubt on it being an “attachment” disorder. There are good reasons for expecting that early institutional care might involve impaired social relationships but these might not take the form of insecure attachments. *Corresponding author. Email: [email protected] © 2015 Taylor & Francis
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Another important issue concerned the question of whether all institutions should be regarded as similar in both their qualities and their effects. This study of the later development of young people who spent their early life in the Metera Babies Centre in Athens, Greece, was designed to focus on institutional rearing that had not been preceded by adverse experiences prior to institutional care. Ninety-five percent were admitted before six months, and 40% during the first month of life, because the babies were placed in Metera at, or soon after, birth (on the grounds that the mother was unable to care for her child). Metera was chosen for the study on the basis that it involved a lack of individualized personal care, but nevertheless involved neither gross general deprivation nor subnutrition (Vorria et al., 2003). The study was distinctive (probably unique) in that there was a detailed study of the institutional rearing in Metera and a follow-up after adoption – initially at age four years and now at age 13 years. This means that it was possible to investigate changes within individuals, as well as make between-group comparisons. The babies were initially housed in a unit that meant that each new-born was in a separate small room in which social contacts and interactions were severely restricted making it the most depriving period of their time in Metera. At about the age of five months the infants moved to a different pavilion where care was less depriving. Earlier discussions of Metera conditions (e.g. van IJzendoorn et al., 2011) tended to focus on the baby circumstances in the first five months and were, because of that, highly critical. Subsequent research involving much worse Romanian institutions (e.g. Rutter, Kumsta, Schlotz, & Sonuga-Barke, 2012) has shown (surprisingly) that adverse sequelae were minimal, or even absent, provided that the depriving care did not persist beyond the age of six to 12 months. Accordingly, here we focus on the quality of care provided in the pavilion for infants aged over five or six months. Detailed standardized measures were obtained on the children’s attachment behavior (with 77% for both the forced A, B and C classifications and the D versus non-D classification, giving rise to kappa values of .65 and .58, respectively). The quality of childcare was evaluated using the Early Childhood Environmental Rating Scale (ECERS; Harms & Clifford, 1980). The findings for Metera were compared with those in a day care environment. The quality of caregiver/maternal sensitivity was assessed using the Parent/ Caregiver Involvement Scale (PCIS; Farran, Kasari, Comfort, & Jay, 1986). Inter-rater reliability showed an intra-class correlation of .89. When infants move to a pavilion, each caregiver in Metera is expected to facilitate a special relationship with at least one infant who then considers her as his/her mother (Vorria et al., 2003). Earlier studies of Metera (Dontas, Maratos, Fafoutis, & Karangeli, 1985; Stevens, 1975) found that, even in this polymatric institution, most children developed selective attachments (but these early studies did not assess attachment security). We did do so, finding that a quarter of Metera infants showed a secure attachment (compared with 41% of those in the comparison family care group). The caregivers in Metera did not differ from mothers using day care, on amount of interaction or caregivers’ sensitivity but they did show a significantly lower quality and appropriateness of interactions with the children. There was a relatively low caregiver turnover at Metera but shift work meant that the effective caregiver child ratio ranged from 1:4 up to 1:6. In summary, the choice of Metera meant that the overall quality of care was relatively good but that, nevertheless, there was a marked limitation in personalized caregiving of individual infants. In this paper we present the findings on attachment relationships as assessed at 13 years of age; other papers report the findings on cognitive development and scholastic achievement (Vorria, Ntouma, & Rutter, 2014a) and on behavior (Vorria, Ntouma, &
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Rutter, 2014b). A fourth paper puts the findings together (Vorria, Ntouma, & Rutter, 2015) to investigate possible influences on individual differences in overall vulnerability and resilience. The third concern was whether use of the SSP functioned in the same way as it did in non-institutional family settings (Bakermans-Kranenburg et al., 2011). This applied particularly to the coding of disorganized attachment which has been found to be the predominate pattern in institutional settings. We tested that by comparing the predictive validity of that pattern in the family-reared and adoptive groups. The number of familyreared children was too low for the use of statistics but, in both groups, the rate of disorganization at the first follow-up at age four years was much lower and the proportion proceeding to move from disorganization to security was much the same (about onethird). We conclude therefore that, at least in Metera, the rating probably had much the same meaning as in the family setting. However, in the first follow-up report when the children were aged four years (Vorria et al., 2006) it was tentatively suggested that, contrary to expectations, a rating of disorganization might predict security post-adoption. This paradoxical finding arose because the instrument used was the Attachment Q Sort (AQS; Waters & Deane, 1985) which included no coding for “disorganization”. When, instead, the Attachment Story Completion Task (ASCT; Bretherton & Ridgeway, 1990) was used at age four years, disorganization no longer predicted security because it sometimes led to disorganization when the AQS had indicated security (see online appendix for details). Accordingly, the misleading earlier paradoxical suggestion is hereby unreservedly withdrawn and, throughout this paper, the ASCT is used for all attachment codings at age four years. It is also relevant that, in the Vorria et al. (2006) paper, it was noted that paradoxical finding applied in much the same way to the family-reared comparison group as to the adopted group – suggesting that it was likely to reflect a general instrument