Review

The science of early adversity: is there a role for large

institutions in the care of vulnerable children?
Anne E Berens, Charles A Nelson

Lancet 2015; 386: 388–98 It has been more than 80 years since researchers in child psychiatry first documented developmental delays among
Published Online children separated from family environments and placed in orphanages or other institutions. Informed by such
January 29, 2015 findings, global conventions, including the 1989 UN Convention on the Rights of the Child, assert a child’s right to
http://dx.doi.org/10.1016/
S0140-6736(14)61131-4
care within a family-like environment that offers individualised support. Nevertheless, an estimated 8 million children
are presently growing up in congregate care institutions. Common reasons for institutionalisation include orphaning,
See Editorial page 312
abandonment due to poverty, abuse in families of origin, disability, and mental illness. Although the practice remains
Harvard Medical School,
Boston Children’s Hospital,
widespread, a robust body of scientific work suggests that institutionalisation in early childhood can incur
Boston, MA, USA developmental damage across diverse domains. Specific deficits have been documented in areas including physical
(A E Berens MSc, growth, cognitive function, neurodevelopment, and social-psychological health. Effects seem most pronounced when
C A Nelson PhD); and Harvard
children have least access to individualised caregiving, and when deprivation coincides with early developmental
Center on the Developing Child,
Harvard Graduate School of sensitive periods. Offering hope, early interventions that place institutionalised children into families have afforded
Education, Cambridge, MA, substantial recovery. The strength of scientific evidence imparts urgency to efforts to achieve deinstitutionalisation in
USA (Prof C A Nelson) global child protection sectors, and to intervene early for individual children experiencing deprivation.
Correspondence to:
Prof Charles A Nelson, Harvard Introduction been enlisted in various roles to serve armed forces
Center on the Developing Child,
Harvard Graduate School of
Societies have always faced the question of whether and worldwide.6 What might the science of early development
Education, Cambridge, how to care for children who do not have access to a safe tell us about appropriate strategies to meet the needs of
MA 02138, USA family environment; however, absolute numbers provided these children?
charles.nelson@childrens.
by reports suggest the question has arguably never been In 1915, JAMA published an article entitled “Are
harvard.edu
larger. The UN’s 2006 World Report on Violence against institutions for infants really necessary?”,7 in which the
Children1 estimates that 133–275 million children every author made a simple claim that children do best in family
year witness violence between primary caregivers on a environments. It states, “Strange to say, these important
regular basis, whereas at least 150 million girls and conditions have often been overlooked, or, at least, not
73 million boys are victims of forced sexual activity.1 sufficiently emphasised, by those who are working in this
Among the most vulnerable are “children outside of field”.7 Following the publication of this article nearly a
family care”.2–4 UNICEF estimates that up to 100 million century ago, scientific studies began to document stunted
children live on the street, while 1·2 million are victims of cognitive, social, and physical development among
sex and labour trafficking;5 the UN’s 2007 Paris Principles children placed in institutions during key developmental
on Children Associated with Armed Forces or Armed Groups years.8–12 In 1989, the UN Convention on the Rights of the
estimates that “hundreds of thousands” of children have Child13 (endorsed by nearly all countries, although not in
the USA) drew upon scientific findings to generate
international normative standards, asserting that “the
Search strategy and selection criteria child, for the full and harmonious development of his or
We searched multiple databases including PubMed and her personality, should grow up in a family environment,
Medline, Embase, PsycINFO, and the Cochrane Library for in an atmosphere of happiness, love, and understanding”.
articles published in English, French, Spanish, or Portuguese. Despite strong rhetoric and evidence, the practice of
Emphasis was placed on articles published since 2005, raising children in large institutions persists in every
although older relevant earlier articles were not excluded but region of the world, with estimates suggesting that at least
interpreted accordingly. We used MeSH terms on the exposure 8 million children worldwide are now growing up in
of interest “orphanage” or “institutionalisation”, in institutional settings.14 In some locations, the practice even
combination with outcomes of interest “human development” seems to be increasing. For example, in 2004, the Chinese
(which included prenatal, perinatal, infant, child, and Government launched the construction of new large-scale
adolescent development) or “psychosocial development”, as orphanages to house children who had lost parents to
well as numerous free search terms on outcomes including HIV/AIDS.15 The question remains: is the global child
“IQ”, “intelligence”, “cognition”, “social”, “emotional”, protection community still inadequately prioritising core
“psychological”, “child development”, “child behaviour”, developmental needs for individualised caregiving in
“neurodevelopment”, and others. Additional sources were family-like environments?
drawn from the references of other articles included in the In this Review, we discuss the worldwide phenomenon
Review. When necessary, we contacted key authors to make of child institutionalisation as a social strategy to raise
sure that no relevant sources were missed. children lacking access to safe family care. With
a comprehensive search strategy, we assess scientific

