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common underlying risk factor leading to children
The Effects of
Institutional Care on
Children
Institutional care is harmful to children. Decades of
research prove that growing up in institutions has
detrimental psychological, emotional and physical
implications including attachment disorders,
cognitive and developmental delays, and a lack of
social and life skills leading to multiple disadvantages
during adulthood.
A catalogue of child rights violations has been
documented within, and as a result of, institutional
care. A 2006 UN study found that children in
institutions are particularly at risk of violence
compared to children in other settings, including
verbal abuse, beatings, excessive or prolonged
restraint, rape, sexual assault and harassment.
Institutional care is not necessary.
Contrary to popular belief, the majority of children in
orphanages are not orphans, but have either one or
both parents alive. Virtually all have extended family.
Even when children are without parental care and
alternative care is needed, it should be provided with
kinship or foster families or in a family-like setting in
the community, as recommended by the UN
Guidelines on Alternative Care.
Institutional care is deeply unjust.
As a system, it attracts children coming from
situations of poverty or from families with a history
of institutionalisation, marginalisation and
discrimination. Children with disabilities and children
belonging to ethnic minorities are over represented
in institutional care and the system sets them up for
a life of vulnerability and abuse.
Institutional care is intrinsically connected with the
poverty of families and communities and the
inadequate provision of services. Poverty is the most
being separated from parents.
Institutional care leavers suffer multiple
disadvantages in adult life including reduced
economic opportunities, social exclusion, increased
tendency to substance abuse, mental health
problems, high suicide rates, exposure to criminal
activities and exploitation.
Almost all countries in the world ratified the UN
Convention on the Rights of the Child (UNCRC),
whose preamble is clear in recognising that children
should grow up in a family environment.
Furthermore, the United Nations General Assembly
endorsed the Guidelines for the Alternative Care of
Children in 2009, which set the overall objective to
phase out institutions as a care option.
Eliminating institutional care is necessary and
possible.
A number of governments across the world have
already started to reform outdated child protection
systems relying on institutional care, re-integrating
children into families and communities, developing
family strengthening and family alternative care. Yet,
with millions of children still warehoused in
institutions, and several million more at risk, we face
a truly global problem.
While protecting, respecting and fulfilling children’s
rights is primarily a responsibility of the State,
coordination among a number of actors is critical to
achieve a global breakthrough. Hope and Homes for
Children calls on all the stakeholders that play a role
in developing, running, supporting or influencing
national care systems to join forces in a collaborative
action to eradicate institutional care once and for all.
The Harmful Effects of Institutional Care
Institutional care has damaging effects on children,
both in terms of early childhood development and
outcomes later in life. Institutional care does not
support the optimal development of the child, and
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the neglect and damage caused is equivalent to studies and in-depth investigations into cognitive,
violence to a child (Johnson et al 2006). psychosocial and physical development of children in
institutions and the subsequent changes when they
Research documents the way in which children’s are placed into family-based care and also
brains develop in a context of deprivation, and the summarises the evidence on long term outcomes,
profound negative consequences in adult life. Even in although the scope and volume of this research is
better-resourced institutions, this deprivation less extensive and robust evidence is limited.
prevails as a consequence of the instability and
insufficiency of caregiving, inadequate living
conditions including poor nutrition, health, hygiene
and education, neglect and abuse, strict routines,
poor provision of learning and play, lack of identity,
individuality and integration, and isolation and
segregation from communities which characterise
institutional care worldwide. Together, these
contribute to poor brain development and
attachment with damaging consequences for
children’s physical, cognitive and psychosocial
development during childhood.

Institutionalisation is particularly damaging for the

youngest children during the critical early years of
development. Intervening early, whilst a child is
young and before they have spent a significant time
in institutional care, and returning them from
institutional care to nurturing and supportive family-
based care has positive benefits for children’s
subsequent development. It can result in
developmental recovery or significant improvement,
in turn reducing the extent of negative outcomes in
later life.

As a consequence of multiple deprivation and

developmental delays, children raised in institutional
care suffer poorer outcomes as they age through and
out of care. They face particular difficulties in
accessing educational, employment, housing and
other developmental and transitional opportunities
and experience social exclusion and poor outcomes.
Children raised in institutions are severely and
multiply disadvantaged throughout their lives.

This paper synthesises key evidence regarding the

effects of institutional care on brain development
and attachment, the way this plays out across
different domains of child development, and the
long-term outcomes that are experienced even after
leaving institutional care. It draws on longitudinal
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Brain Development: How does it work and brain. Neglect leads to excessive pruning of brain
cells, which can result in developmental and
why is it important? behavioural deficits (Schore 2001a, 2001b).
Institutional care has been associated with reduced
The first few years of life is a period of rapid brain
metabolism in the temporal and frontal cortices,
development and an unparalleled time of
reductions in white matter connectivity and brain
developmental change, particularly during the first
electrical activity, dysregulation of the hypothalamic-
three years. 80% of the brain cells a person will ever
pituitary-adrenocortical system, and changes in brain
have are formed in the first three years of life (ref??).
volume (Walker et al 2011). This results in neural and
An infant is born with some 100 billion neurons
behavioural deficits, especially for social interactions
(brain cells) and each neuron forms about 15,000
and emotions (right temporal cortex), and language
connections - or synapses - during the first few years
(left temporal cortex) (Schore, 2001a 2001b).
of life. By the age of 3 the child has formed about
1,000 trillion connections which allows the brain to
Furthermore, without a caring adult to protect the
adapt in response to the environment (Balbernie,
child, toxic stress (the strong, unrelieved activation of
2001). Connections that are frequently used are
the body’s stress management system caused by
strengthened whilst redundant synapses are ‘pruned’
poverty, neglect and abuse) can further weaken the
– in other words, they die (Harvard Centre for Brain
architecture of the developing brain (Centre on the
Development 2014). Thus, early experience
Developing Child 2014). This evidence suggests that
determines which neural pathways will become
the neglect that can occur in institutional settings is,
permanent and which will be eliminated.
therefore, damaging to brain development and the
earlier age at which a child is placed in an institution,
For normal brain development to occur, a young
the more profound the damage will be
child needs a living and responsive environment and
particularly needs social interaction with a consistent
Evidence from the Bucharest Early Intervention
caregiver. One of the most essential experiences in
Project reveals brain scans of two three-year olds
shaping the architecture of the developing brain is
showing the profound effect that neglect has on the
"serve and return" interaction between children and
neurological development of young children.
significant adults in their lives (Centre for Brain
Children who were placed shortly after birth into
Development 2014). Young children naturally reach
institutional care with conditions of severe neglect
out for interaction through babbling, facial
show dramatically decreased brain activity compared
expressions and gestures, and adults respond with
to children who were never institutionalized.
the same kind of vocalizing and gesturing back at
them. This back-and-forth process is fundamental to
the wiring of the brain, especially in the earliest years Brain Development: Evidence from the Bucharest Early
as the nervous system is stimulated, triggering the Intervention Project
release of β-endorphins and dopamine which
regulate the uptake of glucose and enables the brain These brain scans of two three-year olds
to grow. demonstrate the profound effect that neglect – a
Neglect, abuse or the lack of a consistent primary characteristic of institutional care – has on the
caregiver in the early years of life has the potential to neurological development of young children.
adversely affect brain functioning. A child raised in Children who were placed shortly after birth into
institutional care is typically deprived of the orphanages with conditions of severe neglect show
supportive, intensive, one-to-one relationship with a dramatically decreased brain activity compared to
primary caregiver that is essential for optimal children who were never institutionalized.
development. Without a caregiver to guide infant
learning, there is no process to direct synaptic
connections and the development of pathways in the
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Attachment