artifact. Indeed the paper concluded that “no safe conclusions can be drawn”. The only other systematic, prospective follow-up studies of adopted children who had experienced institutional care in infancy that did not involve either profound deprivation or substantial subnutrition were the Hodges and Tizard’s study (1989) of adopted adolescents who spent the first two years of their life in institutions in Great Britain and the Feast, Grant, Rushton, and Simmonds (2013) follow-up in mid-adult life of girls who experienced residential care in China/Hong Kong. Personal follow-up was undertaken at a mean age of 48 years. However, there is a larger number of studies with some relevant data (see Bakermans-Kranenburg et al., 2011; Feast et al., 2013 for details). Feast et al. (2013) did not measure attachment relationships specifically but they did find that, on the whole, the women developed good functional, committed, intimate relationships. A total of 82% of the women had married, with an average length of partnership of 18 years; 71% had at least one child and most had confiding friendships. This mostly good social outcome contrasts markedly with the much higher rate of adverse outcomes found with young people adopted from profoundly depriving institutions (Chisholm, 1998; Howe, 2003; Rutter & Sonuga-Barke, 2010; Rutter et al., 2007). The Feast et al. (2013) sample of 72 women began with placement in one of four orphanages in Hong Kong. They were not studied directly by the researchers but there was access to detailed orphanage records. Most of the children had been “abandoned” in infancy, but left in a place where it could be expected that they would be found. The orphanages generally provided reasonable physical and medical care but the staff:child ratio varied between 1:8 and 1:22 with a lack of personalized caregiving. On average, the children spent 20 months in orphanage care before adoption.
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Children adopted in China in the Cohen and Farnia (2011) study at a mean age of 13.5 months were able to be attached to their adoptive parents within six months after the placement in their adoptive family but compared with controls the growth of attachments then slowed down, with growth greatest in those of higher cognitive ability. The Hodges and Tizard (1989) study began when the children were in a residential nursery. By the age of two years the children had been cared for by 24 different adults and by the age of 4½ years the figure was 50. Twenty-four children were adopted between the ages of two and four years. All were reassessed at 4½ years. A comparison was made between the 15 who had been restored to their natural parents and the 24 who had been adopted (see Tizard, 1977). Both groups tended to show attention-seeking “over-friendly” behavior, and this was still apparent at age eight. However, most seemed appropriately closely attached to their adoptive parents. The key question addressed in this paper is whether the initially greater level of disorganized attachment in the adopted individuals (as compared with the daycare children) would persist into adolescence in the form of some type of impaired attachment relationships with parents.
Hypothesis The experience of institutional care would lead to some continuing impairment in attachment relationships in adolescence, which would be associated with a difference from that found in the comparison group.
Methods The study investigates the attachment of adopted adolescents who have spent their first two years of life in residential group care and then were adopted. The results were compared with those for a group of adolescents who were reared in their own biological families and who, as infants, attended full-time public care. All adolescents were seen for the first time in infancy, and again at the age of four, and then once more at age 13 years.
Participants From the initial sample of the 86 infants from the Metera Babies Centre, 67 (78%) were adopted, 14 (16%) children returned to their biological parents, three (4%) were fostered, and two (2%) were still in the Metera Babies Center. From those children who were adopted, six (9%) adopted children declined to participate in the first follow-up study. Thus, 61 adopted children participated in the first follow-up study. In the present, second follow-up study, nine years later, seven (11%) of the adopted adolescents declined to participate and two (3%) adopted girls could not be traced. The comparison adolescents reared in their biological families were also followed longitudinally. In the original study in infancy, the comparison group had been chosen on the basis of their parents’ being married and living together, with both parents working and the infants attending full time at a public day care center in Athens, for which the costs were quite low. From the initial sample of 41 infants, two (5%) declined to participate in the first follow-up study and three (7%) adolescents declined to participate in the second follow-up. Thus, in the present second follow-up study, the participants were 52 adopted adolescents (mean age = 13.1 years, SD = 0.5 years, range = 12.2–13.8;
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27 boys and 25 girls) and 36 comparison adolescents (mean age = 13 years, SD = 0.5 years, range = 12.3–13.8; 18 boys and 18 girls). The participation rate from the first follow-up study to the second follow-up study was 85% in the adopted group and 92% in the comparison group. We examined whether there were any differences between the 52 adopted adolescents who participated in all three stages of the study and the 15 adolescents who declined to participate in the two follow-up studies, by looking at the attachment with their caregiver when they were infants in the Metera Babies Center. No significant association was found between security of attachment in infancy and participation in the follow-up studies. Twenty two (43%) adopted adolescents were living in Athens and 30 (57%) in the country; 89% of the adolescents in the comparison adolescents lived in Athens.
Measures Attachment in infancy The quality of attachment of the infants was assessed, using the Infants Strange Situation Procedure (ISSP; Ainsworth, Blehar, Waters, & Wall, 1978), with the primary caregiver in the institution and with the mother for the family-reared infants. The videotapes of the behavior in the Strange Situation were coded by two experts who were blind to the group membership of the infants (77% agreement for the D vs non-D classification; Vorria et al., 2003).