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evidence on the developmental effects of early institutional

care. Within this vast body of evidence, many decades of Panel 1: What makes an institution?
observational data and a recent randomised controlled A European Commission22 expert group report suggests that
trial (RCT; 2000 to present)16 document profound institutions across diverse settings tend to acquire common
developmental delay across nearly all domains among characteristics harmful to developing children. Among these
children who spend their early years in institutional care. are: depersonalisation, or a lack of personal possessions, care
Furthermore, the data suggest that there might be relationships, or symbols of individuality; rigidity of routine,
particular windows of time in early childhood, commonly such that all life activities occur in repetitive, fixed daily
termed sensitive periods, when the effects of intervention timetables unresponsive to individual needs and preferences;
are most substantial, and after which deficits become block treatment, with most routine activities performed
increasingly intractable. These findings have implications alongside many children; and social distance, or isolation
for policy and practice that aim to care for vulnerable from extra-institutional society.
children worldwide while protecting them from the worst
forms of institutionalisation.
Inevitably, facilities termed institutions are highly
Global child institutionalisation diverse. The US federal Adoption and Foster Care
Significance Analysis and Reporting System (AFCARS) designates
Findings on the effects of early institutionalisation might institutions as substitute care facilities that house more
yield broader insights into the developmental effects of than 12 children,18 and similarly small institutional
early deprivation and adversity. Children growing up in homes have been studied in South Africa and elsewhere.19
institutions represent a small share of the much larger However, many international institutions are much
number of children who need protective services. Yet the larger, with populations in the hundreds.20 Yet even
experiences of these children might offer more general within this diversity, the Eurochild working group21 notes
insights about the effects of early psychosocial deprivation. an empirical tendency for institutions to acquire some
These insights, in turn, have relevance to our under- shared and fundamentally depriving characteristics,
standing of the more globally prevalent problem of including a tendency to isolate children from the broader
child neglect. Indeed, in the USA, 2012 data from the social world and an inability to offer the consistent and
Department of Health and Human Services documented personalised caregiver attention thought to underlie
that 78·3% of children receiving child protective services healthy social and emotional growth (panel 1). Some
were victims of neglect, more than the percentages of deem these empirical findings inherent to institutional
children experiencing physical, sexual, psychological, and care. In a report in 2007, UNICEF22 quoted disability
medical abuse combined.17 Research presented here on the rights activist Gunnar Dybwad stating that: “four decades
developmental effects of early psychosocial deprivation in of work to improve the living conditions of children with
institutions could also lend insight to spur future work on disabilities in institutions have taught us one major
neglect and development more broadly. It might also lesson: there is no such thing as a good institution”.
suggest that societies still relying on large institutions are
failing to grasp core needs that must inform child Counting unseen children
protection strategies more generally. Efforts to quantify and describe worldwide child
institutionalisation are limited by the scarcity of high-quality
Definition of child institutionalisation data. In 2009, UNICEF23 documented more than 2 million
In the context of this Review, an institution is defined as institutionalised children aged 0–17 years using available
any large congregate care facility in which round-the-clock data, a figure that they assert “severely underestimates” the
professional supervision supplants the role of family-like actual scale of child institutionalisation. They suggest a
caregivers. Institutions might house children having no handful of reasons for underdocumentation. For example,
family care for reasons of orphaning, abandonment, or many institutions are unregistered, while under-reporting
abuse, in addition to children with disabilities, mental or is widespread and many countries do not routinely collect
physical illness, or other special needs. This Review or monitor data on institutionalised children. UNICEF23
excludes settings that could be deemed hospitals or also notes increasing child institutionalisation in settings
medical facilities for disorders that need continual of economic transition and severe poverty where
specialist care—although it should be noted that monitoring capacity might be weaker. The UN’s World
advocates of deinstitutionalisation in various medical Report on Violence against Children1 cites an estimate of
fields call for the political and social support needed to 8 million institutionalised children aged between 0 and
make home-based and community-based care feasible 17 years, although it again notes that undercounting and
for a wider range of children.18 Drawing on the definition limited monitoring suggests that the actual figure could
used by UNICEF, this Review defines childhood as the be far higher.
period from 0 to 17 years of age and early childhood as Child institutionalisation has received the most attention
the period from 0 to 8 years of age. in former Soviet states, where prevalence of this practice is