One way in which the lack of consistent, one-to-one

caregiving in institutional care affects children’s
development is known as attachment disorder.
Attachment is an enduring emotional relationship
with a specific person which brings safety, comfort,
soothing and pleasure. The loss or threat of loss of
the person to whom a child is attached evokes
intense distress. Consequences of poorly formed
attachment include poor emotional development,
social competence, behaviour, cognitive
development and mental health.

Bowlby (1951) argued that institutions fail to provide

children with the intimate, warm and continuous
relationships that primary caregivers can give,
resulting in the lack of properly-formed attachment.
Numerous studies reinforce this idea by providing
evidence that institutionalised children display
attachment disorders and poor social responsiveness
such as indiscriminate friendliness / overfriendliness,
severe response to strangers and separation, poor
development of social relationships with a carer and
disinhibited behaviour compared to children who had
never been institutionalised or were institutionalised
after the age of two years (Zeanah et al 2005,
Chisholm 1998, Rhiengold and Bayley 1959, Tizard
and Joseph 1970, Tizard and Rees 1975, Tizard and
Hodges 1978, Marcovich et al 1997, Chisholm 1998,
O’Connor et al 1999). Superficially, the behaviour of
institutionalised children can appear ‘normal’ (or
pseudo-secure), but their lack of discrimination in
seeking affection is in fact indicative of
disorganised/disorientated or disinhibited
attachment disorder (Zeanah 2000).

Consistency of caregiving, group size and duration of

institutionalisation / deprivation were commonly
found to affect the nature and severity of attachment
disorders. The presence of attachment disorder is
more common in children who have spent more than
6 months in institutional care (O’Connor et al., 1999,
2000a). Johnson et al (2006) conclude that “In terms
of attachment, even apparently “good” institutional
care can have a detrimental effect on children’s
ability to form relationships later in life. The lack of a
warm and continuous relationship with a sensitive
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caregiver can produce children who are desperate for
adult attention and affection”.
This pattern is not an inevitable consequence of
institutionalisation and there are mediating factors,
such as the child being a particular favourite of a
residential care worker and receiving more sensitive
care giving. Nevertheless, children in institutional
care have limited opportunities to form selective
attachments compared to children in family-based
care. The child’s first emotional attachment to their
primary caregiver is considered to be a ‘blueprint or
inner working model’ for all later emotional
attachments, as the young child learns how to love
and to be loved, which forms the basis of self-worth
and empathy for others (Bowlby, 1969). The lack of
secure attachment therefore has consequences for
physical, cognitive, behavioural and psychosocial
development of children and for the development of
emotions and relationships in later life (Browne et al
2006).

Attachment: Evidence from the Bucharest Early

Intervention Project
Only 3.2% of institutionalised children had a clear
attachment with a caregiver, compared to 100% of
children living with their parents.

In the Strange Situation Procedure only 22% of

young children in institutions had organized
attachment strategies in interactions with their
‘‘favourite’’ caregivers, whereas 78% of children
living with their parents had organized attachments
to their mothers.Source: Zeanah et al (2005)

