The Development and Care of Institutionally Reared Children

Abstract

This article briefly summarizes the literature on elements of research, practice, and policy pertaining to the development and care of children raised in institutions. It covers such childrens development while they reside in institutions and after their transition to adoptive or foster families. Of special interest are attachment and indiscriminate friendliness, physical growth, neurobiological deficits, and sensitive periods. Early exposure of a year or 2 to a substandard institution is related to higher than expected rates of a variety of long-term neurological, physical, cognitive, and behavioral deficiencies and problems, even if the children are subsequently reared in advantaged families. Countries hoping to transition from a reliance on institutions to family care alternatives face a variety of unique challenges relating to their prevailing historical, cultural, political, and financial circumstances. Although there has been progress, developing a child welfare system of family alternatives may take time in some countries.

Full text

The Development and Care of Institutionally
Reared Children
The Leiden Conference on the Development and Care of Children
without Permanent Parents
ABSTRACT—This article briefly summarizes the literature
on elements of research, practice, and policy pertaining
to the development and care of children raised in institu-
tions. It covers such children’s development while they
reside in institutions and after their transition to adoptive
or foster families. Of special interest are attachment and
indiscriminate friendliness, physical growth, neurobiologi-
cal deficits, and sensitive periods. Early exposure of a
year or 2 to a substandard institution is related to higher
than expected rates of a variety of long-term neurological,
physical, cognitive, and behavioral deficiencies and prob-
lems, even if the children are subsequently reared in
advantaged families. Countries hoping to transition from
a reliance on institutions to family care alternatives face a
variety of unique challenges relating to their prevailing
historical, cultural, political, and financial circumstances.
Although there has been progress, developing a child wel-
fare system of family alternatives may take time in some
countries.
KEYWORDS—institutionalized children; development; prac-
tice; policy
One of the central questions for developmental sciences is
the contribution of early experiences to contemporary and
long-term development. Scholars are paying increased atten-
tion to children reared in substandard institutions, because
they represent a naturally occurring population that has atypi-
cal early experience.
Numbers Worldwide
Institutionalized children are those without permanent parents, a
group that includes ‘‘true orphans’’ who do not have living par-
ents and ‘‘social orphans’’ who have at least one living parent
who may be unable, unwilling, or unfit to rear the child.
Although accurate figures are impossible to obtain (Engle
et al., 2011), an estimated 163 million children in 93 countries
lack permanent parents (UNAIDS, UNICEF, & USAID, 2004).
The vast majority live in villages, in kinship groups, in refugee
camps, on the street, and in a variety of other formal and infor-
mal care arrangements (Engle et al., 2011), but an estimated
2–8 million (Human Rights Watch, 1999; USAID, 2009) live in
institutions, mostly in Eastern Europe, Latin America, Asia, and
Africa. Although institutionalized children—typically living in
orphanages but sometimes in hospitals and other residential
facilities—represent a small fraction of those without permanent
This article is based on a conference sponsored by SRCD, Institute
for the Study of Education and Human Development (The Nether-
lands), the Rommert Casimir Institute for Developmental Psycho-
pathology, the NWO Spinoza Prize (to M. H. van IJzendoorn),
Leiden University, and The Philip and Amy Goldman Foundation
(McCall, van IJzendoorn, Juffer, Groark, & Groza, 2011). Partici-
pants in the Leiden Conference project in alphabetical order are
Marian J. Bakermans-Kranenburg, Leiden University; Kelley
McCreery Bunkers, Consultant to UNICEF; Natasha A. Dobrova-
Krol, Socires Foundation; Patrice Engle, California Polytechnical
State University; Nathan A. Fox, University of Maryland; Gary
Gamer, Families for Children Foundation; Philip Goldman, Maestral
International; Aaron Greenberg, UNICEF; Christina J. Groark,*
University of Pittsburgh; Victor Groza,* Case Western Reserve Uni-
versity; Megan R. Gunnar, University of Minnesota; Dana E. John-
son, University of Minnesota; Femmie Juffer,* Leiden University;
Jana M. Kreppner, King’s College; Lucy LeMare, Simon Fraser Uni-
versity; Robert B. McCall,* University of Pittsburgh; Rifkat J. Muha-
medrahimov, St. Petersburg State University; Charles A. Nelson,
Harvard Medical School; Jesus Palacios, University of Seville;
Edmund J. S. Sonuga-Barke, University of Southampton; Howard
Steele, New School for Social Research; Miriam Steele, New School
for Social Research; Marinus H. van IJzendoorn,* Leiden Univer-
sity; Frank Verhulst, Erasmus University, Rotterdam; Panayiota
Vorria,* Aristotle University of Thessaloniki; and Charles H. Zea-
nah, Tulane University School of Medicine. The asterisk indicates
contributing author.