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thought to be greatest. UNICEF reports that in 2009, However, various sources suggest substantial rates of
slightly more than 800 000 children younger than 18 years institutionalisation in settings in which data are scarce.
were reported to be living in institutions in central and In Latin America and the Caribbean, one detailed public
eastern Europe and the Commonwealth of Independent sector report has emerged from Brazil,27 where the
States (CEE/CIS)—more than any other region.23 In 2002, government reported providing public funding to more
a non-governmental organisation (NGO) sector survey24 of than 670 institutions housing about 20 000 children as of
institutions in 20 eastern European and former Soviet 2004. Meanwhile, many other informal, private, and
countries estimated roughly 1·3 million institutionalised NGO institutions exist without government funding.27
children younger than 17 years of age—more than twice In Asia, the Chinese Government has been building
the officially reported figure of 714 910. The report also institutions for children orphaned by HIV/AIDS since
notes that the 13% decrease in child institutionalisation in 2004.15 News reports of a deadly fire in a private orphanage
these countries since the fall of the Soviet Union fails to in central China have drawn attention to the existence of
account for concurrent plummeting birth rates; the rate of unregulated institutions in the country.28 In sub-Saharan
institutionalisation per livebirth has risen by 3% in the Africa, where an estimated 90% of orphans and
20 surveyed countries.24 vulnerable children are cared for by extended family
The practice of child institutionalisation extends far members,29 some reports note a rise in institutional care
beyond the former Soviet Union. Indeed, UNICEF because family networks are overburdened and some
reports that the country group with the second largest donor funding for Africa’s perceived orphan crisis flows
number of documented institutionalised children (just into institutional care facilities.30
over 400 000) is the 34 most developed countries of
the Organisation for Economic Co-operation and Drivers of institutionalisation
Development (OECD).23 Looking at the whole of Europe, Although worldwide data are scarce, findings from a
researchers from the University of Birmingham 2005 EU survey indicate distinct drivers of
compiled results from a survey of 33 European countries institutionalisation across developed and less-developed
(excluding Russian-speaking countries) done by the countries. In EU states classified as developed (Belgium,
WHO Regional Office for Europe and data from the Denmark, France, Greece, Portugal, and Sweden),
UNICEF Social Monitor and documented a total of abuse or neglect was the most prevalent reason for
43 842 (about 1·4 per 1000) children aged between 0 and institutionalisation (69% of children), with a small
3 years housed in institutional care.25 The highest rates of proportion institutionalised owing to abandonment
early childhood institutionalisation was reported in (4%) or disability (4%). However, in EU countries
Bulgaria (69 in 10 000 children), Latvia (58 in 10 000), and undergoing economic transition (Croatia, Cyprus,
Belgium (56 in 10 000). France (2980) and Spain (2471) Czech Republic, Estonia, Hungary, Latvia, Lithuania,
were both among the top five with the greatest absolute Malta, Romania, Slovakia, and Turkey), abandonment
number of institutionalised children aged 0–3 years.25 In was the most commonly reported reason for
North American OECD states, child protection data early-childhood institutionalisation (32%), followed by
are somewhat opaque. The US Department of Health disability (23%), with a somewhat smaller proportion
and Human Services reports that on Sept 30, 2011, attributed to abuse or neglect (14%) or orphaning (6%).
9% (34 656) of the 400 540 children in public care in the In both settings, roughly a quarter of children were
USA were living in settings defined as institutions.26 institutionalised for “other” reasons.31 Notably, there
Notably, some institutions represent small residential might be much overlap between abandoned and
care homes for children with medical and psychological disabled children in settings of stigma against disability,
needs, quite distinct from large institutions described or in countries in which there is little structural support
elsewhere. The figure provided also does not capture for families to meet special needs. Further data for
whether institutional placement was temporary or causes of institutionalisation have emerged from Brazil,
sustained. Despite scarce numbers, the report indicates where a survey of 589 publicly funded institutions
that a significant institutionalisation problem remains in suggests a pattern similar to that seen in EU countries
the USA. in economic transition. Abandonment, whether due
In much of the rest of the world, UNICEF’s best to poverty (24%) or “other reasons” (18%), was the
available data are limited and uncertain. A 2009 report by most frequently cited reason for institutionalisation,
UNICEF states that “numbers in the Latin America/ with lesser shares attributed to abuse or orphaning.
Caribbean, Middle East/north Africa, eastern/southern Thus, what little data exist suggest that drivers of
Africa, and east Asia/Pacific regions are likely to be institutionalisation differ with societal variables such as
highly underestimated due to the absence of registration poverty levels.
of institutional care facilities”, with rough estimates from A diverse range of characteristics might make some
official reported figures for each region ranging from children more vulnerable to institutionalisation than
150 000 to 200 000. No estimates were made for west or others. Notably, few children who are institutionalised fit
central Africa and south Asia due to “lack of data”.24 the common cultural conception of an orphan—ie, a child

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who has lost both parents (what UNICEF defines as a

double orphan). In 2003, data from 33 European countries Panel 2: Children at risk
suggested that 96% of institutionalised children had As evidenced by data for “drivers of institutionalisation”
one or more living parents.31 However, many of these at national and regional levels, key risk factors for
children might still meet the UN definition of orphanhood, institutionalisation include poverty, loss of a parent, and the
which also includes single orphans (who have lost only experience of child abuse. Yet various additional
one parent). In 2011, Belsey and Sherr32 provided an characteristics might put children at heightened risk, many
excellent discussion on the need for more careful representing markers of social inequality and vulnerability.
differentiation of maternal versus paternal and single UNICEF notes that the institutionalisation of millions of
versus double orphans to characterise patterns disabled children globally currently violates the Convention
of vulnerability.32 Importantly, most orphans are not on the Rights of Persons with Disabilities22 whereas European
institutionalised. Most of the 151 million orphans mental health professionals call attention to the “overuse” of
worldwide identified by UNICEF in 2011 remain in family institutional care for mentally ill children in post-communist
care.33 In sub-Saharan Africa, even orphans who have lost countries, as well as for many vulnerable European children
both parents to AIDS (double orphans) receive care from without mental illness.25 In settings of stigma, children with
extended family in 90% of cases.29 Nevertheless, despite a HIV might be especially vulnerable. Additional data suggest
need for more and clearer data, orphans seem to remain higher rates of institutionalisation in Roma children from
more vulnerable to institutionalisation than do Romania24 and among children of African descent in Brazil.27
non-orphans in many settings, and various other markers Institutionalisation remains a multifactorial problem
of social and economic vulnerability could put children at affecting children from various backgrounds.
further risk (panel 2).