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Behaviour and Psycho-Social
Development
Research has highlighted negative consequences of
institutional care for behaviour, social competence,
play and peer and sibling interactions. Consequences
during childhood include higher levels of apathy,
restlessness, disobedience, hyperactivity, anxiety,
depression, attention-seeking, sleep disorders, eating
disorders and stereotypical behaviours1 (e.g. rocking,
head banging, self-harming) and lower levels of social
maturity, attentiveness, concentration and
communication (Goldfarb 1944, Tizard and Rees
1975, Tizard and Hodges 1978, Hodges and Tizard
1989a and 1989b, Kaler and Freeman 1994, Sloutsky
1997, Fisher et al 1997, Markovitch et al 1997, Vorria
et al 1998, Beckett et al 2002).
Of the 17 studies investigated by Johnson et al.
(2006) concerning the social and behavioural
development of children who have been raised in
institutions, 16 studies (94%) found negative social or
behavioural consequences including poor social
competence, play and peer/sibling interactions. This
is largely a function of poor brain development and
attachment, but is also linked to isolation,
discrimination and segregation experienced in
institutional care. Rutter et al (2007) found that one
in ten children who spent their early lives in
Romanian institutions displayed ‘quasi-autistic’
behaviours such as face guarding and/or
stereotypical self-stimulation and comforting
behaviours (Rutter et al 1999, 2007). This is more
common in very low quality institutions, where
stimulation and caregiver interaction are particularly
low
Behaviour and Psycho-Social Development: Evidence
from the Bucharest Early Intervention Project
Children who were currently or previously
institutionalised had a much higher rate of
psychological disorders compared to never-
1 Stereotype behaviours are defined as repetitive, invariant
movements with no obvious goal or function (Mason 1991)
Stereotypies are commonly associated with a number of
institutionalised children (53.2% vs 22%) (Zeanah et
al 2009).
Over 60% of children in institutional care exhibited
stereotype behaviours. When placed into foster care,
stereotyped behaviours significantly reduced, and
with earlier and longer family-based placements the
reductions became larger. (Bos et al 2010).
Cognitive Development
Institutional care is typically detrimental to the
cognitive development of children. In particular,
children raised in institutional care experience delays
in terms of IQ, language, speech and vocabulary
(Goldfarb 1944, 1945, Pringle and Tanner 1958,
Rheingold and Bayley 1959, Tizard and Hodges 1978,
Tizard & Joseph, 1970, Hodges and Tizard 1989b,
Kaler and Freeman 1994, Sloutsky 1997, Rutter et al
1998, O’Connor et al 2000). For example, Bos et al
(2009) found that school-age children with a history
of early institutional care performed worse on
measures of both memory and executive functioning
compared to their peers without a history of
institutional care. A meta-analysis of 75 studies
covering over 3,800 children in 19 countries found
that children reared in orphanages had, on average,
an IQ 20 points lower than their peers in foster care
(van Ijzendoom 2008). When comparing a group of
institutionalised children in the UK with a control
group of children in foster care, Roy and Rutter
(2006) found that one third of the institutionalised
children displayed delayed reading skills, compared
with none of the children in foster care. Giese and
Dawes (1999) suggest language development is
inhibited by ‘regulative’ style of staff-child
interactions, and poor quality language input from
caregivers is correlated to poor language ability and
comprehension (Tizard et al 1972).
Cognitive Development: Evidence from the Bucharest
Early Intervention Project
different medical conditions, including autism, and are also
known to develop in association with atypical and especially
restricted sensory environments or deprivation
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Children raised in institutions display reduced
cognitive development when compared to children
placed into foster care or raised in their families of
origin, including:
– lower intellectual performance, measured by IQ
– substantial language delays, with some of these children
not yet producing intelligible words at 30 months.
– significant intellectual and language gains when placed
into foster care, especially when placed before the age
of 2 years old.
Source: Nelson et al (2007) and Windsor et al (2007)
Growth and Physical Development
Children raised in institutional care experience delays
in physical growth, as demonstrated through studies
on several indicators including height, weight and
head circumference (Johnson and Dole 1999,
Johnson et al 2010, Judge 2003, Miller 2000). For
example, Le Mare and Audet (2006) found that
institutionalised children in Romania, at a mean age
of 24 months, had dramatically fallen off their growth
curves, with the average weight dropping to the
fourth percentile. The correlation between birth
weight and weight at adoption was virtually zero. In
Ukraine 31% of institution-reared children were
stunted at 48 months whereas none of the family-
reared children were (Dobrova-Krol et al 2008).
Psychosocial growth failure is usually a consequence
of psychosocial deprivation and also nutritional
deprivation (Johnson and Dole 1999, Johnson and
Gunnar 2011). As linear growth and muscle mass are
significantly more affected by institutionalisation
than weight and fat accretion, Johnson (2001) asserts
that both protein-energy malnutrition and
psychosocial deprivation are responsible for growth
stunting but that the latter is predominant in
institutional care, with psychosocial deprivation
resulting in decreased hormone release or inefficient
use of nutrients (Johnson 2001).
Caregiver practices such as group feeding and leaving
young infants to feed themselves also hinder
children’s ability, opportunity and desire to consume.
Johnson (2001:140) concludes that “Whether a child
is institutionalised in Romania (Ames 1997; Johnson
et al 1992) the Former Soviet Union (Albers et al
1997) or China (Johnson et al 1996c, Johnson and
Traister 1999) analysis of growth data from a variety
of orphanage systems indicates that children lose 1
month of linear growth for approximately every 3
months spent in institutional care”. This effect of
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institutional care is often very visible, but is not
always so, depending on the level of deprivation.
Diagram source: Johnson (2001).
Catch-up in height and weight are rapid when
children are placed in family-based environments,
and the potential for growth recovery is greatest in
younger children and within more nurturing
environments where caregiver sensitivity and
positive relationships are higher (Johnson and
Growth and Physical Development: Evidence from
the Bucharest Early Intervention Project
– Children raised in institutions displayed lower height,
weight and head circumference compared to children
raised in families.
– Children moved into foster care significantly recovered
height and weight, but not head circumference, within
12 months
– The percentage of children within the normal range
increased from 91% to 100% for height, 75% to 90% for
weight, and 84% to 94% for height-weight.

Gunnar, 2011). For example, Le Mare and Audet

(2006) found that institutionalised children in Source: Johnson et al. (2010)
Romania mostly recovered their physical growth
when placed with adoptive families in Canada.
Growth recovery has wider implications for child
well-being than size alone, because catch-up in
height is a positive predictor of cognitive recovery as
well.