Correspondence concerning this article should be addressed to
Robert McCall, Office of Child Development, University of Pitts-
burgh, 400 N. Lexington Avenue, Pittsburgh, PA 15208; e-mail:
mccall2@pitt.edu.
ª2012 The Author
Child Development Perspectives ª2012 The Society for Research in Child Development
DOI: 10.1111/j.1750-8606.2011.00231.x
Volume 6, Number 2, 2012, Pages 174–180
CHILD DEVELOPMENT PERSPECTIVES

parents, those reared in, adopted from, or fostered from such
institutions have become the object of substantial study in recent
years.
Characteristics of Institutions
The physical, educational, and affective characteristics of the
care that institutions provide children all vary from country to
country, within countries, and over time. The few narrative and
empirical published reports (Rosas & McCall, in press; van
IJzendoorn et al., 2011) typically pertain to orphanages for
infantsandyoungchildren.Thegroupsizestendtobelarge
(9–16 children per ward, but sometimes up to 70), the ratio of
children to caregiver is high (six to eight children per caregiver,
although it is often much higher), children are grouped homo-
geneously by age and disability status, and they are ‘‘graduated’’
to new groups or institutions periodically when they reach
certain developmental milestones or ages.
There are also typically many different and changing caregiv-
ers per ward, and caregivers often work long shifts (up to 24 hr)
and then are off for up to 3 days. For example, children in two
Russian orphanages saw 60–100 different caregivers in the first
19 months of life, and they saw no caregiver today whom they
saw yesterday or would see tomorrow (St. Petersburg-USA
Orphanage Research Team, 2008).
Finally, although there are exceptions (e.g., Gavrin & Sacks,
1963; Vorria et al., 2003; Wolff & Fesseha, 1998), caregivers
are frequently described anecdotally and empirically as being
businesslike and perfunctory in performing their caregiving
duties, with little talking and minimal warm, sensitive, contin-
gently responsive interactions with children even when the num-
ber of children per caregiver is relatively low (Vorria et al.,
2003). This environment is in stark contrast to that of an ordinary
family.
CHILDREN’S DEVELOPMENT
It is not surprising that children reared in institutions are sub-
stantially developmentally delayed, with potentially lifelong con-
sequences.
Children Residing in Institutions
Children living in institutions around the world average more
than 1 SD below levels expected of noninstitutionalized children
in their physical growth, cognition, and general behavioral devel-
opment, and their attachment and social-emotional development
are mostly disorganized and delayed (Johnson & Gunnar, 2011;
van IJzendoorn, Bakermans-Kranenburg, & Juffer, 2007; van IJz-
endoorn et al., 2011). But the variation is substantial; although
some develop within typical ranges, it is not uncommon to find
children averaging 2 SD below the mean, with 40%–50% of
institutionalized children below the 10th percentile of parent-
reared children (McCall et al., 2010; St. Petersburg-USA
Orphanage Research Team, 2005).
Postinstitutionalized Children Placed in Families
Postinstitutionalized (PI) children adopted by typically advan-
taged parents (for a review, see Palacios & Brodzinsky, 2010)
display immediate and substantial catch-up in physical growth
(height, weight, and to a lesser extent head circumference),
attachment, and cognitive and behavioral development as mea-
sured by standardized assessments (Juffer et al., 2011; van
IJzendoorn & Juffer, 2006). This catch-up growth provides retro-
spective testimony to the developmentally depressing character
of the institutions compared to family care.