Developmental costs of institutionalisation institutionalised as older children or adolescents are scarce

The prevalence of child institutionalisation worldwide is (for a recent exception, see Whetten and colleagues39). This
alarming in view of scientific evidence for the developmental summary of key findings most clearly shows the effects of
risks of institutional care. For more than 80 years, institutionalisation in early childhood (very early childhood
observational studies have shown severe developmental institutionalisation). Yet, looking only at the first 3 years of
delays in nearly every domain among institutionalised life is highly illustrative given a broader child development
children compared with non-institutionalised controls. literature describing the existence of sensitive periods in
Contemporary meta-analyses have reported significant the first months and years of life, in which children are
deficits in intelligence quotient (IQ),34 physical growth,35 especially vulnerable to the vagaries of their environments
and attachment36 among institutionalised and post- (figure 1, figure 2).
institutionalised children from more than 50 countries.
The Bucharest Early Intervention Project (BEIP)16 provided Physical growth
the first RCT data comparing longitudinal outcomes Children in institutional care worldwide consistently show
among young institutionalised children (younger than growth suppression, with specific deficits such as
2 years at baseline) randomised into high-quality foster care decreased weight, height, and head circumference.35,40
(n=68) to outcomes among those remaining in Romanian Proposed mechanisms include nutritional deficiency,
state institutionalised care (n=68). The study is limited by prevalent illness, low birthweight, and adverse prenatal
its contextual specificity since it examines only institutions exposures. Notably, paediatric HIV infection, which can
in Bucharest; nevertheless it offers the strongest evidence cause growth suppression if inadequately treated, is
to date that institutional care has a causal effect on rates of thought to be more prevalent among institutionalised
developmental deficits and delays. This evidence counters children than among community-based peers in many
critics who have long claimed that delays among settings.41 For instance, although figures likely in part
institutionalised children merely reflect the risk factors reflect uneven detection, in 1990 following the fall of
(poverty, perinatal deprivation, and higher rates of illness) Romania’s Ceaușescu regime, 62·4% of all HIV infections
that resulted in their institutionalisation in the first place.37 in the country were in institutionalised children.42 The
As such, we will draw significantly upon its findings. persistence of growth deficits among institutionalised
In 2007, the English-Romanian Adoptees (ERA) Study38 children after controlling for variables such as disease
published detailed results through to 17 years of age on the burden and nutrition have led researchers to posit that
developmental outcomes of 144 children who were adopted children experience some amount of psychosocial growth
to the UK from Romanian institutions before the age suppression, or stunting; this phenomenon is thought to
of 2 years. The outcomes were compared with those of result from stress-mediated suppression of the growth
never-institutionalised domestic adoptees from the UK, hormone/insulin-like growth factor 1 (GF/IGF-1) induced
with analysis indicating persistent developmental deficits by the institutional environment.43 Additionally, decreased
associated with institutional care experienced past head circumference among neglected children could arise
6 months of age. Unfortunately, studies of individuals from an excess of neural pruning in response to

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 Review

95% CI 0·82–2·60).35 A review by Johnson estimated that

infants and toddlers lose 1 month of linear growth for
every 2–3 months spent in an institution.46
The ERA study47 noted that institutionalised Romanian
adoptees had a mean head circumference and height that
was more than 2 standard deviations below the mean for
age-matched children in the general UK population, and
51% (55 of 108 children) of the adoptees were below the
third percentile for weight at the time of entry to the UK.
Longitudinally, more complete catch-up in height and
weight was reported in children removed from
institutions before 6 months of age compared with
children removed after 6 months at age. Similarly,
children in the younger than 6 month group showed
significantly reduced head circumference at 11 years of
age if they were undernourished (t[30]=10·12, p<0·001),
but not if they were of normal weight (t[16]=1·74, p=0·10).
By contrast, children older than 6 months had reduced
circumference irrespective of nutritional status.45 At
Figure 1: Children in a state-run institution in Bucharest, Romania 15 years of age, a greater reduction in head circumference
Photograph courtesy of Michael Carroll.
was significantly and independently related to duration of
institutionalisation (n=196, b=–0·895, p<0·001).48 Using a
randomised controlled trial design, the BEIP49 reported
similar patterns in which placement of institutionalised
children into foster care produced better recovery in
height and weight than in head circumference. Among
predictors of poorer catch-up in height and weight was
removal from institutional care after 12 months of age
(Z=−1·13[0·49], p<0·05 for height; Z=−1·79[0·57], p≤0·01
for weight). Further indicating the importance of these
findings, Johnson and co-workers reported that greater
catch-up in height was a significant independent predictor
of a greater increase in verbal IQ.49