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Neglect and Abuse
The isolated and closed nature of institutions makes
children particularly vulnerable to a wide range of
abuse. Indeed, physical, emotional and sexual abuse
has been reported as existing in a number of
institutions worldwide (e.g., Barter, 2003; UNICEF,
2002). These include systematic rape and other
forms of sexual abuse; exploitation, including
trafficking; physical harm such as beatings and
torture; and psychological harm including isolation,
the denial of affection and humiliating discipline.
A survey undertaken by UNICEF (2002) covering 7.8%
of all children in residential care in Romania found
that 37.5% of children reported they had been
victims of severe physical punishment or “beatings”
(approximately two-thirds were boys and one-third
girls). The perpetrators of this physical abuse were
residential care staff in the vast majority of the
reports (77%). Nearly one fifth (19.6%) of the
respondents (approximately half boys and half girls)
claimed to have been blackmailed for sexual
activities and a further 4.3% claimed that they were
“constrained” to have sex. The reported perpetrators
of these acts of sexual abuse were older residents of
the same sex (50%), older residents of the opposite
sex (12%) and institutional staff (1.3%) (UNICEF,
2002). It is this group that is most at risk of offending
against others in later life (Haapasalo and Moilanen,
2004; Hamilton, Falshaw and Browne, 2002).
Anecdotal evidence suggests that children abused in
institutions may have greater difficulty in reporting
the abuse, escaping from the situation, or getting
support from outsiders. Due to the child’s
dependence on the institution, the abuse may
continue for a long time. Children with disabilities are
especially vulnerable.
Neglect and Abuse in Institutions Worldwide
– Kazakhstan: 63% of children in children’s homes
had been subjected to violence (Alternative Report
of Non-Governmental Organisations of Kazakhstan,
2002)
– Romania: almost half of institutionalised children
confirmed beating as routine punishment, and
more than a third knew of children who had been
forced to have sex. (Stativa, 2000)
– Ireland: 800 perpetrators were identified as having
perpetrated physical and sexual abuse of 1,090
children in residential institutions between 1914
and 2000. (Commission to Enquire into Child
Abuse, 2009)
– India: 52% of children in institutions were
subjected to beatings and other forms of physical
abuse. (Kacker et al 2007)
– Middle East and North Africa: Children highlighted
violence in institutions as a key concern for them in
the 2005 Regional Consultation for the UN Study on
Violence against Children. (UNICEF and National
Council for Childhood and Motherhood, 2009)
– North America: violence against children in
residential institutions is six times more prevalent
than violence in foster care (Barth 2002)
While it is especially difficult to obtain statistical data
on the exploitation and trafficking of children in
institutions, there is evidence to suggest this is a
widespread and growing concern. Some children
placed in institutions are, in effect, then ‘trafficked’
under the guise of intercountry adoption (Csáky
2009)
Furthermore, poor health and sickness often result
from overcrowded conditions, with cots back to back
and limited environmental experiences inhibiting the
development of the immune system. Soiled clothing
is often left on babies and infants for long periods of
time and poor hygiene practices are widespread.
Infectious diseases and serious medical illness are
frequent, and children are routinely isolated when
they are sick (Miller et al 1995, Hostetter 1991).
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Long Term Outcomes of Institutional
Care
As children grow up, the consequences of early
deprivation and institutional experiences lead to
diverse and deep-rooted difficulties. Young people
leaving care are one of the most vulnerable and
disadvantaged groups in society. They face particular
difficulties in accessing educational, employment and
housing and experience poor health and social
outcomes. Multiple disadvantage and clusters of
difficulties commonly lead or contribute to social
exclusion and poverty.
These poor outcomes reflect a number of factors
including ongoing emotional trauma stemming from
experiences of abuse and neglect before and during
care, developmental delays, inadequate support
while in care, accelerated transitions to adulthood
and lack of support to facilitate this transition
(Mendes and Moslehuddin 2006). Children in
institutional care are generally housed and educated
in one place, with little or no opportunity for
interaction or integration in the community. They are
dislocated from their families and communities, and
also from their culture and identity. Marginalisation,
stigma and discrimination run through their lives. In
institutional care there is little exposure to risk,
denial of freedom of expression and decision making,
and failure to transfer critical life skills. Children are
left poorly prepared to deal with adult life.
People leaving care are more likely to have lower
educational qualifications and participation in post-
16 education, be young parents, be homeless, and
have higher levels of unemployment, offending
behaviour, criminality, and mental health problems
(Stein 2006).
Evidence shows that institutionalised children have a
greater probability of low self esteem, loneliness,
anxiety and depression, often leading to social
withdrawal, antisocial behaviour and delinquency
(Andersson, 2005; Browne and Herbert, 1997; Fisher
et al., 1997). Previously institutionalised children are
more likely to be adult oriented and have difficulties
in their peer relationships, and less likely to have a
special friend, turn to peers for emotional support
and be selective in choosing friends (Hodges and
Tizard 1989a). Disinhibited attachments and
emotional vulnerability experienced by
institutionalised children place them at increased risk
of physical and sexual abuse. Their craving for
attention may result in a readiness to trust teenage
and adult strangers and increase their vulnerability to
sexual exploitation (Carter, 2005). The prevalence of
mental health issues is significantly higher for
children in care than in the general population, and
the prevalence is even higher for children and young
people in residential care (Meltzer et al 2002, Casey
Family Programme 2006). Higher rates of suicide are
also found amongst previously institutionalised
adults (Tobis 2000).
Social exclusion amongst care leavers is extensive,
with higher rates of homelessness, criminality and
imprisonment, early parenthood and substance
misuse. Affordable and accessible housing remains
unattainable for a many care leavers, resulting in
homelessness or unstable housing situation. Early
parenthood after leaving care has been commonly
identified across a wide range of studies (Mendes
2009). Unstable housing situations, limited life skills,
lack of guidance and a yearning for love and
something to nurture and family patterns of
instability and risk can all contribute to the early
childbearing of care leavers (Reilly 2003). Research
suggests that the children of these young mothers
are more likely to end up in care, creating a tragic
cycle of involvement in the care system (Casey 2006).
In terms of education, evidence shows that children
in care have lower educational attainment, are more
frequently excluded, have lower high school
completion rates and progress less in the education
system (Urban Institute 2008, Courtney et al 2001,
Stein 2006). Subsequent unemployment, unstable
employment patterns, very low incomes and
dependency on benefits and state welfare are
common (Urban Institute 2008, Stein 2006),
reinforcing income poverty in adulthood. A report by
the Urban Institute Youth (2008:29) concludes that
employment outcomes are correlated to placement
in group homes or institutions prior to exiting care.
Youth placed in residential settings prior to exit fare
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worse than youth in non-relative foster homes on

many of the employment outcomes. Furthermore,
the Urban Institute found that average monthly
earnings for care leavers aged 24 is $575, compared
to youth nationally who earn $1,535 a month.

These consequences of institutional care are

interconnected and mutually reinforcing. The
combination of developmental delays and
institutional experiences commonly results in young
people entering adulthood ill equipped for
independent life and unable to interact with, and
contribute to, the world around them. Evidence also
suggests that this cycle of deprivation and exclusion
is transmitted between generations. The jigsaw in
Figure 1 highlights the key outcomes of institutional
and alternative care, and examples of supporting
evidence.