But catch-up is not always complete for general indices of
social and behavioral development and especially attachment
(Van den Dries, Juffer, van IJzendoorn, & Bakermans-
Kranenburg, 2009) and specific cognitive and behavioral prob-
lems (Gunnar, 2001; Juffer & van IJzendoorn, 2005; MacLean,
2003; Pollak et al., 2010; Rutter et al., 2010). Although most PI
children develop quite typically after entering a family, those
exposed to institutions for longer periods display higher rates of
relative deficiencies and problems in several areas, as well as
more multiple problems (Hawk & McCall, 2011; Rutter et al.,
2010), than would be expected of noninstitutionalized children
residing in the PI children’s adoptive society or country of origin.
Specifically, even after spending years in an advantaged adop-
tive family, PI children may be slightly undersized physically
and score slightly below expectations on general mental tests,
and they can exhibit a variety of executive functioning deficien-
cies (i.e., short-term working memory, attention, inhibitory
control, and set shifting); attachment, relationship, social engage-
ment problems; and a variety of internalizing and externalizing
behavior problems, especially in middle childhood and adoles-
cence. At least one review (Julian, 2009) and a large longitudinal
study (Van der Vegt, Van der Ende, Ferdinand, Verhulst, &
Tiemeier, 2009) suggest that these problems do not simply repre-
sent an extremely troublesome adolescent period but persist in
one form or another into adulthood.
Institutional Exposure or Other Factors?
Most research in this area is nonexperimental, so technically it
is impossible to unequivocally attribute the delayed development
of children within institutions and the higher rates of long-term
deficiencies to institutional rearing. Undoubtedly, genetics, pre-
natal conditions (such as maternal exposure to drugs, alcohol,
and other agents linked to birth defects), birth complications
(such as low birth weight, poor Apgar scores, lung immaturity),
and preorphanage experience (such as birth hospital or an abu-
sive or neglectful family) all have the potential to produce these
developmental outcomes (Juffer et al., 2011; van IJzendoorn
et al., 2011). Furthermore, these potentially confounding condi-
tions are known to occur at higher than expected rates in at least
some institutional populations (St. Petersburg-USA Orphanage
Research Team, 2005; van IJzendoorn et al., 2011).
Nevertheless, the preponderance of circumstantial evidence
indicates that institutional experience contributes substantially
Child Development Perspectives, Volume 6, Number 2, 2012, Pages 174–180
Development and Care of Institutionally Reared Children 175

to these concurrent and persistent developmental deficiencies
(McCall, 2011; Rutter, et al., 2007). The most prominent evi-
dence includes: (a) the uniformly delayed development of institu-
tionalized children and their substantial catch-up growth in
every domain after placement in family care despite variations in
institutions and families, (b) a dose–response effect observed for
time in the orphanage, and (c) intervention studies demonstrating
profound improvement in children’s development when the insti-
tutional environment is improved (St. Petersburg-USA Orphan-
age Research Team, 2008) or when children are randomly
assigned to foster care (Bakermans-Kranenburg, van IJzendoorn,
& Juffer, 2008; Nelson, Furtado, Fox, & Zeanah, 2009).
SPECIFIC DEVELOPMENTAL PROBLEMS AND ISSUES
Researchers have studied several specific issues with particular
vigor because of their broader theoretical and practical implica-
tions.
Attachment and Indiscriminate Friendliness
Although much of the literature is descriptive, attachment theory
has provided theoretical guidance regarding the long-term effects
of early social-emotional and relationship deficiencies that most
institutionalized children experience (Bakermans-Kranenburg
et al., 2011). Indeed, six studies (Bakermans-Kranenburg et al.,
2011) assessing the attachment of institutionalized children to
their favorite caregiver using the Strange Situation Procedure or
modifications of it indicate that on average 73% of institutional-
ized children display insecure disorganized attachment behavior:
an incoherent (fear without solution) strategy to separation and
reunion with an attachment figure (Main & Hesse, 1990). This is
not surprising given the typically neglectful environments and
the lack of sensitive, responsive interactions with changing and
inconsistent caregivers that most of these children experience.