Cognitive functioning
IQ has been the most studied developmental outcome.
In 2008, a meta-analysis assessed the effects of
institutionalisation on IQ (or development quotient [DQ]
for infants) in data from 42 studies of more than
3888 children in 19 countries. Institutional care, when
Figure 2: Sleeping quarters in a state-run institution in Bucharest, Romania
compared with family-based care, had a significant
Photograph courtesy of Michael Carroll. combined effect size on IQ/DQ of d=1·10 (95% CI
0·84–1·36, p<0·01), with variable age at assessment.
under-stimulation.44 Supporting this contention, the ERA Mean IQ or DQ in children exposed to early institutional
study noted that duration of deprivation longer than care was 84·40 (SD 16·79, n=2311, k=47), which was more
6 months among its 144 participants was associated with than a full SD lower than the mean (104·20) of the
smaller head circumference independent of nutritional age-matched controls (SD 12·88, n=456, k=16). Again,
status.45 In 2007, a meta-analysis to quantify growth deficits early age at time of exposure to institutional care was
reported a combined effect size of exposure to institutional associated with greater effects on IQ or DQ of the children.
care on height of d=–2·23 (95% CI –2·62 to –1·84) among Young children institutionalised during the first
2640 children in regions including eastern Europe, South 12 months of life had significant deficits in IQ/DQ when
America, and Asia. However, the variable age of the compared with family-raised peers; this difference was
children at assessment complicates interpretation. Within also significantly larger than that observed when
this same study, meta-analysis of a subset of 893 children comparing children placed in institutions after 12 months
(eight studies) removed from institutions before 3 years of with children raised in families ([d=1·10, k=24, and
age found that longer duration of institutionalisation was d=–0·01, k=9] Q[df=1]=13·00, p<0·001). Interestingly,
associated with more substantial height deficits (d=1·71, longer total stay in institution was not associated with a

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significantly greater effect on IQ/DQ; at least in these mean age 10·7, range 2·8 years) in models including age
studies, timing of exposure had a more significant effect and sex as a covariate when significant. Importantly, in an
on later cognitive outcomes than did length of exposure.34 attempt to isolate the effects of institutional exposure per
Differences in caregiver–child ratios between the se from confounding risks, children were excluded from
institutions were not particularly related to differences in the post-institutionalised group for reasons including
effect sizes for IQ, even when comparing the worst subset history of premature birth, prenatal or perinatal
of ratios to the best.34 difficulties, major current or historical medical illnesses,
Since 2008, additional data have proved consistent with or evidence of intrauterine alcohol or drug exposure.
earlier findings. The ERA study reported significantly Despite the small size of this study and absence of
lower IQ at time of adoption among adoptees to the UK age-matched and sex-matching of controls, it provides
from Romanian institutions compared with age-matched indication of deficits warranting further research.58
adoptees from within the UK. However, by age Another diffusion tensor imaging study reported more
11 years, post-institutionalised children adopted before pervasive connectivity deficits in children previously
6 months of age had IQs statistically equivalent to institutionalised in Eastern Europe (n=10) or central Asia
never-institutionalised UK adoptees, whereas children or Russia (n=7). Unfortunately, countries are not provided.
removed after 6 months remained significantly behind.50 Significantly decreased fractional anisotropy was noted in
IQ at age 11 years was significantly and independently frontal, temporal, and parietal white matter (including
affected by duration of institutionalisation (F=29·15, parts of the uncinate and superior longitudinal fasciculi)
p=0·001) and by undernutrition (F=9·58, p=0·002).45 The compared with age-matched controls. Among other
BEIP noted significantly marked cognitive deficits findings, white matter abnormalities (measured by
among institutionalised children at baseline (n=124, age reduced functional anisotropy) in the right uncinate
<2 years), who had a mean DQ of 74·26, which was fasciculus were significantly correlated with duration of
29 points, or more than two standard deviations, below institutionalisation (R=0·604, p=0·01) and with both
the mean for age-matched and sex-matched peers from inattention (R=0·499, p=0·004) and hyperactivity scores
families in the community (n=66, DQ=103·43, p<0·001).51 (R=0·504, p=0·004).59
During follow-up, the study reported significant Other studies used MRI to assess volumetric differences.
differences between children randomly assigned to One such study examined 31 adoptees who had mean age
remain in institutional care and those assigned into 10·9 years (SD 1·63) at the time of assessment who were
foster care, with an effect size of 0·62 at 42 months adopted as toddlers from institutions in Romania, Russia,
(t[116]=3·39, p=0·001) and 0·47 at 54 months (t[108]=2·48, and China. Smaller superior–posterior cerebellar lobe
p=0·015). While results at 8 years were less robust, volumes, and poorer performance on memory and
probably because of movement of children between executive function tasks were reported in these children
care settings, early foster care placement remained compared with age-matched, typically developing
significantly predictive of a pattern of stable, typical IQ controls.60 Meanwhile, reported effects on volume of the
scores over time.52 amygdala, a region supporting emotional learning and
Although in-depth examination of more detailed reactivity, have been inconsistent. Some investigators have
cognitive function testing is beyond the scope of this reported significant increases in amygdala volume and
Review, many studies have documented a significant activity in institutionalised children compared with
effect of institutionalisation on delays in specific never-institutionalised controls.61,62 Among these two
domains of cognitive functioning including memory, studies, Tottenham and colleagues61 reported that an
attention, learning capacity and, perhaps most increase in amygdala volume was significantly associated
importantly, executive functions.38,53,54 Several groups with older age of deinstitutionalisation after adjusting for
reported persistent deficits in several domains of current age (r[31]=0·54, p<0·001), as was lower IQ
executive function despite removal from institutional (R[32]=0·34, p<0·05). The other study by Mehta and
care and placement into a family.54–57 colleagues62 found that the overall larger amygdala size was
dominated by effects on the right amygdala, and that
Brain characteristics longer period of institutionalisation was actually associated
Several investigators reported signs of decreased with smaller volume in the left amygdala.62 By contrast, the
connectivity between areas supporting higher cognitive BEIP study63 reported no difference, whereas Hanson and
function among children exposed to early institutional colleagues64 noted a significant reduction in amygdala
care. A small diffusion tensor imaging study recorded volume in institutionally deprived children. Further work
significantly reduced fractional anisotropy in the left is needed to clarify the potential role of this region in
uncinate fasciculus of children placed in Romanian mediation of neurodevelopmental effects of deprivation.
institutions at birth and removed between 17 and Considering prospects for volumetric recovery after
60 months of age (five girls and two boys; mean age 9·7; deprivation, BEIP researchers noted partial catch-up
range 2·6 years at testing) compared with family-reared, in white matter volume by age 11 years among children
typically developing controls (four girls and three boys; randomised into foster care compared with community