Attachment in preschool years The follow-up was undertaken at approximately four years of age, some two years (on average) after adoption. Because of the change in age, the ASCT (Bretherton, Ridgeway, & Cassidy, 1990) was used in order to assess children’s representations of relationships with attachment figures. The ASCT is a semi-projective measure in which the child is asked what happens next following a variety of attachment-related story beginnings. These give rise to codings of secure, insecure and disorganized attachments. The reliability of the disorganization coding (the key one for the study) was examined by M.N. independently coding 30 children. Her ratings agreed with those of P.V. in 28 out of 30 cases – giving rise to a kappa value of .84. It has been usual with representational codings to give more weight to validity determined by assessing contemporaneous or retrospective agreement with the SSP (Bretherton, 2005; Bretherton & Munholland, 2008; Solomon & George, 2008). We did the same by comparing disorganization and no disorganization on the ASCT at age four with the ISSP ratings in Metera. Of the seven cases showing disorganization on the ASCT, all showed disorganization on the ISSP in Metera – compared with 0 out of 54 of those without disorganization on the ASCT. A 2-tailed exact test showed a value of less than .0001. We may conclude that the disorganization coding on the ASCT is both reliable and valid. The ASCT also has the advantage of there being several successful translations into other languages.
Attachment in adolescence Attachment in adolescence was assessed using the Child Attachment Interview (CAI; Target, Fonagy, & Shmueli-Goetz, 2003). The CAI is a 19-question, semi-structured interview that assesses the child’s mental representations of attachment figures. Each
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adolescent’s interview was videotaped and then transcribed. The CAI is coded using eight different scales: Emotional Openness, Balance of Positive/Negative References to Attachment Figures, Use of Examples, Preoccupied Anger, Idealization, Dismissing/ Avoidance, Resolution of Conflicts, and Overall Coherence. Each dimension is rated on a 9-point scale from 1, showing a low score, to 9, showing a high score. Scores on the eight scales enable classification of each child in one of the four main attachment classifications: Secure, Dismissing, Preoccupied and Disorganized.
Internal consistency for CAI scales Target and colleagues (2003) reported that the five “state of mind” scales (emotional openness, balance, use of examples, conflict resolution, and coherence) were highly intercorrelated. In the present study, the alpha coefficient for the above five scales was .97, and the standardized item alpha for the state of mind representations of mother and father was .79.
Inter-rater reliability for CAI main classifications and for CAI scales In the present study, the CAI was administered and rated by M.N., who had been trained on scoring by Yael Shmueli-Goetz at the Anna Freud Centre. A second rater, M.V., who had also been trained by Yael Shmueli-Goetz, independently coded, randomly, 20 (23%) of the cases. The agreement between the coders on security/insecurity was kappa = .89, with similarly high intra-class correlations (ranging from .72 to .95) for the subscales.
Data collection procedures All families were contacted by phone by P.V., who was the main investigator in the previous stages of the study and the families knew her. Parents were informed about the purpose of the present study and the data collection procedures. Parents and adolescents who agreed to participate were visited at their home; the appointment time was set by the parents. Parents and adolescents who participated in the study signed a consent form, which informed the participants, voluntarily agreeing to participate in the research study, that they had a right to withdraw from the study at any time without adverse consequences. Ethical approval was obtained from the Research Committee of the Aristotle University of Thessaloniki, in order to ensure that the research conformed to ethical principles and standards. Families who had moved were traced through the telephone directory. In seven (13%) cases where we could not trace them, the families were contacted by the social workers of Metera Babies Center and they agreed to participate in the study. The families were visited by the two investigators, P.V. and M.N. M.N was blind as to which group each adolescent belonged to. M.N. gathered the data from the adolescents and P.V. from the mothers. Each home visit lasted 2–3 hours.
Results Factors affecting between-group differences Because the outcome findings might be influenced (a) by differences from the general population in Greece, (b) by between-group differences in parental education and social
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class and (c) by selective placement, it was necessary to consider these possibilities before turning to substantive findings on the adolescent follow-up.
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Differences between the education of participating parents and the general population in Greece According to the data from the National Statistical Service of Greece for people aged 50–54 years, 49% of the general population (44% males and 53% females) had primary education only; 32% had secondary education (35% males and 29% females); and 12% had tertiary education (15% males and 10% females) (see Vorria et al., 2014a for further details). A chi square for trends analysis showed that both groups differed from the general population [adoptive parents: χ2 (2, 52) = 26.95, p < .001, and comparison group: χ2 (2, 36) = 32.85, p < .001] in being better educated. This difference mainly arose from the smaller proportion of the two groups who had received primary education only.
Between-group differences in parental education and social class In order to compare the two groups followed into adolescence, the parental education findings were converted into a composite score as follows. A score of 1 was allocated if either parent had only primary education, a score of 3 if either parent had tertiary education, and a score of 2 for the remainder. The adoptive parents had a mean of 2.06, SD = .75; and the comparison group parents had a mean of 2.22, SD = .65. There was no significant difference between these means, t(1, 86) = −1.07, p = .286. No national statistics are available for social class classification in Greece. However, between-group comparisons were possible. Social class was classified on the basis of a three-point scale with “low” for farm workers and laborers, “middle” for traders and craftsmen, and “high” for doctors, teachers and other professionals. The distribution did not differ significantly between the two groups.