Children living in institutionalized settings also show more
indiscriminate friendly behavior than noninstitutionalized chil-
dren (Bakermans-Kranenburg et al., 2011). Apprehension about
strangers is the norm for family-reared children, whereas a
friendly approach to any adult willing to pay attention may
enhance institutionalized children’s chances of being cared for
and actually promote positive caregiving (Chisholm, 1998). How-
ever, PI children who are adopted then present a more compli-
cated picture (Bakermans-Kranenburg et al., 2011). Although
most PI children become attached to their adoptive parent, some
are simultaneously indiscriminately friendly to strangers (Bruce,
Tarullo, & Gunnar, 2009; Rutter, et al., 2007). It is unclear why
indiscriminately friendliness persists in some PI children but not
others.
Psychosocial Growth Failure
It is not widely appreciated that inadequate social-emotional and
caregiver–child relationship environments can produce deficien-
cies in physical growth, a phenomenon called psychosocial
growth failure (Johnson & Gunnar, 2011). This phenomenon is
supported by evidence that children in institutions that appar-
ently provide adequate general nutrition and medical care are
nevertheless undersized, and children show substantial catch-up
growth when they leave the institution, especially before
1–2 years of age (van IJzendoorn et al., 2007). Further, it is pos-
sible to improve growth by improving the psychosocial environ-
ment of the orphanage without changing nutrition (St.
Petersburg-USA Orphanage Research Team, 2008) or by provid-
ing foster care in a randomized trial (Johnson et al., 2010).
But psychosocial growth failure does not mean that nutrition is
irrelevant to institutional children’s development. Even in
orphanages that provide adequate macronutrients, children may
be undernourished in specific elements through dietary insuffi-
ciency or infection with parasites that diminish absorption or
promote loss (Johnson & Gunnar, 2011). For example, iron defi-
ciency can persist even after an adoptive family switches the
child to a nutritious diet because of high iron demands for
expanding red blood cell mass to accommodate catch-up growth.
Thus, children with psychosocial growth failure may also experi-
ence relatively prolonged iron deficiency, which opens the possi-
bility of associated cognitive and behavioral deficiencies. Other
micronutrients critical for brain development, such as zinc,
copper, selenium, and iodine, could be implicated in similar
scenarios but are as yet understudied.
Another apparent consequence of psychosocial deprivation in
PI girls and to a lesser extent in boys is much higher rates of
early puberty (Johnson & Gunnar, 2011), even when compared
to non-PI children of the same ethnicity (Teilmann et al., 2009).
No studies have compared PI girls who experience early versus
typical menarche and their longer term behavioral problems.
However, among non-PI girls in Western cultures, early puberty
is related to higher rates of mental health problems, especially
depression, earlier sexual activity, and more externalizing symp-
toms—all characteristics that occur at higher rates among PI
children.
Neurobiological Costs of Institutionalization
Recent studies have looked at PI children from a neurobiological
perspective (Nelson, Bos, Gunnar, & Sonuga-Barke, 2011), and
the neurobiological evidence at least parallels the behavioral
outcomes observed at higher rates in PI children.
Specifically, there is less metabolic, physiological, and neuro-
chemical activity in the brains of PI children in middle child-
hood than in family-reared children, and there is abnormal
development of the prefrontal cortex and amygdala. These
regions are typically associated in non-PI children with higher
cognitive functions, memory, and emotion, and some studies
show that PI children with these brain deficiencies tend to have
mild impairments of impulse control, attention, and social rela-
tions. These deficiencies may also be related to PI children’s
problems in inhibitory control, emotional regulation, and execu-
tive functioning, especially connecting separate aspects of the
Child Development Perspectives, Volume 6, Number 2, 2012, Pages 174–180
176 The Leiden Conference

environment in thought (Nelson et al., 2011). For example, the
amygdala is sensitive to early negative or stressful experiences,
such as abuse and neglect, and an atypical amygdala might be
related to diminished or more extreme emotional responses to
stress and threat, which in turn might underlie a variety of inter-
nalizing and externalizing behavior problems that tend to be in-
tercorrelated (Hawk & McCall, 2011).