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attachment style classified as insecure-other among

Panel 3: Sensitive periods in child development formerly institutionalised children, a style characterized
BEIP researchers used electroencephalograms (EEG) to compare institutionalised by atypical, non-normative, age-inappropriate behaviour
children with community controls before randomisation (baseline). They found that (eg, strong approach and attachment maintenance with
institutionalised children had significantly greater slow-frequency (theta) activity— strangers, extreme emotional over-exuberance, nervous
associated with less developed brains—and less high-frequency (alpha/beta) activity excitement, silliness, coyness, or excessive playfulness
indicative of neural maturation. By age 8 years, remarkable evidence of intervention with parent and stranger alike). This insecure-other
timing effects emerged. Children in the foster care group who had been removed from style was seen in 51·3% of children adopted out of
institutions before the age of 2 years displayed a pattern of brain activity Romanian institutions after 6 months of age, compared
indistinguishable from the never-institutionalised group of community controls, with with only 38·5% of children adopted from institutions
higher mature alpha activity and lower less mature theta activity. Children in the before 6 months of age and 16·3% of children adopted
foster care group placed after 24 months of age had the opposite pattern, and indeed from within the UK. Follow-up at ages 6 and
remained indistinguishable from children assigned to remain in institutional 11 years showed that insecure attachment significantly
care-as-usual group (CAUG). These findings suggest that there might be a sensitive predicted rates of psychopathology and social service
period for the development of neural structures underlying increased alpha power in use.73 BEIP researchers reported that children
the EEG signal. For figure see Vanderwert and colleagues.66 randomised into foster care had significantly higher
scores on a continuous measure of attachment security
at age 42 months compared with children remaining in
controls; no white matter volume catch-up was seen in institutions. These higher scores were also seen in both
children assigned to standard institutional care. Foster girls (F[1,61]=31·2, p<0·001) and boys (F[1,61]=7·8,
care intervention did not seem to have an effect on total p=0·007). Secure attachment predicted significantly
cortical volume and total grey matter. MRIs done once in reduced rates of internalising disorders in both sexes.
children aged 8–11 years old showed reduced size In girls, the protective effect of secure attachment fully
compared with community controls, with no significant mediated the effects of foster care intervention on rates
gains compared with children assigned to stay in of internalising disorders.74
institutions. These findings suggest that foster care Additional work has examined emergent psycho-
intervention had a slightly beneficial effect on white but pathology in post-institutionalised children. The ERA
not grey matter.63 study75 reported that by mid-childhood, children who had
In addition to connectivity and size, some studies have been adopted into UK homes after 6 months of age
investigated neural function. Tottenham and colleagues65 frequently displayed what Rutter and colleagues75 term
used functional MRI to compare 22 adoptees from “institutional deprivation syndrome”, proposed to be a
east Asian and eastern European institutions to novel constellation of impairments including inattention
never-institutionalised controls aged about 9 years. When or hyperactivity, cognitive delay, indiscriminate friend-
shown faces expressing fear, previously institutionalised liness, and quasi-autistic behaviours. In a study of
children showed greater activity in the emotion-processing children still living in Romanian institutions, Ellis
region of the amygdala (consistent with observations and colleagues76 noted that longer duration of
of structural change) and corresponding decreases in institutionalisation was significantly associated with
cortical regions devoted to higher perceptual and anxiety or affective symptoms (F[3,47]=6·49, p<0·01). A
cognitive function. Changes in electroencephalogram potential difference in patterns of psychological disorders
findings in institutionalised children were recorded in might exist between boys and girls. BEIP researchers
the BEIP. Foster care placement had a beneficial effect noted that at 54 months of age, girls in foster care had
on neural function, and it was reported that age at family fewer internalising disorders (eg, depression and anxiety)
placement made the difference between complete than girls remaining in institutions (OR 0·17, p=0·006),
recovery and unabated impairment (panel 3).66 whereas intervention effect on internalising disorders in
boys was not significant (OR 0·47, p=0·150), despite
Social-emotional and psychological development significant effects on other measures of psychological
In the domain of social-emotional development, studies wellbeing.74 Again, this reduction in anxiety and
have largely focused on documenting unfavourable depression in girls was significantly mediated by
attachment patterns, which are believed to be associated attachment security, which predicted lower rates of
with later psychopathology and behavioural difficulties. internalising disorders in both sexes.77
Increases in insecure or disorganised attachment (the
style most predictive of later difficulties) and decreases Timing matters
in secure attachment (the most protective style) have Published work on early institutionalisation offers
been reported among children institutionalised in early consistent evidence of developmental sensitive periods,
childhood across a range of settings in countries or time periods in which experiences have especially
including Greece,67 Spain,68 Ukraine,69 and Romania.70–72 marked and durable effects on longitudinal outcomes.
The ERA study72 noted a particular predominance of an Considering the mechanism of sensitive periods in brain