Selective placement considering biological and adoptive mother’s education Table 1 shows the distribution of adopted adolescents according to the educational level of biological and adoptive mothers. Only 16% (6 out of 37) of the children were born to a biological mother with primary education only (or education not known, as analyses showed that this functioned similarly with respect to children’s cognitive level) had been placed with an adoptive mother with tertiary education, as compared with 53% (8 out of 15) of those born to a biological mother with secondary schooling or technological Table 1.
Maternal educational levels. Adoptive mother’s educational level
Biological mother’s education Illiterate or primary education or missing info (n = 37) Secondary school or technological training (n = 15) Total
Primary
Secondary
Tertiary
8 2 10
23 5 28
6 8 14
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training. This difference was significant at the 2% level, χ2 (2, 52) = 5.70, p = .017, indicating some tendency for selective placement.
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Differences between the adopted and the comparison adolescents Due to the high concordance between attachment classifications of mother and father [in the adopted group: χ2 (9, 50) = 132.97, p < .001, in the comparison group: χ2 (4, 35) = 70.00, p = .000], we used attachment classifications with respect to mothers only for the analyses. There were no significant differences between the adopted and the comparison adolescents in the security of attachment with the mother, χ2 (1, 88) = 1.66, p = .275 (Table 2). There were scarcely any children in the adopted group (only three adolescents) who showed disorganized attachment at age 13 and none at all in the comparison group. The overall coherence showed no significant difference between the adopted and the comparison adolescents, but the adopted showed significantly less emotional openness, F(1, 86) = 5.48, p = .022, η2 = .06. Multivariate analysis of variance (MANOVA) for the group effect on the five “state of mind” scales CAI subscales showed non-significant results, Pillai’s = .17, F(11, 73) = 1.39, p = .196. Nevertheless, this result should be treated with caution in view of the non-significant multivariate findings. In order to explore further the quality of attachment relationships in the two groups, the attachment measure and the emotional openness measure (using a cut-off score of 6) were combined to create three groups: secure and emotionally open; not secure or emotionally open; and a group that showed either security or emotional openness but not both. Table 3 shows the between-group comparisons. There were no significant differences in the quality of attachment relationships between the adopted and the comparison adolescents, χ2 for trends (2, 88) = 1.86, p = .172. Twenty-three (44%) of the adoptees were neither secure nor emotionally open, as compared with nine (25%) of the comparison adolescents. The groups did not differ on the proportion that were both secure and emotionally open (about half in both groups). Table 2. Distribution of main attachment classifications with respect to mother and group differences in CAI scales. Adopted (n = 52)* Attachment classification with respect to Mother
Comparison (n = 36)
n
(%)
n
(%)
χ2
p
26 26
(50) (50)
23 13
(64) (36)
1.66
.275
CAI scales
Mean
(SD)
Mean
(SD)
F
p
Emotional openness Balance of positive/negative references to AF Use of examples Resolution of conflicts Overall coherence
5.41 4.56
(2.06) (1.60)
6.38 5.15
(1.61) (1.36)
5.48 3.31
.022 .072
5.14 4.80 5.15
(1.90) (1.67) (1.86)
5.68 5.13 5.69
(1.51) (1.49) (1.58)
2.06 .86 2.03
.155 .349 .158
Secure Insecure (Dismissing, Preoccupied, & Disorganized)
*Missing cases: Two adoptive mothers had died so the CAI coding was done for the child’s adoptive father in one case and for child’s stepmother in the other case. AF = Attachment Figures.
Attachment & Human Development Table 3.
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Quality of attachment relationships in the two groups. Adopted adolescents n (%) Comparison adolescents n (%)
Secure & emotionally open Intermediate Neither secure nor emotionally open
26 (50) 3 (6) 23 (44)
21 (58) 6 (17) 9 (25)
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*χ2 (2, 88) = 1.86, p = .172.
The justification for combining the two measures is that attachment is a multifaceted phenomenon and that putting together two different approaches might better pick up between-group differences. Of the five main CAI scales, openness was the only one to show a statistically significant between-group difference.
Attachment classification in the three stages of development Table 4 presents the attachment classifications of the adolescents who participated in infancy, in preschool and in adolescence. Attachment classifications were divided into secure, insecure and disorganized. There were significant differences in security of attachment between the institutional and the comparison in infancy, χ2 for trends (2, 75) = 5.17, p = .002. The between-group differences were also significant in the first follow-up, χ2 for trends (2, 86) = 13.12, p = .001. However, the between-group differences were not significant in the last follow-up, χ2 for trends (2, 88) = 2.59, p = .108. It was already noted that, while they were in the institution, the adopted group showed a high rate of disorganization as compared with the comparison group. By sharp contrast, at the time of the adolescent follow-up, there were no significant differences in attachment between the two groups. Accordingly, it was necessary to look in more detail at the ways in which attachment security varied from infancy to adolescence. Figure 1 shows the findings from infancy to adolescence. Table 4.
