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.
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.
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.
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.
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.
summarizes some of the key findings of that research.
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]
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.
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.
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.
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.
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.
offers evidence that poor social-emotional interactions play a role in a number
of troubling developmental outcomes ranging from poor physical growth[iii], [iv],
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.
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]
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
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
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.
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.
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.
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
The children showed immediate and significant gains in physical and behavioral
growth and became attached to their new parents.
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
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.
developmental outcomes are found among children who were adopted, especially at
an early age, out of an institution to live with families.
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 wererandomly 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.
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
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.
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
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.
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.
these nations some guidance having identified several key requirements for developing
an effective professional child welfare system.[xiii]
- 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
- 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 takemany
- 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.
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.
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.
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
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.
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.
R. M. (1990). Psychosocial short stature. In F. Lifshitz (Ed.), Pediatric endocrinology (pp. 77-91). New
York, NY: Marcel Dekker.
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:
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.
Petersburg-USA Orphanage Research Team (2005), op. cit.
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.
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.
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),
Petersburg-USA Orphanage Research Team (2008), op. cit.
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.
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.