A child sleeps with his hand tied to the bars at an orphanage May 16, 1990 in Ploiesti, Romania. The orphanage is for children who have birth defects such as retardedness and deformities. (Cynthia Johnson/Getty Images)

Izidor Ruckel’s devotion to the cause of Romania’s institutionalized children is driven in part by what he has seen happen to them. As a functioning adult who lives on his own, he is the rarity. He has kept in touch with many fellow orphans from Sighetu, and he has seen the ravages of the system play out in many who were rescued when he was — and in some who never got out.

This does not surprise experts who have worked with Romania’s orphans.

“They were unusual kids,” said Jane Aronson, a physician and founder of the Worldwide Orphans Foundation, who has studied orphanages around the world. “They were so punished that they were depressed. And many of them even had psychotic features, autistic-like behavior and had severe failure to thrive and were tiny.”

Cognitive ability and psychological well-being correlate directly with the amount of attention and nurturing children receive when they are young, according to recent research that includes studies of Romanian institutions.

Everything from brain size to intellectual prowess to the ability to form emotional bonds to staying focused on a job is improved when children receive attention, are held and read to, experts say.

Izidor Ruckel spent more than a decade of his life growing up in a Romanian institution before appearing on an ABC "20/20" special and being adopted by a California family and brought to the U.S. Now in his thirties, Izidor is trying to begin a new chapter in his life. (Brad Horn/The Washington Post)

Romania’s communist-era orphans got next to none of this. As a result, they suffered from attention deficit hyperactivity disorder, post-traumatic stress disorder, psychiatric illnesses and bipolar disorder, Aronson said.

They also had the most severe reactive attachment disorder she has seen anywhere. “It is a pathologic and psychiatric diagnosis where an individual person, a child in this case, would be unable to have affectional connection to an adult, to a parent, incapable of exchange of love.”

Some of these effects can be reversed if children leave an institution early enough, said Charles Nelson, a professor of pediatrics at Harvard Medical School and Boston Children’s Hospital who, along with colleagues from the University of Maryland and Tulane University, is conducting a longitudinal study in Romania comparing children’s development in government-run orphanages to high-quality foster care.

Nelson’s new book on the topic, “Romania’s Abandoned Children,” due out this month, describes the stark disadvantages faced by institutionalized children, whose cognitive development is likely to be irreversibly stunted if they stay in orphanages past age 2.

“The brain is dependent on experience to develop normally,” he said. “What happens in situations of neglect, such as kids raised in institutions, is that the experiences are lacking. So the brain is sort of in a holding pattern saying, ‘Okay, so where’s the experience? Where’s the experience? Where’s the experience?’ And when the experience fails to occur, those circuits either fail to develop or they develop in an atypical fashion — and the result is, in a sense, the mis-wiring of circuits.”

“The big question is, what happens 10 or 20 or 30 years down the line,” he said. “The speculation would be you will progressively find yourself more and more disadvantaged or more and more handicapped.”

Nelson’s study found such stark differences between children in institutions and foster care that the Romanian government began its own foster care system and in 2005 passed a law prohibiting institutionalization of children younger than 2 .

But across the world, as international adoption has increasingly dried up, more children are remaining in orphanages for longer periods of time, according to a 2013 report by the New York-based Donaldson Adoption Institute.

Attachment has not come easily to the orphans of Sighetu. Of the dozen whose current whereabouts The Washington Post was able to trace, all remain single. Few live independently.

A close friend of Izidor’s, Cardos, never got out. On his last trip to Romania, Izidor tracked him down in an adult facility that was not much better than the orphanage, with the same stench of urine. Like Izidor, Cardos had a lame leg. He played the piano beautifully and had no mental handicaps. But he never learned to function outside an institution.

Among those who were taken in by Americans, the outcomes varied widely. Another friend of Izidor’s, Christina, attended community college for a time in San Diego, runs a marathon every year, and wants to be an athletics coach. Ana, the singer, has developmental issues and still lives with her adoptive family in Michigan. They have hired staff to help take care of her. Isabella, the other girl adopted by the Ruckels, now lives in a group home for disabled adults near their house and sees them regularly.

But some were too deeply damaged to fit in with adoptive families. “They were so violent, so traumatized, the family couldn’t even care for them,” Izidor says. Some families sent children to U.S. institutions or back to Romania when they were unable to handle them.

Izidor didn’t leave Sighetu until he was 11, but Nelson speculated that he may have been helped by some factor in his genetic makeup — or by the fact that he was 6 months old when he arrived at the orphanage.

“Somewhere at 6 or 7 months, kids start to form attachments, and even if it’s broken later it seems to help if there was an initial attachment,” Nelson said. “So it’s possible that those six months in a family served as a protective factor.”

Brad Horn contributed to this report.