Understanding Institutionalized Children: Developmental Issues, Intervention and Policy Implications
The following article was featured as the Special Report in the November 2012 issue of the Office's newsletter Developments. To download a PDF of the issue, click here.

Nations trying to improve the outcomes of children without permanent parents face steep challenges, particularly those that have long relied on institutions to house such children and whose child welfare systems remain works in progress. While many obstacles confront their efforts, the lack of research essential to understanding the developmental issues of those children and creating more effective interventions is not one of them.

The number of vulnerable children being raised in institutions throughout the world is imprecise. Estimates range from 2 to 8 million – a small percentage of the total international population of vulnerable children, which also includes children living on the street, in refugee camps, in informal kinship or community care, and those who are runways, are recruited as child combatants or are trafficked for labor or sexual exploitation.

Institutionalized children, however, are the focus of a substantial body of research on their development, both while living in institutions and, for some, after they were placed with families through adoption or other means.

Interest in such research has increased in recent decades, driven, in part, by the appalling conditions within Romanian orphanages that were exposed following the fall of the regime of Nicholae Ceausescu. As adoptions from the world’s orphanages increased, so did the desire to learn more about the development of children raised in them, as well as the willingness of more nations to explore alternatives to institutionalizing their vulnerable children.

The research sheds light on issues that are important in addressing the needs of vulnerable children, including the developmental outcomes experienced by children raised in institutions, how the interactions between caregivers and children affect those outcomes, developmental changes that occur after children are placed with adoptive or foster families, and interventions that show promise to improve the development of children who remain in institutions.

This report summarizes some of the key findings of that research.

Orphanage Characteristics
It is not unusual for the care found in orphanages to differ from institution to institution in a country, or over a period of time in the same country or from one country to another. However, anecdotal evidence and recent empirical studies of orphanages in several locations, including the Russian Federation and Central America, suggest institutions share several characteristics, although variations are sometimes seen that can be significant.[i]

Common structural characteristics of orphanages, for example, include wards that house relatively large numbers of infants and young children, sometimes as many as 30 in each. The number of children under the care of a single caregiver during their waking hours is often high, ranging from 6 to 10 or more children per caregiver, including infants in the first year of life.

Many different caregivers often serve the children. When vacations, staff turnover and other factors are considered, children may be exposed to 60-100 different caregivers over their first two years of life. The care they receive tends to be highly regimented. There is also a tendency to segregate children with disabilities in different wards or different institutions.

Studies also find common characteristics in the quality of caregiver-child interactions that occur in institutions. These interactions often tend to be limited to the routine chores of the day, such as feeding, bathing and changing. Such chores are often done in a perfunctory, business-like manner with little social interaction. Caregivers tend not to respond to a crying child or to play with the children. Little warmth and sensitivity is afforded the children. One-on-one interaction is rare. And reciprocal verbal and nonverbal "conversation" is limited.

Some institutions have been found to be globally deficient. In such institutions, not only are structural characteristics and caregiver-child interactions found wanting, they also fail to provide adequate medical care, nutrition, sanitation and safety. Other orphanages offer adequate medical care, nutrition and sanitation, but the nature of their structural characteristics and caregiver-child interactions cast them as social-emotionally depriving institutions.

Children’s Development
In general, studies suggest that infants and young children who are raised in institutions as typically operated develop more poorly than children who are raised at home and have not been institutionalized. The research, which is fairly substantial, tends to focus on outcomes such as a child’s physical growth and general behavioral development as measured by standardized tests that include cognition, language, personal-social, motor and adaptive behaviors.

Infants and young children raised in orphanages are, on average, more than a standard deviation below the mean of non-institutionalized children raised at home on measurements of height, weight, head circumference and general behavioral development. And it is not unusual to find orphanage-raised children well below those levels.

Young children in three St. Petersburg, Russian Federation institutions, for example, averaged more than 1.5 standard deviations below home-raised children.[ii] About half of those children would rank in the bottom 10 percent of non-institutionalized children in physical growth and mental development.