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OUTCOMES JIGSAW: EMPLOYMENT MENTAL HEALTH SUBSTANCE ABUSE

OUTCOMES FOR CHILDREN IN
CARE
EDUCATIONAL ATTAINMENT
UK: In 2008, just
14% of children in care
achieved 5 A* – C grade
GCSEs, compared to 69% of all
children (DCSF 2009)
US: 11.8% of foster care
leavers had obtained a
Bachelors degree at age 25,
compared to 28% of the
general population
(Casey 2006)
SCHOOL EXCLUSION AND
DROP OUT
- Scotland: 227/1,000 school
exclusions for children in care,
compared to 50/1,000 for the
general population
60% of children in care are
not in education, training or
employment at age 16-16,
compared to 14% of the
general population
(Scottish Government 2004)
U.S: 64% of care leavers
are employed at age 24,
compared to 92%
nationally (Urban Institute
2008)
U.S: 50% of care leavers
received no career advice
or training and support for
job applications (Reilly
2003)
POVERTY
U.S: 1/3 of care leavers
lives in poverty, and 83%
of these had an income
more than three times
below the poverty line
(Casey 2006)
US: Average monthly
earnings for care leavers
aged 24 is $575 compared
to youth nationally, who
earn $1,535 a month.
(Urban Institute 2008)
PEER RELATIONS
UK: Ex-institutionalised
children are more likely to
have difficulties with peer
relations and less likely to
have a special friend or
turn to peers for
emotional support
(Hodges and Tizard 1989a)
U.S: care leavers are 2.1 to 2.8 times
more likely to display symptoms of
five mental health disorders. ¼
displays symptoms of Post-Traumatic
Stress Disorder (PTSD) which is
double the PTSD rates of veterans
returning from recent wars, and over
six times the rate among the general
U.S
population. (Casey 2006)
U.K: 49% of institutionalised children
aged 11-15years old had a mental
disorder, compared to 11% of the
general population. 2/3 children in
residential care had mental
disorders, compared to 4/10 in foster
care. (Meltzer 2002)
SUICIDE
Russia: 1 in 10 ex-institutionalised
children commit suicide (Tobis 2000)
CRIME
Russia: 1/5 end up with a criminal
record after leaving care (Tobis 2000)
U.S: 1/3 care leavers had been
arrested and 1/5 had spent time in
prison (Casey 2006)
U.S: 33% of care leavers had
drug and/or alcohol problems
(Barth 1990)
Australia: half of care leavers
admitted using drugs in the
past 6 months (Maunders et al
1999)
YOUNG PARENTHOOD
Australia: One third of women
became pregnant shortly after
leaving care. By age 24, 64% of
care leavers had become a
parent (Cashmore and Paxman
1996)
U.S: Female care leavers are 2.5
times more likely than the
general population to have
been pregnant by age 19
(Bilaver and Courtney 2006).
HOMELESSNESS
Russia: ¼ of care leavers
experiences homelessness
(Tobis 2000)
U.S: 60% of care leavers
experienced homelessness
within 6 months of leaving care
(Choca 2004)

Example: Institutional Care and Delayed
Development Leads to High Unemployment
Children in institutions often experience cognitive
development delays as a result of their environment
and care giver interaction, and lower than average
IQs and poor language skills often result in children
performing poorly at school. As a result they are less
likely to obtain good qualifications, and are over
represented in special education and vocational
schools. Communication problems are also common
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in children who grow up in institutional care. With
depersonalised routines and little social interaction
children can find it hard to form normal relationships,
even later on in life. These developmental delays
affect children’s abilities and behaviours and are
compounded by poor preparation for independent
living and lack of support networks, limiting their
ability to secure employment later in life and
contributing to poverty in adulthood
Example: Institutional care leads to early parenthood
Young adults leaving care usually crave adult
attention, have no support network, and become
dependent on the state for their basic welfare. They
often yearn for a meaningful relationship and
something to love and nurture, leading them into
early parenthood. With no experience of family life,
many struggle when they become parents
themselves, putting their children at risk of
institutionalisation and transmitting the problem
from one generation to the next.
Reliable evidence regarding the long term outcomes
of institutional care is relatively scare. Evidence is
more widely available for children in care, rather
than in institutional care per se, and from developed
country contexts such as the U.K. U.S and Australia.
Children in care have worse outcomes than children
who have never been in care, of whom those in
foster care achieve better outcomes whilst those
who have lived in institutional care are particularly
disadvantaged. In the absence of evidence regarding
children raised in institutions, evidence related to
children in care more widely can be considered
indicative, thus the outcomes of both institutional
care and alternative care more broadly have both
been reflected in this discussion.
Factors Mediating Development Delays
and Long-Term Outcomes of
Institutionalisation
The nature and severity of children’s developmental
delays and outcomes in institutional care, and the
extent to which these can be recovered after they
have been placed into family based care or
independent living, is dependent on a variety of
factors. Indeed, many problems show rapid
improvement once the child is removed from
institutional care and placed in a supportive family
environment.
The level of deprivation experienced in institutional
care plays an important role, including consistency
and sufficiency of caregiving, group size, rigidity of
routine, provision of healthcare and education,
degree of integration, and experience of abuse.
Furthermore, and very importantly, a strong body of
evidence shows that age and duration of
institutionalisation is strongly correlated with
developmental delay and recovery.
Institutionalisation at the youngest age has the most
severe and long lasting negative impact. Children
under the age of 3 years are acknowledged to be the
most at-risk of developmental delay in institutional
care, and particularly those under 6 months (Johnson
et al 2006.) The earlier a child is placed into family-
based care the greater the recovery. In other words,
early deprivation significantly compromises long
term outcomes for children, and early intervention
can result in recovery. For example, a study
following the progress of children removed from
institutional to family care before the age of 2 years
in Romania found that the children were severely
cognitively impaired when they were first placed with
their families. However, by the age of 4, children had
made substantial developmental catch-up. Those
who had been placed into family care before the age
of 6 months performed no differently to children
who had never been separated from their families.
Children placed into family care later made
significant developmental gains after leaving
institutional care but recovery was incomplete and
they were still disadvantaged some years later
(O’Connor et al., 2000).
The nature of the family-based environment after
institutional care also affects the recovery of
developmental delays and the long term outcomes
for children. Evidence demonstrates that many
children with institutional care backgrounds can
make a rapid recovery and ‘catch up’ on their
physical and cognitive development when they are
placed in a caring family environment at an early age
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as long as the family is responsive to their needs
(Rutter and The English and Romanian Adoptees
Study Team, 1998; Marcovitch et al, 1997). Research
shows that the quality of the subsequent family
environment is an important factor, including the
personal motivation and resources of parents. A
common theme through much research is that
placement with a family is not enough by itself to
overcome difficulties, indicated by the poor
outcomes of some children restored to their birth
family. For example, Hodges and Tizard (1989) found
that attachment and social relationships improved
markedly for children who were moved from
institutional care at a young age – but children
restored to birth families fared much worse than
those who were adopted. This was linked to the
motivated and supportive family environment of
adoptive families. Placement stability is also
important, as children who have a long term stable
placement and/or who are placed within their own
area are likely to do better.
In the most severe institutional environments, where
particularly harsh conditions and deprivation have a
profound effect on development, complete recovery
has only been observed so far in children who were
placed in family-based care before the age of six
months (Beckett et al 2007, O’Connor et al, 2000).
Children placed later can make significant
improvements in their development after leaving
institutional care, but are likely to still be at an
intellectual and social disadvantage later in life
(Browne 2009). Furthermore, some areas of
development are more difficult to recover. For
example, whilst placement in a supportive family can
result in the formation of close attachments within
that family unit, many institutionally raised children
still have problems interacting with peers and adults
outside the family unit (Johnson et al 2006)
Limitations
The evidence regarding developmental and long term
effects of institutional care has several limitations.
Control studies have not been widely undertaken,
and differences based on age, time in institutional
care, quality of care, placement quality and children’s
backgrounds can lead to misleading or inconclusive
evidence.
The standard of care that children receive in
institutions varies enormously, and most research
focuses on either ‘good’ residential care or extremely
poor institutional settings. As a result, research
findings vary widely and whilst trends can be
identified, some figures can be misleading.
Conclusion
According to the United Nations Convention on the
Rights of the Child, every child has the right to grow
up in a family and live free from abuse and neglect.
Global evidence clearly indicates that institutional
care does not support the optimal development of
children, and results in developmental delays and
negative long term outcomes that can last a lifetime.
Children living in institutions, and in care more
widely, suffer multiple deprivation as a result of their
care environment which leads to social exclusion and
poverty in adulthood.
Institutions are not only limiting children’s
development and their futures, but also restricting
national economic, social and political growth.
Evidence suggests that they grow into adults who are
less able to make social or economic contributions to
society and also require addition support from the
state. Priority must be given to ensuring that children
do not have to suffer the intense and long-term
consequences of institutional care.
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Returning children in institutions to family-based care