Attachment classifications in the three stages of the study.
Infancy (ISS)
Secure Insecure Disorganized
First follow-up Preschool years (ASCT)
Second follow-up Adolescence (CAI)
Group care infants (n = 48)
Family care infants (n = 27)
Adopted (n = 52)
Comparison (n = 34)
Adopted (n = 52)
Comparison (n = 36)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
14 (29) 4 (8) 30 (63)
10 (37) 11 (41) 6 (22)
5 (10) 41 (79) 6 (11)
15 (44) 18 (53) 1 (3)
26 (50) 23 (44) 3 (6)
23 (64) 13 (36)
Missing cases: Infancy: four group care and nine family care infants were unclassified, therefore missing. Preschool: in two comparison children the ASCT could not administered. Adolescence: two adoptive mothers had died. In one case we used the CAI father, since the father did not have a partner; in the other case the adolescent’s stepmother was used. Infancy: χ2 for trends (2, 75) = 5.17, p = .002. First follow-up: χ2 for trends (2, 86) = 13.12, p = .001. Second follow-up: χ2 for trends (2, 88) = 2.59, p = .108.
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P. Vorria et al. Secure Group Care Infants & Adopted Adolescents Attachment type in Adolescence
Secure Infants n = 14 (29%)
Secure Family Care Infants Attachment type in Adolescence
8 (57%) Secure
7 (70%) Secure Secure Infants n = 10 (37%)
6 (43%) Insecure
Insecure Group care Infants & Adopted Adolescents
3 (30%) Insecure
Insecure Family care Infants
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Attachment type in Adolescence
Insecure Infants n = 4 (8%)
4 (100%) Secure
Disorganized Group care Infants & Adopted Adolescents
Attachment type in Adolescence
Insecure Infants n = 11 (30%)
Disorganized Family care Infants
Attachment type in Adolescence
Attachment type in Adolescence
11 (37%) Secure Disorganized Infants n = 30 (63%)
16 (53%) Insecure
6 (55%) Secure 5 (45%) Insecure
2 (33%) Secure Disorganized Infants n = 6 (17%)
4 (67%) Insecure
3 (10%) Disorganised
Figure 1. Attachment type of adopted and comparison adolescents who were secure, insecure or disorganized in infancy. Difference between infancy and adolescence in rate of security was not statistically significant in either group. Adoptees χ2 (1,33) = .01 p = .915 and comparison group χ2 (1,25) = .27 p = .601 The fall in rate of disorganization between infancy and adolescence was significant χ2 (1,75) = 31.03 p < .001. The proportion of adolescents who showed insecurity at the follow-up did not differ significantly according to the attachment rating in infancy. A binary logistic regression analysis of adoptees showed a just significant effect at the 5% level of disorganization in infancy in increasing the likelihood of insecurity (including disorganization); B = 1.24. Wald = 3.91, p = .048.
Stability of attachment security from infancy to adolescence Figure 1 shows the attachment type of adopted and comparison adolescents who were secure, insecure or disorganized in infancy. Only the children who participated in the original study, in infancy, and in the second follow-up in adolescence are included in the figure. One key finding is that the overall rate of security was greater in adolescence than it had been in infancy and that this change applied to both groups, not just one. Thus, there were overall 24 (32%) infants with security at the beginning [14 (29%) in the adoptees and 10 (37%) in the comparison group] whereas there were 38 (51%) in adolescence [23 (48%) in the adoptees and 15 (56%) in the comparison group]. The difference in the proportions between infancy (32%) and adolescence (51%) was not significant at p < .05 level, χ2 (1, 75) = 1.46, p = .228. The same applies for the adopted, χ2 (1, 37) = .01, p = .915, and the comparison group, χ2 (1, 25) = .27, p = .601. The majority of those with security in infancy continued to show security in adolescence (15 out of 24, 63%) and this tendency did not differ between the two groups, χ2 (1, 15) = .00, p = .988.