Sensitive Periods
A central question is whether there is a sensitive age period
during which exposure to a deficient institution produces the max-
imum developmental damage (Zeanah, Gunnar, McCall, Krepp-
ner, & Fox, 2011). Of course, it is impossible to conduct the
crucial experimental studies, and most children enter the institu-
tion at a very early age and leave at varying ages, which con-
founds time in the institution with specific ages and total duration
of exposure. Consequently, there is no way to answer the question
definitively, but exposure for several months during the first
2 years of life is potentially sufficient to produce the higher rates
of long-term problems common to PI children.
At least two lines of evidence converge on this proposition
(Zeanah et al., 2011). First, substantial research shows that long-
term problems are more frequent in PI children who are adopted
at older ages, and conversely, developmental catch-up and devel-
opmental improvements are greater when children transition to
families earlier. Second, in several studies that have investigated
children adopted at several different ages during the first 3 years
of life, a variety of long-term adverse outcomes—multiple prob-
lems and problems with behavior, executive functioning, and
social skills—have been shown to be a step function of age at
adoption. That is, children adopted at ages before the step have
the same rates of problems as family reared never-institutional-
ized children; then rates of problems increase precipitously, and
the rates do not increase further with longer exposure to the
institution.
However, the age at which the step occurs depends on several
factors, including the severity of the orphanage experience and
the specific outcome variable and its measurement. Children
adopted from the severely and globally depriving Romanian
orphanages in the 1990s show a step-like increase in risk for mul-
tiple long-term problems when they are approximately 6 months
old (Kreppner et al., 2007; Stevens et al., 2008). Children from
psychosocially depriving Russian orphanages have a step function
around the age of 18 months for several parent-reported problem
behaviors, executive functioning, and social skills that are usually
reported for adolescents (Hawk & McCall, 2011; Julian, 2010;
Merz & McCall, 2010a, 2010b). For children adopted from various
countries including a large number from China (thought to be from
better circumstances), the step function may occur around the
second birthday (Gunnar et al., 2007; Merz & McCall, 2010a).
Furthermore, studies suggest that children first entering the
orphanage after 2 years of age may have fewer such problems
(Lee, Seol, Miller, Sung, & Minnesota International Adoption
Project Team, 2010; McKenzie, 1997, 2003; Vorria, Rutter, Pick-
les, Wolkind, & Hobsbaum, 1998).
Studies revealing step functions of age at adoption are individ-
ually consistent with a sensitive period hypothesis, but the
pattern between studies of a step at earlier ages the more
severely deficient the institution suggests a cumulative exposure
hypothesis and possible epigenetic interpretations. In any case,
these results imply that some duration of exposure to the institu-
tion is necessary to increase risk, but the effects may well be
observed after as little as 6 months in very severely depriving
orphanages and within the first 2 years for many other institu-
tions. This result implies that children should be transitioned out
of institutions as soon as possible, because any specific institu-
tion will not know what length of exposure is too long.
WHAT SHOULD BE DONE?
The research provides practitioners and policy makers with a
few simple and profound conclusions: (a) most institutions for
infants and young children are not supportive of children’s devel-
opment and may produce long-term, perhaps permanent impacts
on children’s brains and their physical, cognitive, and social-
emotional development; (b) these consequences can be disrup-
tive and expensive for societies; (3) every effort should be made
to avoid placing infants and toddlers in institutions in the first
place and to transition children out of institutions as early as
possible because damage can occur early and after relatively
short exposure; and (d) adoptive, foster, and other family type
arrangements are better for young children’s development than
most institutions.
There is no question that on average family care environments
are better and cheaper long-term than institutions, but efforts to
implement modern child welfare systems of family care alterna-
tives in countries that still rely on institutions face a variety of
challenges (Engle et al., 2011; Groza, Bunkers, & Gamer, 2011).