has a critical impact of their subsequent
development and can result in catch-up or recovery
in a supportive family environment if intervention is
early enough.

Research demonstrates that children who are moved

from institutional care before the age of 6 months
can reach optimal development and that children
removed from institutional care later in life can still
make dramatic improvements and lead fulfilling and
productive lives.

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Key Resource List

– Bucharest Early Intervention Project
http://www.bucharestearlyinterventionproject.org/
– Centre on the Developing Child, Harvard University
http://developingchild.harvard.edu/
– Keeping Children Out of Harmful Institutions - Corinna
Csáky, Save The Children, 2009
– The Risk of Harm to Young Children in Institutional Care
– Kevin Browne, 2009
– Families not Orphanages – John Williamson and Aaron
Greenberg, 2010

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Full Bibliography

– Andersson, G. (2005) Family relations, adjustment and well-being in a longitudinal study of children in care. Child & Family
Social Work, 10: pp 43–56
– Alternative Report of Non-Governmental Organisations of Kazakhstan (2002). Available at
www.crin.org/docs/resources/treaties/crc.33/kazakhstan_ngo_report.pdf
– Balbernie, R. (2001). Circuits and circumstances: The neurobiological consequences of early relationship experiences and
how they shape later behaviour. Journal of Child Psychotherapy,27, 237-255.
– Barth, R. (1990) On their own: The experiences of youth after foster care. Child and Adolescent Social Work, 7:5, pp.419-40.
– Barth, R. P. (2002) Institutions vs Foster Homes:The empirical base for a century of action, Chapel Hill, NC, University of
North Carolina, School of Social Work, Jordan Institute for Families.
– Beckett, C., Bredenkamp, D., Castle, J., Groothues, C., O’Connor, T. G., Rutter, M., & The English and Romanian Adoptees
Study Team (2002) Behaviour patterns associated with institutional deprivation: A study of children adopted from Romania.
Journal of Developmental & Behavioral Pediatrics,23:5, pp297-303.
– Bilaver, L. A., & Courtney, M. E. (2006). Science says: Foster care youth. Washington, DC: National Campaign to Prevent Teen
Pregnancy. Available online at: www.teenpregnancy.org/works/pdf/ScienceSays7_FosterCare.pdf
– Bos, K.J., Fox, N.A., Zeanah, C.H., Nelson C.A., (2009) Effects of Early Psychosocial Deprivation on the Development of
Memory and Executive Function. Frontiers in Behavioural Neuroscience. Available online at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741295/#B2
– Bos, K.J., Zeanah, C.H., Smyke, T., Fox, N.A., Nelson C.A., (2010) Stereotypies in Children with a History of Early Institutional
Care. Archives of Pediatric and Adolescent Medicine 2010; 164:5, pp 406-411. Available at
http://archpedi.jamanetwork.com/article.aspx?articleid=383173
– Bowlby, J. (1951) Maternal care and mental health. Geneva, Switzerland: World Health Organisation.
– Bowlby, J. (1969). Attachment: Attachment and Loss Volume 1. London: Hogarth Press.
– Browne, K. D., (2009) The Risk of Harm to Young Children in Institutional Care. Save the Children
– Browne, K. D., Hamilton-Giacritsis, C. E., Johnson, R., Agathonos, H., Anaut, M., Herczog, M. et al. (2004). Mapping the
number and characteristics of children under three in institutions across Europe at risk of harm. European Union Daphne
Programme, Final Project Report No. 2002/017/C. Birmingham, UK: University Centre for Forensic and Family Psychology.
– Browne, K.D. and Herbert, M. (1997). Preventing Family Violence. Chichester: Wiley
– Carter R. (2005). Family Matters: A study of institutional childcare in Central and Eastern Europe and the Former Soviet
Union. London: Everychild.
– Casey Family Programmes (2008) Casey Young Adult Survey: Findings Over Three Years. Available at
http://www.casey.org/Resources/Publications/pdf/CaseyYoungAdultSurveyThreeYears.pdf
– Casey Family Programs (2006) Young Adult Survey Examining Outcomes For Young Adults Served In Out-Of-Home Care.
Available online at http://www.casey.org/NRlrdonlyres/B43D2D 1-17F3-4B53-
AC4BE35C2907683B/639/2006YoungAdultSurveyFR.pdf.
– Cashmore, J. & Paxman, M. (1996) Longitudinal study of wards leaving care. Social Policy Research Centre, Sydney.
– Centre on the Developing Child (2014). InBrief Series.
http://developingchild.harvard.edu/index.php/resources/briefs/inbrief_series/

http://www.offshore-inc.com

www.hopeandhomes.org
……………………………………………………………………………………….…………………………………...