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Conversely, there was a statistically significant massive drop in the rate of disorganization from 36 (48%) in infancy to just three (4%) in adolescence, all of them adopted, χ2 (1, 75) = 31.03, p < .001. The proportion of disorganized infants who showed insecurity at the second follow-up (20 out of 36, 56%) was slightly higher than the proportion with either secure infants (9 out of 24, 38%), χ2 (1, 29) = .25, p = .620, or insecure infants (5 out of 15, 33%), χ2 (1, 25) = .18, p = .674. Although the proportion of insecure adolescents who were disorganized as infants was lower in the adopted group, this general tendency applied to both groups, χ2 (1, 25) = .18, p = .674. The majority of infants showing insecurity were rated as secure in adolescence (10 out of 15, 67%). Although the proportion of secure adolescents who were insecure as infants was greater in the adoptees, this tendency applied to both groups, χ2 (1, 10) = .71, p = .399. Binary logistic regression analysis was conducted to examine the effect of disorganized attachment in infancy in attachment relations with parents in adolescence. The results showed that, in adopted adolescents, disorganization of attachment in infancy did have a just-significant effect (at the 5% level) in increasing the likelihood of insecurity (including disorganization) of attachment in adolescence, B = 1.24, Wald = 3.91, p = .048. Nineteen adopted adolescents (63%) who showed disorganization in institution were insecure in adolescence, whereas 11 adopted adolescents (37%) who were disorganized in institution were secure in adolescence. In the comparison group, disorganization of attachment in infancy had no effect on attachment relationships in adolescence. However, this has little meaning, since only six comparison adolescents showed disorganized attachment in infancy; the sample size was smaller, making it necessary for the differences to be larger in order to reach statistical significance. Stability of attachment security from preschool years to adolescence In both the adoptees and the comparison group, there was a tendency for insecurity to be less common in adolescence than in the preschool years. In the adoptees, the decrease was from 55.7% to 40.3%, and in the comparison group the decrease was from 52.0% to 44.0%. In other words, the trends over time were closely comparable in the two groups. Pooling the two groups, the majority (13 out of 16–81%) of those with security in the preschool years continued to show security in adolescence. Conversely, of those insecure at age four, 30 out of 50 (60%) still showed insecurity in adolescence. There were too few children showing disorganization at age four to quantify time trends up to adolescence, but there were only three adoptees and none in the comparison group showing disorganization in adolescence. The effect of age of adoption, reason of admission and gender on attachment in adolescence Age of adoption had a significant effect on emotional openness in adolescence, F(2,49) of 5.22, giving a p value of .009. An age of two years or more at the time of adoption predicted a worse score on emotional openness. The 20 children adopted at over the age of 24 months had a mean score of 4.35 (SD = 2.21), the 15 adopted between 17 and 24 months had a mean score of 6.30 (SD = 1.58), and the 17 adopted below the age of 17 months had a mean score of 5.88 (SD = 1.79). Reason of admission had no effect on emotional openness, F(1, 50) = .40, p = .529. There was also a lack of significant gender effect on either attachment, F(1, 85) = .10, p = .926, or CAI scales, Pillai’s = .12, F (8, 78) = 1.22, p = .299.
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Discussion Differences between the adopted and the comparison adolescents One of the main research questions was to establish whether there were differences in attachment relationships with their parents between the adopted and the family-reared comparison adolescents. In the original study, the differences between the institutional and the comparison infants were significant. The vast majority of the institutional infants had a disorganized attachment with their caregivers. In the preschool years, when the children had been adopted and had lived with their families for approximately 2½ years, the differences between adopted and comparison children in attachment relationships with their mothers were still significant (Vorria et al., 2006). In adolescence, however, the between-groups differences in attachment relationships with their parents lessened to the point of statistical non-significance (see Table 4). The findings were similar to those reported in other studies using the CAI in school-aged children (Borelli et al., 2010; Zachrisson, Røysamb, Oppedal, & Hauser, 2011). With the sample sizes we had, there was not adequate statistical power to detect a small difference. Because the sample size for the first follow-up was similar to that in adolescence (see Table 4), it is clear that the substantial difference between the groups found in the preschool period was not evident in adolescence. However, with the statistical power available, we could not determine whether there was nevertheless a residual small difference.
Attachment classification in the three stages of development Our findings on the longitudinal course of attachment security/insecurity showed an interesting mixture of stability and change. The majority of children showing security in infancy continued to show security in adolescence. On the other hand, although a smaller proportion of those showing disorganization in infancy showed security in adolescence, only a trivial proportion continued to show disorganization. Most especially, there was a huge fall in the rate of disorganized attachment between infancy and adolescence. A possibility was that the SSP findings in infancy might have greater predictive value in the comparison group (because of the lesser validity in the institutional situation). However, the findings showed no between-group difference in predictive value. It might be thought that our finding of modest stability of attachment ratings between infancy and adolescence runs counter to the general finding from other studies that infancy measures have little predictive value for social functioning in adult life (Grossmann, Grossman, & Waters, 2005). However, our findings mainly concern the difference between security and disorganization rather than security and insecurity. Also, the stability has been shown only up to adolescence so far. It remains to be seen what adult findings will show. Probably the most important finding is that, although there were a few suggestions of possibly slightly more attachment problems in the adoptee group, these fell well short of significance and the finding of no difference between the groups on a composite measure combining attachment insecurity and a lack of emotional openness indicates that attachment qualities in the adoptees were mainly satisfactory.
Strengths and limitations The first strength is that, unlike almost all previous prospective studies of children adopted after early institutional rearing, the Metera study focused on the possible long-term effects of
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rearing that lacked personalized caregiving but was not complicated by the additional adversities of either subnutrition or global deprivation involving neglect or abuse. The second strength is that the qualities of the institutional care were directly assessed using standardized measures of both the care provided and by whether or not a secure attachment was formed with the care staff. The third strength is that the design involved a starting point in infancy whilst the children were experiencing institutional care and then a prospective follow-up first at age four years after adoption and then again most recently at age 13 years. Comparable assessments at the same ages were undertaken with a family-reared sample which experienced day care but were not in institutional care. However, because the design was prospective, effects could be examined by means of the stronger test of withinindividual changes as well as between-group comparisons. As far as we are aware, there has been no other study that had all these strengths. A further strength is that the followup included standardized measurement of the quality of attachment relationships. There are four important limitations. First, age 13 years is too young to determine the ultimate quality of attachment relationships as evident in adult life. A further follow-up is planned to meet that need. Second, there is continuing uncertainty about how best to measure attachment relationships in the post-childhood years (Cassidy and Shaver, 2008). Third, in view of the findings of relationship anomalies following profound global deprivations not covered by the usual measure of attachment, it would have been desirable to use an observational measure such as that developed by Cassidy and Marvin (see Solomon & George, 2008). Unfortunately, funding constraints made that impossible. Fourth, with the sample size available we lacked the statistical power to detect small residual differences in the quality of attachment.