Forexample,theremaybelongstanding historical, cultural,
social, political, or religious hesitation or resistance of parents to
rear someone else’s child. This, coupled with insufficient finan-
cial means, can make it difficult to recruit enough domestic
adoptive or foster parents. Financial systems must start providing
incentives and adequate support to birth, kin, foster, and adop-
tive parents. Many children may not be eligible for family care
in some countries because they lack birth certificates or are not
legally relinquished, and adoptive or foster parents often do not
want children with special needs or disabilities and older chil-
dren, especially those with behavior problems. Nevertheless,
children are now adopted domestically at higher rates than in
the past in countries such as Brazil, India, and China, and tradi-
tionally hard-to-place children are also being taken into domes-
tic family care more frequently, such as girls in China and India
(Selman, 2009).
A burning issue of the 21st century is how to provide adequate
care to the numerous children affected by the HIV ⁄AIDS pan-
Child Development Perspectives, Volume 6, Number 2, 2012, Pages 174–180
Development and Care of Institutionally Reared Children 177

demic. Alternative solutions to institutional care, such as kinship
care, may rise to meet the challenge or fall apart when financial
resources are very limited or traditional extended family net-
works unravel because of this pandemic (Engle et al., 2011).
Further, many children in institutions have at least one parent,
but there is often a reason why that parent placed the child in
the institution, and there is often a shortage of professional ser-
vices and community-based support for such parents to keep
their children or to have children restored to them. It will likely
take many years to build the professional infrastructure to select,
train, support, and provide services to such parents.
Finally, although intercountry adoption provides excellent
homes for institutionalized children, it should be regulated
strictly and carefully according to the 1993 Hague Adoption
Convention. Under this convention, financial gains in intercoun-
try adoption and illegal child trafficking should be banned.
Importantly, to safeguard increasing possibilities for domestic
family care alternatives, the subsidiarity principle should be fol-
lowed. This principle implies that a country’s first priority is to
try to place the child in the birth family or in kinship care, and if
that is not possible, in domestic adoption, foster care, or kaffala
(Islamic guardianship). Only when a family cannot be found
within the country does intercountry adoption become an accept-
able alternative.
In practice, if a country has substantial political will, leader-
ship, and financial resources; a well-conceived, long-term plan;
and few of these challenges, it should be able to develop and
implement a professional child welfare system of family care
alternatives in a few years. Even so, sometimes progress can be
slow. Ukraine, for example, had the political will, administrative
commitment, and resources, but after 5 years of intensive effort,
only 5,000 children had been placed in foster care while 45,000
children remained in orphanages (Groark, McCall, & Li, 2009).
Thus, in many countries, large numbers of children are likely
to remain in institutions for the foreseeable future, even when
there is progress toward creating family care alternatives. Fur-
ther, older children and children with disabilities or HIV ⁄AIDS,
who are often less preferred by parents, are likely to constitute an
increasing proportion of the remaining institutional population.
Of course, research shows that it is possible to improve institu-
tions and increase the development of both typical children and
those with disabilities (St. Petersburg-USA Orphanage Research
Team, 2008). Advocates, however, think that improving institu-
tions sometimes represents a simpler solution for a country than
developing a comprehensive child welfare system and would
divert attention and funds from developing family alternatives
that are more in the children’s best interest. But, importantly,
because family care alternatives are generally cheaper, the
savings could be used to improve the institutions in which the
remaining children live. In the end, each country will need to
develop a system consistent with its own values, resources, cul-
ture, and practices, and some countries and nongovernmental
organizations have developed rather unique approaches to solv-
ing this issue (Engle et al., 2011; Groza et al., 2011).
The research convincingly suggests that infants and young
children either should not be placed in institutions or should be
removed from them as early as possible. Nations would do best
for these children and their societies to develop community-
based services to support birth parents and their extended
families to keep their children while modernizing child welfare
systems to create alternative family care environments such as
foster care, kaffala, and adoption. However, it is likely that
developing a system of family care will take time and that many
children will remain in institutions for some years. Thus, coun-
tries should improve the institutions for infants and young chil-
dren while simultaneously aiming to improve family care and
other rearing for children of all ages and genders, with and with-
out disabilities, and all racial-ethnic origins.
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