– Chisholm K. (1998). A three year follow-up of attachment and indiscriminate friendliness in children adopted from
Romanian orphanages. Child Development, 69, pp 1092–1106.
– Commission to Enquire into Child Abuse (2009) Report on the Commission to Enquire into Child Abuse, Ireland.
– Courtney, M.E., Piliavan, I., Grogan-Kayor, A. and Nesmith, A. (2001) Foster care youth transitions to adulthood: a
longitudinal view of youth leaving care. Child Welfare. 6, pp685-717
– Csáky, C. (2009) Keeping Children out of Harmful Institutions. Save the Children.
– Department for Children, Schools and Families (2009) Improving the Educational Attainment of Children in care (Looked
after Children). DFCS.
– Dobrova-Krol, N. A., Van IJzendoorn, M. H., Bakermans-Kranenburg, M.J., Juffer, F., & Cyr, C. (2008). Physical growth delays
and stress dysregulation in stunted and non-stunted Ukrainian institution-reared children. Infant Behavior and Development,
31, pp. 539–553.
– Fisher, L., Ames, E. W., Chisholm, K., & Savoie, L. (1997)Problems reported by parents of Romanian orphans adopted to
British Columbia. International Journal of Behavioral Development, 20:1, pp67-82.
– Giese, S., & Dawes, A. (1999). Child care, developmental delay and institutional practice. South African Journal of
Psychology,29:1, pp 17-22.
– Goldfarb, W. (1944). The effects of early institutional care on adolescent personality. Journal of Experimental Education,12,
pp106-129.
– Goldfarb,W.(1945).Effects of psychological deprivation in infancy and subsequent stimulation. American Journal of
Psychiatry,102, pp18-33.
– Haapasalo, J. and Moilanen, J. (2004). Official and self-reported childhood abuse and adult crime of young offenders.
Criminal Justice and Behavior, 31, pp 127–149.
– Hamilton, C.E., Falshaw, L. and Browne, K.D. (2002). The link between recurrent maltreatment and offending behaviour.
International Journal of Offender Therapy and Comparative Criminology, 46, pp 75–94.
– Harvard Centre for Brain Development (2014) InBrief Series. Available at
http://developingchild.harvard.edu/index.php/resources/briefs/inbrief_series/
– Hodges,J.,&Tizard,B. (1989a).Social and family relationships of ex-institutional adolescents. Journal of Child Psychology &
Psychiatry,30(1), 77-97.
– Hodges,J.,&Tizard,B. (1989b).IQ and behavioural adjustment of ex-institutional adolescents. Journal of Child Psychology &
Psychiatry, 30:1 pp53-75.
– Hostetter M.K., Iverson, S., Thomas, .W, McKenzie, D., Dole, K. and Johnson DE. M(1991) Medical evaluation of
internationally adopted children. New England Medical Journal. 325:7, pp 479-85.
– Johnson, D. E. (2000). Medical and developmental sequelae of early childhood institutionalization in Eastern Europe and
adoptees. In C.A. Nelson(Ed.), The Minnesota symposia on child psychology, Vol 31: The effects of early adversity on
neurobehavioral development. (pp. 113-162). Mahwah, NJ, US: Lawrence Erlbaum Associates.
– Johnson, D.E. (2001) Medical and developmental sequelae of early childhood institutionalization in Eastern European
adoptees. In: Nelson (ed) The Minnesota Symposia on Child Psychology. Vol 31: The Effects of Early Adversity on
Neurobehavioral Development. Lawrence Erlbaum Associates Publishers; Mahwah, NJ. Available at
http://www.peds.umn.edu/iac/prod/groups/med/@pub/@med/documents/asset/med_57668.pdf
– Johnson D.E., and Dole, K. (1999) International adoption: Implications for early intervention. Infants and Young Children, 11,
pp 34–45.

http://www.offshore-inc.com

www.hopeandhomes.org
……………………………………………………………………………………….…………………………………...

– Johnson, R., Browne, K., Hamilton-Giachritsis, C (2006) Young Children in Institutional Care at Risk of Harm. Trauma,
Violence, & Abuse, 7:1, pp34-6.
– Johnson D.E., Guthrie, D., Smyke, A.T., Koga, S.F., Fox, N.A, Zeanah, C.H, Nelson, C.A. 3rd. (2010) Growth and associations
between auxology, caregiving environment, and cognition in socially deprived Romanian children randomized to foster vs
ongoing institutional care. Archives of Pediatric and Adolescent Medicine, 164:6, pp 507-16. Available online at
http://www.ncbi.nlm.nih.gov/pubmed/20368481
– Johnson, D. E. and Gunnar, M. R. (2011). IV: Growth Failure in Institutionalized Children. Monographs of the Society for
Research in Child Development, 76, pp 92–126. Available online at
http://www.thinkchildsafe.org/thinkbeforevisiting/resources/4_growth_failure_in_institutionalized_children.pdf
– Judge, S. (2003) Developmental recovery and deficit in children adopted from Eastern European orphanages. Child
Psychiatry and Human Development, 34, pp 49–62.
– Kacker, L. Varadan, S. Kumar, P. (2007) Study on Child Abuse: India. Ministry of Women and Child Development: India.
– Kaler, S.R., &Freeman, B.J.(1994) Ananalysis of environmental deprivation: Cognitive and social development in Romanian
orphans. Journal of Child Psychology & Psychiatry, 35, pp 769-781.
– Le Mare, L. and Audet, K. (2006) A longitudinal study or the growth and physical health of postinstitutionlised Romanian
adoptees. Paediaticr Child Health. 11(2) pp 85–91.
– Marcovitch, S., Goldberg, S., Gold, A., Washington, J., Wasson, C., Krekewich, K., and Handley-Derry, M. (1997).
Determinants of behavioural problems in Romanian children adopted in Ontario. International Journal of Behavioral
Development, 20, pp 17–31.
– Mason, G. (1991). Stereotypies: a critical review. Animal Behaviour. 41:6, pp 1015- 1037
– Maunders, D., Liddell, M., Liddell, M., & Green, S. (1999). Young people leaving care and protection. Hobart: National Youth
Affairs Research Scheme.
– Meltzer, H. Gatward, R. Corbin, T. Goodman, R. and Ford, T. (2002) The mental health of young people looked after by local
authorities in England. Office for National Statistics and Department of Health.
– Mendes, P. (2009) Improving outcomes for teenage pregnancy and early parenthood for young people in out-of-home care:
A review of the literature. Youth Studies Australia, 28:4
– Mendes, P. and Moslehuddin, B. (2006) From dependence to interdependence: towards better outcomes for young people
leaving state care. Child Abuse Review, 15:2, pp 110–126.
– Miller L.C., Kiernan, M.T., Mathers, M.I., and Klein-Gitelman, M. (1995) Developmental and nutritional status of
internationally adopted children. Archives of Pediatric and Adolescent Medicine. 149: 1, pp 40-4.
– Miller, L.C. (2000) Initial assessment of growth, development, and the effects of institutionalization in internationally
adopted children. Pediatric Annals, 29, pp 224–32.
– Nelson C.A., Zeanah, C.H., Fox, N.A., Marshall, P.J., Smyke, T., & Guthrie, D. (2007). Cognitive recovery in socially deprived
young children: The Bucharest Early Intervention Project. Science, 318, pp 1937-1940. Available at
http://www.bucharestearlyinterventionproject.org/Nelson_et_al__combined__2007_.pdf
– O’Connor, T. G., Rutter, M., & The English and Romanian Adoptees Study Team. (2000a). Attachment disorder behaviour
following early severe deprivation: Extension and longitudinal follow-up. Journal of the American Academy of Child &
Adolescent Psychiatry, 39:6, pp 703-712.
– O’Connor,T.G., Bredenkamp,D., Rutter,M., &The English and Romanian Adoptees Study Team. (1999). Attachment
disturbances and disorders in children exposed to early severe deprivation. Infant Mental Health Journal, 20:1, pp 10-29.