Caregiver-Child Interactions
Research offers evidence that poor social-emotional interactions play a role in a number of troubling developmental outcomes ranging from poor physical growth[iii], [iv], [v] to attachment problems and general behavioral and mental deficits. Studies suggest that young children raised in institutions where quality interactions with their caregivers are not prevalent are particularly at risk of experiencing such outcomes.

When interactions with children in orphanages improve, many of their outcomes tend to improve as well. Steps that led to improved caregiver-child interactions in Russian Federation orphanages, for example, were followed by improvements in children’s physical development, even without changes in their nutrition.[vi]

Being deprived of interacting with their caregivers, talking and the benefits of one-on-one responses contribute to general behavioral and mental deficiencies in children. A large body of research shows behavioral and mental development markedly improved when institutionalized children were given sensory and perceptual stimulation, with or without a social component, and interventions were implemented to improve the social and educational nature of caregiver-child interactions.

Attachment is another issue influenced by a child’s interactions with his or her caregivers. Children raised in institutions have much higher rates of insecure and disorganized attachments, as assessed by the Strange Situation Procedure. Such issues even occur with their favorite caregiver or with someone whom they know well. In studies of children in institutions, about 73 percent of them displayed disorganized attachment or were not able to be scored – outcomes that might be expected in only 15 percent of low-risk children raised by their parents outside of an institution.

To some extent, the nature of children who are placed in institutions contributes to the substantial developmental delays researchers find and to the atypical behaviors the children display. Few studies have examined children’s development when they enter an institution. But those that have report finding higher rates of low birth weight, prematurity, low Apgar scores and other perinatal risk factors that lead to poor developmental outcomes when the conditions children are raised in are poor.[vii] On the other hand, few studies report finding such risk factors among children who leave institutions to live with advantaged adoptive families.

Intervention Studies
Several interventions have been studied that largely focus on improving the caregiver-child interactions in orphanages. Findings suggest that certain steps to improve those interactions can improve the physical and general behavioral development of children being raised in institutions.

The studies show that the more comprehensive and intensive children’s interactions are with their caregivers the greater their development improves. In one study, substantial improvements in children’s physical and general behavioral development were reported after a family-like environment was created in an orphanage and caregivers provided better care.[viii] Fewer children showed disorganized attachment, and atypical behaviors became scarce. And improvements were broadly seen across the population of orphanage children, including those with disabilities.

More dramatic improvements occur when infants and young children leave an institution and are placed with adoptive families or high-quality foster homes. The studies reporting such improvements involved children who were placed with families that provided much better conditions than those they experienced in institutions.[ix] The children showed immediate and significant gains in physical and behavioral growth and became attached to their new parents.

Research also demonstrates the importance of improving children’s environments as early in their lives as possible. The long-term development and adjustment of institutionalized children tend to be influenced by how long they are exposed to conditions that deprive them of the interactions, warmth and other factors important to healthy development.

In general, children removed from institutions at a young age tend not to have long-term deficits. But the age at which long-term deficits become a significant risk often depends on the severity of their experiences in the institution. That “step,” for example, can occur in as little as six months for children in extremely depriving conditions, such as those characteristic of Romanian orphanages several decades ago.

Studies of children who are removed from orphanages to family settings offer further evidence of how the length of time spent in an institution affects their outcomes. A large body of research shows that children who are placed in family care after spending a long period of time in institutions have higher rates of physical developmental delays and behavior and psychiatric problems. They are, for example, more likely to have deficits in executive functioning, such as short-term memory and cognitive inhibition, and in language development – all of which can contribute to poor academic performance later in life.

The best developmental outcomes are found among children who were adopted, especially at an early age, out of an institution to live with families.