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 Review

development specifically, Fox and colleagues78 noted that political resistance. BEIP researchers noted some gains in
human brains have their greatest total number of function among children randomly assigned to remain in
synapses in infancy. During development, human brains state institutions who were later moved into a new
undergo a process of pruning unused connections, while Romanian state foster care system, even though state
confirming those most stimulated to specialise to foster families received far less monitoring and support
environmental cues. The genome provides a timeframe than did BEIP families.82 While replete with their own
in which networks must be confirmed to allow challenges and pitfalls, and by no means a panacea for
development to advance.79 Children who experience an vulnerable children, there is hope that foster care
abnormally small range of social and environmental programmes in poor states undergoing economic and
stimulation might undergo excessive or aberrant political transition can confer real benefits to children.
neuronal pruning. This model explains repeated findings Yet, however clear the development literature, deinsti-
that children institutionalised during earlier months or tutionalisation remains politically and socially challenging
removed into family care later experienced worse and is fraught with pitfalls for children and professionals
impairment.34,49,50,66 Unfortunately, deprivation during alike. Institutions also, in many settings, represent staging
neurodevelopmental sensitive periods could have grounds for international adoption, a practice evoking
lifelong consequences. As discussed, early months are passionate political support and detraction across national
also important for children establishing patterns contexts and involving major social and economic
of attachment important for ongoing psychosocial interests. Institutions represent foci of economic interests
development, with similarly foundational developmental aside from the adoption processes. In December, 1998,
processes likely occurring across many domains in the institutions employed a documented 41 200 Romanians;
earliest months of life. Thus, early intervention is crucial. deinstitutionalisation therefore had profound economic
and political effects on community, at times producing
New frontiers resistance (Bogdan S, Executive Director of Solidarite
Advances in cellular and molecular biology and Enfants Roumains Abandonnes; Personal communication;
neuroscience will push our understanding of the Nov 12, 2014). Expert working groups with the WHO and
developmental consequences of early adversity into new European Council83 stress that deinstitutionalisation is not
arenas. In the BEIP, the effects of institutionalisation on simply a matter of removing children from group homes,
cellular ageing were investigated, and DNA specimens but a policy-driven process aimed at the transformation of
were used to assess telomere length when children were child protection services to focus on family-level and
between 6 and 10 years of age. Children with longer community-level support. Experiences in Rwanda
exposure to institutional care were reported to have highlight this reality, with efforts to close down orphanages
significantly shorter telomeres in middle childhood.80 opened after the 1994 genocide requiring broad investment
Another analysis reported that functional polymorphisms from the national government and UNICEF into the
in brain-derived neurotrophic factor and serotonin design of robust family-based child protection systems,
transporter genes modified the effects of foster care and political will extending to the adoption of an orphan by
placement on rates of indiscriminate behaviour, the Prime Minister.84 In Ethiopia, deinstitutionalisation
suggesting genetic underpinnings of a possible plasticity efforts have often been undertaken by NGOs; such
phenotype that enabled some children to benefit more decentralised approaches can open additional funding
from intervention.81 Time will afford greater understanding streams but also pose challenges around coordinating
of how childhood adversity can change human DNA, and a cohesive national plan for non-institutional child
how genes change longitudinal effects of adversity. protection.85 Other case studies from Uruguay, Chile,
Argentina, Italy, and Spain similarly stress the
Implications of findings complexity and uniqueness of this transformation in each
In this Review, we present evidence from a vast body of socio-political environment.86
child development research suggesting that there is no In view of the complexity of transforming social services,
appropriate place in contemporary child protection some argue that a moratorium on institutions will do
systems for the large, impersonal child-care institutions more harm than good to vulnerable children, since some
documented in many studies, at least for young children. states will have few other options for child protection.
Across diverse contexts, studies have shown that Nevertheless, economic data make institutionalisation an
institutionalised children have delays or deficits in undesirable option for poor states. Cost-effectiveness
physical, cognitive, emotional, and social development. analyses from diverse contexts have reported that
Developmental catch-up among fostered and adopted institutions are consistently more costly than family-based
children suggest hope for recovery with targeted or community-based care, in terms of both direct outlays
intervention, particularly in the earliest months and years and indirect costs.21,87 In perhaps the most detailed report,
of life. There is also reason to believe that a change towards researchers at the University of Natal, South Africa,
developmentally informed protection strategies, although compared kinship-based, community-based, and
difficult, is possible in settings of limited resources and institutional models of orphan care in South Africa, and