http://www.offshore-inc.com

www.hopeandhomes.org
……………………………………………………………………………………….…………………………………...

– Pringle, M.L.K., & Tanner, M. (1958). The effects of early deprivation on speech development: A comparative study of 4 year
olds in a nursery school and in residential nurseries. Language & Speech,1, 269-287.
– Reilly, T. (2003) Transitions from Care: Status and Outcomes of Youth Who Age Out of Foster Care. Child Welfare, 82:6.
– Rheingold,H.L.,&Bayley,N.(1959).The later effects of an experimental modification of mothering. Child Development, 30,
pp363-372.
– Roy, P. and Rutter, M. (2006). Institutional Care: associations between inattention and early reading performance. Journal of
Child Psychology and Psychiatry, 47, pp480–487.
– Rutter, M., & The English and Romanian Adoptees Study Team.(1998).Developmental catch-up, and deficit, following
adoption after severe global early privation. Journal of Child Psychology & Psychiatry,39:4, pp 465-476.
– Rutter, M., Kreppner, J., Croft, C., Murin, M., Colvert, E., Beckett, C., Castle, J., Sonuga-Burke, E. (2007). Early adolescent
outcomes for institutionally-deprived and non-deprived adoptees III: Quasi-autism. Journal of Child Psychology and
Psychiatry 48(12) pp 1200–1207
– Schore, A.N. (2001a). Effects of a secure attachment relationship on right brain development, affect regulation, and infant
mental health. Infant Mental Health Journal, 22, pp7–66.
– Schore, A.N. (2001b). The effects of early relational trauma on right brain development, affectr egulation, and infant mental
health. Infant Mental Health Journal, 22, pp 209–269.
– Sloutsky, V. M. (1997). Institutional care and developmental outcomes of 6- and 7-year-old children: A contextualist
perspective. International Journal of Behavioral Development, 20 (1), pp 131-151.
– Stativa, E. (2000) Survey on Child Abuse in Residential Care Institutions in Romania (ABSUR).
– Stein, M. (2006) Research Review: Young People Leaving Care. Child and Family Social Work, 11 (3) pp 273-279
– Tizard, B., Cooperman, O., Joseph, A., & Tizard, J. (1972). Environmental effects on language development: A study of
children in long-stay residential nurseries. Child Development,43, pp 337-358.
– Tizard, B., & Hodges, J. (1978). The effect of early institutional rearing on the development of eight year old children. Journal
of Child Psychology & Psychiatry, 19, pp 99-118.
– Tizard, B., & Joseph, A. (1970). Cognitive development of young children in residential care: A study of children aged 24
months. Journal of Child Psychology & Psychiatry, 11, pp 177-186.
– Tizard,B.,&Rees,J.(1975).The effect of early institutional rearing on the behaviour problems and affectional relationships of
four-year-old children. Journal of Child Psychology& Psychiatry, 16, pp 61-73.
– Tobis, D. (2000) Moving from Residential Institutions to Community-Based Social Services in Central and Eastern Europe and
the Former Soviet Union. The World Bank, 2000.
– UNICEF (2002).Child abuse in residential care institutions: A national survey of Romania. Bucharest: UNICEF
– UNICEF and National Council for Childhood and Motherhood (2005) Outcome Document of the MENA Regional Consultation
on Violence against Children. Available at http://www.crin.org/docs/Outcome-Report-MENA.doc [accessed 15 October
2009]
– Urban Institute (2008) Coming of Age: Employment Outcomes for Youth Who Age Out of Foster Care Through Their Middle
Twenties. U.S. Department of Health and Human Services. Office of the Assistant Secretary for Planning and Evaluation.
Available online at http://aspe.hhs.gov/hsp/08/fosteremp/
– van Ijzendoom, M.H., Luijk, M., and Juffer, F. (2008) IQ of children growing up in children’s homes. Merrill Palmer Quarterly,
54:3.

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– Vorria, P.,Rutter, M.,Pickles, A.,Wolkind, S.,& Hobsbaum, A. (1998). A comparative study of Greek children in long-term
residential group care and in two-parent families: Social, emotional, and behavioural differences. Journal of Child Psychology
& Psychiatry, 39, pp 225-236.
– Windsor, J., Glaze, L.E., Koga, S.F., & the BEIP Core Group. (2007). Language acquisition with limited input: Romanian
institution and foster care. Journal of Speech, Language, and Hearing Research, 50, pp 1365-1381. Available at:
http://www.bucharestearlyinterventionproject.org/Windsor_et_al___2007_.pdf
– Zeanah, C.H.(2000). Disturbances of attachment in young children adopted from institutions. Journal of Developmental &
Behavioral Pediatrics, 21, pp 230-236.
– Zeanah, C.H., Egger. H.L., Smyke, A.T., Nelson, C.A., Fox, N.A., Marshall, P.J., & Guthrie, D. (2009). Institutional rearing and
psychiatric disorders in Romanian preschool children. American Journal of Psychiatry, 166, pp 777-785. Available at
http://ajp.psychiatryonline.org/data/Journals/AJP/3895/09aj0777.PDF
– Zeanah, C.H., Smyke, A.T., Koga, S.F.M., Carlson, E., & the BEIP Core Group. (2005). Attachment in institutionalized and
community children in Romania. Child Development, 76:5, pp 1015-1028. Available at
http://www.bucharestearlyinterventionproject.org/Zeanah_et_al___2005_.pdf

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