Conclusions Children initially placed in an institutional setting that did not involve profound deprivation and subsequently adopted mostly developed good attachment relationships with their adoptive parents. It is noteworthy that this is in keeping with the Chinese follow-up study (Feast et al., 2013) findings (which also did not involve profound deprivation) but very different from the findings with profoundly deprived institutional samples (BakermansKranenburg et al., 2011).
Acknowledgments We are extremely grateful to the young people and their parents for giving their time so generously in all three stages of the study. We are also deeply appreciative of the help throughout of the staff members of the Metera Babies Centre who made all of the work possible. We thank Professor Grigoris Kioseoglou, at the Aristotle University at Thessaloniki, for statistical advice; part of this research, concerning the CAI codings, has been co-financed by the European Union (European Social Fund – ESF) and Greek national funds through the Operational Program “Education and Lifelong Learning” of the National Strategic Reference Framework (NSRF) Research Funding Program: Heracleitus II. We express our great thanks to the Nuffield Foundation for financial support for the travel involved in the follow-up.
Disclosure statement No potential conflict of interest was reported by the authors.
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Supplemental data Supplemental data for this article can be accessed here.
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References Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Erlbaum. Bakermans-Kranenburg, M. J., Steele, H., Zeanah, C. H., Muhamedrahimov, R. J., Vorria, P., Dobrova-Krol, N. A., … Gunnar, M. R. (2011). III. Attachment and emotional development in institutional care: Characteristics and catch-up. Monographs of the Society for Research in Child Development, 76, 62–91. doi:10.1111/j.1540-5834.2011.00628.x Borelli, J. L., Crowley, M. J., David, D. H., Sbarra, D. A., Anderson, G. M., & Mayes, L. C. (2010). Attachment and emotion in school-aged children. Emotion, 10(4), 475–485. doi:10.1037/ a0018490 Bretherton, I. (2005). In pursuit of the internal working model construct and its relevance to attachment relationships. In K. E. Grossmann, K. Grossmann, & E. Waters (Eds.), Attachment from infancy to adulthood: The major longitudinal studies (pp. 13–47). New York, NY: Guilford Press. Bretherton, I., & Munholland, K. A. (2008). International working models in attachment relationships: Elaborating a central construct in attachment theory. In J. Cassidy & P. E. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 102–130). London: Guilford Press. Bretherton, I., & Ridgeway, D. (1990). Story completion task to assess young children’s internal working models of child and parents in the attachment relationship. In M.T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 300–308). Chicago, IL: University of Chicago Press. Bretherton, I., Ridgeway, D., & Cassidy, J. (1990). Assessing internal working models of the attachment relationship. An attachment story completion task for 3-year-olds. In M. T. Greenberg, D. Ciccetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research and intervention (pp. 273–308). Chicago, IL: University of Chicago Press. Burlingham, D., & Freud, A. (1944). Infants without families. London: Allen & Unwin. Cassidy, J., & Shaver, P. R. (Eds.). (2008). Handbook of attachment: Theory, research, and clinical applications (2nd ed.). New York, NY: Guilford Press. Chisholm, K. (1998). A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian Orphanages. Child Development, 69(4), 1092–1106. doi:10.1111/j.1467-8624.1998.tb06162.x Cohen, N. J., & Farnia, F. (2011). Social-emotional adjustment and attachment in children adopted from China: Processes and predictors of change. International Journal of Behavioral Development, 35(1), 67–77. doi:10.1177/0165025410371602 Dontas, C., Maratos, O., Fafoutis, M., & Karangeli, A. (1985). Early social development in institutionally reared Greek infants: Attachment and peer interaction. Monographs of the Society for Research in Child Development, 50, 136–146. doi:10.2307/3333830 Farran, D., Kasari, C., Comfort, M., & Jay, S. (1986). Parent/Caregiver Interaction Scale. Chapel Hill: University of North Carolina Press. Feast, J., Grant, M., Rushton, A., & Simmonds, J. (2013). Adversity, adoption and afterwards: A mid-life follow-up study of women adopted from Hong Kong. London: British Association of Adoption and Fostering. Goldberg, S. (1997). Attachment and childhood behavior problems in normal, at-risk and clinical samples. In L. Atkinson & K. Zucker (Eds.), Attachment and psychopathology (pp. 171–195). New York, NY: Guilford Press. Grossmann, K. E., Grossman, K., & Waters, E. (Eds.). (2005). Attachment from infancy to adulthood: The major longitudinal studies. New York, NY: Guilford Press. Harms, T., & Clifford, R. M. (1980). Early childhood environment rating scale. New York, NY: Teachers’ College Press. Hodges, J., & Tizard, B. (1989). Social and family relationships of ex-institutional adolescents. Journal of Child Psychology and Psychiatry, 30(1), 77–97. doi:10.1111/j.1469-7610.1989. tb00770.x