Foster care is also found to offer children better outcomes than what they would be expected to experience if raised in orphanages or other institutions.[x] In general, the quality of foster care tends to matter. The best evidence of gains seen among institutionalized children after they were placed in foster care were reported in the Bucharest Early Intervention project, in which the quality of foster care was exceedingly high. Studies report that children in the project who were randomly assigned to foster care showed better physical and mental development – particularly children placed with foster families younger ages – than those who stayed in institutions[xi]. While demonstrating the benefits of placing children in high-quality foster care, the project also raises questions as to whether countries with few resources would be willing or able to duplicate such conditions.

But many more children remain in institutions than are adopted or placed in foster care in most countries. For them, research suggests, interventions that improve the quality of their interactions with their caregivers can be critical to their developmental outcomes. In a study of Russian Federation orphanages, interventions that encouraged caregivers to be warmer, more engaged and more responsive was coupled with improvements in the orphanage environment to better promote such practices. After such steps were taken, children’s physical and socio-emotional development improved substantially compared to children in control institutions.[xii]

Studies of interventions aimed at improving the outcomes of institutionalized children vary. But what emerges is evidence suggesting that, in practice, the quality of care may be more important than the type of care. Among the challenges nations face in reforming practices that rely on housing vulnerable children in institutions is to build a professional social work and child welfare infrastructure capable of supporting quality care, especially in families, throughout the system.

Policy Implications
As the research makes clear, the best outcomes for children occur when they are raised in an environment that is safe, provides them with basic necessities, such as adequate nutrition and medical care, and offers them a family-like atmosphere in which they regularly interact with caregivers who are warm and responsive to their needs.

Helping nations develop comprehensive and professional child welfare systems with an emphasis on family alternatives over institutional care is an endeavor several international and national organizations, as well as private foundations, are undertaking, including UNICEF, USAID, the Oak Foundation and others.

The challenges are daunting, particularly in countries whose resources for creating such systems are low. Simply legislating that young children shouldn’t be raised in institutions is not enough to ensure the environments they are raised in are better. Well-functioning child welfare systems require substantial up-front investment. Some family alternatives, such as adoption, can be controversial. In fact, some religions forbid adoption, although alternatives are often possible.

Research offers these nations some guidance having identified several key requirements for developing an effective professional child welfare system.[xiii] For example:

  • Local policymakers and practitioners should lead the development of care arrangements to make sure they are tailored to fit their local populations, cultures and populations. Solutions that work in one country may not be a good fit in others. Advisors and international organizations, therefore, might be most helpful by providing local professionals and policymakers with multiple options and information about each.
  • Nations need to develop a professional social work infrastructure to support child welfare systems. Social services for at-risk children and families are either not well developed or available at all in many low-resource countries. And developing one would likely take many years.
  • A professional social work infrastructure is critical to another requirement for developing a child welfare system: Parents need to be recruited, trained, supported and monitored.
  • Financial investment and the support of a professional social services network are required to help at-risk parents through difficult circumstances and adequately provide for their children so they stand a better chance of retaining custody and avoid having their children placed in institutions, foster care or other alternative arrangements.
  • Family alternatives take time and may not go smoothly when first implemented, placing a premium on persistence and a steady commitment to improvement. In the Ukraine, for example, many requirements for family alternatives were in place, yet after five years only 6,700 children were in such arrangements while 45,000 remained in institutions.[xiv]

In addition to emphasizing the benefits of developing quality child welfare systems focused on family alternatives, studies underscore the importance of moving children out of institutions and into such arrangements as soon as possible. Another challenge for nations in building child welfare systems, therefore, is to develop policies that strike a balance between the custody rights of birth parents and children’s best interests while keeping the time children spend in institutions awaiting placement to a minimum.

Improving Institutions
Despite a nation’s best efforts to develop a child welfare system and family alternatives, the fact remains that substantial numbers of children will likely be living in institutions for many years to come. Research suggests that steps can be taken to improve the conditions of institutions for those children and, in doing so, increase the likelihood they will experience better outcomes.

Institutions do not necessarily have to operate as they currently do. Interventions aimed at changing caregiving practices to afford children more stimulation and closer relationships with their caregivers are fairly consistent in finding such steps improve children’s physical and mental development.