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 Review

reported that “the most cost-effective models of care are should focus not only on the risks of trauma in conflict,
clearly those based in the community”, while institutional but also on factors that create resilience among children,
models were, by comparison, “very expensive”.19 families, and communities. Intervention will prove
Furthermore, the aforementioned difficulties in particularly challenging in situations in which
dismantling existing structures makes institutionalisation government protection has broken down and risk to
a poor interim strategy for a state working towards a more child protection workers is great.
developmentally grounded child protection strategy— Notably, most countries currently institutionalise
once opened, institutions are hard to close.83 No one is children with disabilities and other special medical or
more affected by the challenges of deinstitutionalisation social needs at higher rates than other children. Relatively
than the children who must hang on through difficult few studies have investigated the lives of institutionalised
transitions. In view of the human and economic costs of children with other special needs (for an exception, see
institutional care, and the vast number of children within the St Petersburgh-USA Orphanage Research Team89). As
families needing services, institutionalisation appears to new efforts towards child deinstitutionalisation unfold,
be a damaging and inadequate response to child protection particular attention must be given to the needs of children
needs, representing system failures in child sectors. with disabilities and special medical or social needs to
ensure that plans are made to provide for those needs.
Tasks ahead Such attention will require assimilation of lessons from
Despite some clear lessons from published work, there past experience (for a useful collection on efforts to
remains a challenging road ahead for researchers and advance community-based services for those with
practitioners interested in deinstitutionalisation, and for disabilities, see Johnson and Traustadottir90), careful data
children in need of care. Among the most immediate collection, and further research to document and provide
barriers to knowledge and action towards deinsti- for the needs of institutionalised children with disabilities.
tutionalisation is the absence of consistent practices for Finally, findings supporting the view that children
documentation and monitoring of children in institutional removed from institutional care and placed into
care worldwide. Leadership is needed at an international families later in life (ie, during a sensitive period)
level to craft consistent definitions and monitoring of experience especially persistent challenges suggest a
standards, and encourage uptake of standards across NGO, need to develop new intervention strategies that can
UN, public, and private sectors. Additionally, to build upon be used with older children. The incorporation of
findings compiled in this Review, further research is neuroscientific investigations into this research would
needed to explore the relative merits of various alternative provide insights into the effects of early adversity on
care strategies that could be used to keep children out of neural function later in life, and into the global
institutions. A review of findings on this topic to date would consequences of any neurodevelopmental differences
represent a welcome addition to the scientific literature. In on physical, cognitive, and emotional wellbeing.
most contexts, alternative strategies will likely require the
involvement of well-designed foster care and family Conclusion
reunification programmes, limited use of small group We have analysed robust evidence about the often
homes for specialised and transitional care, and responsible devastating developmental consequences of institution-
domestic and international adoption policies. Such areas of alisation in early childhood. Studies also offer hope,
social policy are often hotly contested and shaped by many showing that children placed into family care, including
considerations beyond the child; however, comprehensive forms of care deliverable in settings of poverty and
information about what is at stake for children might help economic transition, can experience developmental
practitioners to ensure that needs are met. Non-institutional recovery across most domains. Timing effects based on
strategies will require careful management with attention proposed sensitive periods show a need for urgent
to screening, training, and monitoring of care providers, intervention and policy change; when it comes to
and are not without their own pitfalls. removing children from harmful institutions, time is of
In view of the high costs of deinstitutionalisation for the essence. Such changes in policy will require difficult
children and societies, and the imperfection of tasks such as dismantling economically and socially
alternative strategies, further work could focus on entrenched structures, and building viable alternatives.
understanding the processes by which children lose With a robust evidence base to guide transformations,
access to safe family care and on implementation of political will and social organisation are now needed to
preventive measures. Worldwide, particular attention overcome remaining barriers to deinstitutionalisation.
must be paid to children in settings of conflict, Contributors
community violence, and political instability; such AEB drafted the manuscript and managed the library of secondary
settings might pose special challenges for those seeking sources (eg, articles, reports, and web resources) included in the Review.
AEB is responsible for the integrity of all content. CAN critically revised
to build the cohesive child protection strategies needed the report and supervised the study. AEB and CAN conceptualised and
to avoid institutional responses. As explored by designed the paper, conducted the literature search, analysed and
Betancourt and colleagues,88 appropriate responses interpreted the secondary sources, and obtained funding.

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 Review

Declaration of interests 23 UNICEF. Progress for children: a report card on child protection.
We declare no competing interests. Geneva: United Nations Children’s Fund, 2009.
24 Carter R. Family matters: a study of institutional childcare in
Acknowledgments Central and Eastern Europe and the Former Soviet Union. London:
Funding was provided by the Nelson Laboratory at Boston Children’s EveryChild; 2005.
Hospital, and Harvard Medical School provided a living stipend for 25 Browne K, Hamilton-Giachritsis C, Johnson R, Ostergren M. Overuse
AEB during the preparation and writing of the manuscript. CAB receives of institutional care for children in Europe. BMJ 2006; 332: 485–87.
a grant from National Institutes of Mental Health (MH091363). The 26 US Department of Health and Human Services. Adoption and Foster
stipend was not contingent on the generation of a report, and had no Care Analysis and Reporting System (AFCARS) Report #19: FY 2011.
influence on its writing or submission. Washington, DC: US Department of Health and Human Services, 2012.
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