Downloaded by [University of Nebraska, Lincoln] at 07:00 13 April 2015
Attachment & Human Development
15
Howe, D. (2003). Attachment disorders: Disinhibited attachment behaviours and secure base distortions with special reference to adopted children. Attachment & Human Development, 5(3), 265–270. doi:10.1080/14616730310001593965 O’Connor, T. G., Marvin, R. S., Rutter, M., Olrick, J. T., & Britner, P. A. & the English and Romanian Adoptees Study Team. (2003). Child-parent attachment following early institutional deprivation. Development and Psychopathology, 15, 19–38. doi:10.1017/S0954579403000026 Rutter, M., Colvert, E., Kreppner, J., Beckett, C., Castle, J., Groothues, C., … Sonuga-Barke, E. J. S. (2007). Early adolescent outcomes for institutionally-deprived and non-deprived adoptees. I: Disinhibited attachment. Journal of Child Psychology and Psychiatry, 48(1), 17–30. doi:10.1111/j.1469-7610.2006.01688.x Rutter, M., Kreppner, J., & Sonuga-Barke, E. (2009). Emanuel Miller Lecture: Attachment insecurity, disinhibited attachment, and attachment disorders: Where do research findings leave the concepts? The Journal of Child Psychology and Psychiatry, 50, 529–543. doi:10.1111/ j.1469-7610.2009.02042.x Rutter, M., Kumsta, R., Schlotz, W., & Sonuga-Barke, E. (2012). Longitudinal studies using a “natural experiment” design: The case of adoptees from Romanian institutions. Journal of the American Academy of Child & Adolescent Psychiatry, 51, 762–770. doi:10.1016/j.jaac.2012.05.011 Rutter, M., & Sonuga-Barke, E. J. (2010). Conclusions: Overview of findings from the ERA study, inferences, and research implications. Monographs of the Society for Research in Child Development, 75, 212–229. doi:10.1111/j.1540-5834.2010.00557.x Solomon, J., & George, C. (2008). The measurement of attachment security and related constructs in infancy and childhood. In J. Cassidy & P. E. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 102–130). London: Guilford Press. Stevens, A. (1975). Attachment and polymatric rearing. A study of attachment formation, separation anxiety and fear of strangers in infants reared by multiple mothering in an institutional setting. In H.R. Schaffer (Ed.), The origins of human social relations. London: Academic Press. Target, M., Fonagy, P., & Shmueli-Goetz, Y. (2003). Attachment representations in school-age children: The development of the Child Attachment Interview (CAI). Journal of Child Psychotherapy, 29, 171–186. doi:10.1080/0075417031000138433 Tizard, B. (1977). Adoption: A second chance. London: Open Books Publishing. van IJzendoorn, M. H., Palacios, J., Sonuga-Barke, E. J. S., Gunnar, M. R., Vorria, P., McCall, R. B., … Juffer, F. (2011). Children in institutional care: Delayed development and resilience. Monographs of the Society for Research in Child Development, 76, 8–30. doi:10.1111/j.1540-5834.2011.00626.x Vorria, P., Ntouma, M., & Rutter, M. (2014a). The cognitive development and school achievement of adopted adolescents: The Greek “Metera” study. European Journal of Developmental Psychology. doi:10.1080/17405629.2014.933703 Vorria, P., Ntouma, M., & Rutter, M. (2014b). The behaviour of adopted adolescents who spent their infancy in residential group care: The Greek Metera study. Adoption & Fostering, 38, 271–283. doi:10.1177/0308575914543237 Vorria, P., Ntouma, M., & Rutter, M. (2015). Vulnerability and resilience after early institutional care: The Greek “Metera” Study. Development and Psychopathology. Advance online publication. doi:10.1017/S0954579415000243 Vorria, P., Papaligoura, Z., Dunn, J., Van IJzendoorn, M. H., Steele, H., Kontopoulou, A., & Sarafidou, Y. (2003). Early experiences and attachment relationships of Greek infants raised in residential group care. Journal of Child Psychology and Psychiatry, 44, 1208–1220. doi:10.1111/1469-7610.00202 Vorria, P., Papaligoura, Z., Sarafidou, J., Kopakaki, M., Dunn, J., Van IJzendoorn, M. H., … Kontopoulou, A. (2006). The development of adopted children after institutional care: A follow-up study. Journal of Child Psychology and Psychiatry, 47, 1246–1253. doi:10.1111/ j.1469-7610.2006.01666.x Waters, E., & Deane, K. (1985). Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research, Monographs of the Society for Research in Child Development, 50 (1–2, Serial No. 209) (pp. 41–65). Zachrisson, H. D., Røysamb, E., Oppedal, B., & Hauser, S. T. (2011). Factor structure of the child attachment interview. European Journal of Developmental Psychology, 8(6), 744–759. doi:10.1080/17405629.2011.631293