If, however, a nation’s goal is to provide the best environment possible for all vulnerable children, it will likely have to find ways to improve conditions within its institutions. Marshaling limited resources to do both will be a challenge, particularly among low-resource nations. The good news is that numerous studies demonstrate that after initial investments are made to develop family alternatives, nations should begin to see significant cost savings as such less expensive options are able to accommodate more children, creating the opportunity to reinvest the funds in improving conditions within institutions for those children who remain.


McCall, R.B., Groark, C.J., & Goldman, P. Research on Institutionalized Children: Principles for International Child Welfare Practitioners and Policy Makers. Unpublished manuscript. Pittsburgh, PA:University of Pittsburgh Office of Child Development.

This Special Report is based on the above-referenced paper. It is not intended to be an original work but a summary for the convenience of our readers. References noted in the text follow:

[i] Rosas, J., & McCall, R. B., Groark, C. J., Muhamedrahimov, R. J., Palmov, O. I., & Nikiforova, N. V. (2012). Environmental quality as mediator between an institutional interventions and children’s developmental outcomes. Unpublished manuscript, author. Pittsburgh, PA: University of Pittsburgh.

[ii] St. Petersburg-USA Orphanage Research Team (2005). Characteristics of children, caregivers, and orphanages for young children in St. Petersburg, Russian Federation. Journal of Applied Developmental Psychology: Special Issue on Child Abandonment, 26, 477-506.

[iii] Blizzard, R. M. (1990). Psychosocial short stature. In F. Lifshitz (Ed.), Pediatric endocrinology (pp. 77-91). New York, NY: Marcel Dekker.

[iv] Johnson, D. E. (2000). Long-term medical issues in international adoptees. Pediatric Annals, 29, 234-241.

[v] Johnson, D. E. (2000). Medical and developmental sequelae of early childhood institutionalization in Eastern European adoptees. In C. A. Nelson (Ed.), The effects of early adversity on neurobehavioral development. Minnesota Symposium on Child Psychology (Vol. 31, pp. 113-162). Mahwah, NJ: Lawrence Erlbaum.

[vi] St. Petersburg-USA Orphanage Research Team (2008). The effects of early social-emotional and relationship experience on the development of young children. Monographs of the Society for Research in Child Development, Serial Number 291, Vol. 72, No. 3.

[vii] St. Petersburg-USA Orphanage Research Team (2005), op. cit.

[viii] St. Petersburg-USA Orphanage Research Team (2008), op. cit.

[ix] van IJzendoorn, M. H., & Juffer, F. (2006). The Emanuel Miller Memorial Lecture 2006: Adoption as intervention. Meta-analytic evidence for massive catch-up and plasticity in phyiscal, socio-emotional, and cognitive development. Journal of Child Psychology and Psychiatry, 47(12), 1228-1245.

[x] Julian, M., & McCall, R. B. (2011). The Development of Children within Different Alternative Residential Care Environments. International Journal of Child and Family Welfare, 3-4, 119-147.

[xi] Johnson, D. E., Guthrie, D., Smyke, A. T., Koga, S. F., Fox, N. A., & Nelson III, C. A. (2010). Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children randomized to foster care vs. ongoing institutional care. Archives of Pediatric and Adolescent Medicine, 164(6), E1-E10.

[xii] St. Petersburg-USA Orphanage Research Team (2008), op. cit.

[xiii] Engle, P., Groza, V., Groark, C. J., Greenberg, A., Bunkers, K. M., & Muhamedrahimov, R. (2011). Children without parental care. In R. B. McCall, M. H. van IJzendoorn, F. Juffer, C. J. Groark, and V. K. Groza (Eds.), Children without permanent parents: Research, practice, and policy. Monographs of the Society for Research in Child Development, Serial No. 301, 76(4), 190-222.

[xiv] Groark, C. J., McCall, R. B., & Li, J. (2009). Characterizing the status and progress of a country’s child welfare reform. International Journal of Child & Family Welfare, 4, 145-160.