The science of early adversity: is there a role for large institutions in the care of vulnerable children?

The nutritional and feeding status of children living in selected residential child care facilities in Zambia: implications for programs and policies

Introduction

This study aimed to estimate the prevalence of undernutrition and risk of feeding difficulties and describe common feeding practices for children from birth to 10 years of age living in residential care in Zambia.

Methods

This was a secondary analysis of de-identified cross-sectional data on 397 children living in 22 residential care facilities in four provinces. Child demographics, anthropometrics, hemoglobin levels, risk for feeding difficulties, and facility-level feeding practices were collected by a trained study team using Count Me In, a digital health app. Interviews with staff were conducted at 15 residential care facilities.

Results

Around half of the study sample were boys (53.4%) and <5 years old (55.4%). Special healthcare needs were reported in 10.3% of the children, with cerebral palsy being the most common (3.5%). Underweight, stunting, wasting (using weight-for-length/height), and anemia were found in 22.4, 28.0, 7.1 and 54.7% of children, respectively, with higher rates in children with special healthcare needs and children <24 months old. Duration of residential care was positively associated with length/height-for-age but not weight-for-age or weight-for-length/height z-scores. A risk for feeding difficulties was found in 41.4 and 26.0% of children with and without special healthcare needs, respectively. Suboptimal bottle-feeding practices, including the use of altered nipples and poor caregiver-infant interactions, were observed for infants <12 months old. Residential care staff reported suboptimal diets in their facilities and gaps in knowledge and resources to meet children's nutritional needs.

Conclusion

These results demonstrate that a large proportion of children living in residential care in Zambia are at high risk for undernutrition and feeding difficulties and contribute to the small body of literature on children living in residential care, both in Zambia and globally. In the context of Zambia's efforts to improve child nutrition and reform its alternative care, these findings can inform programming and policies for children living in residential care to fulfill their rights to health and family care.

Receptive and expressive vocabulary performance in 2- to 5-year-olds in care: The role of different care types and temperament

The detrimental role of institutionalization in children's development has prompted the introduction of alternative care types designed to offer more personalized care. The current study aimed to test whether children in alternative care types (care villages, care homes, and foster care) performed better on vocabulary than those in institutions. The role of temperament, specifically perceptual sensitivity and frustration, and the interaction between temperament and care types on vocabulary performance were also explored. The study involved 285 2- to 5-year-old children from different care types, and they were assessed through receptive and expressive vocabulary tests and temperament scales. The results of the linear mixed model revealed that children in alternative care types exhibited significantly higher vocabulary scores compared with those in institutions. Moreover, perceptual sensitivity showed a positive association with receptive and expressive vocabulary skills and seemed to act as a protective factor by mitigating the lower vocabulary scores in institutions. Frustration moderated vocabulary outcomes differently for children in institutions and foster care, aligning with the diathesis-stress model and vantage sensitivity theory, respectively. The findings emphasize the positive role of alternative care types in vocabulary performance and the importance of children's temperamental traits in this process.

How do new crises impact HIV risk behaviour - exploring HIV risk behaviour according to COVID-19-related orphanhood status in South Africa?

The COVID-19 pandemic resulted in high death rates globally, and over 10.5 million children lost a parent or primary caregiver. Because HIV-related orphanhood has been associated with elevated HIV risk, we sought to examine HIV risk in children affected by COVID-19 orphanhood. Four hundred and twenty-one children and adolescents were interviewed, measuring seven HIV risk behaviours: condom use, age-disparate sex, transactional sex, multiple partners, sex associated with drugs/alcohol, mental health and social risks. Approximately 50% (211/421) experienced orphanhood due to COVID-19, 4.8% (20/421) reported living in an HIV-affected household, and 48.2% (203/421) did not know the HIV status of their household. The mean age of the sample was 12.7 years (SD:2.30), of whom 1.2% (5/421) were living with HIV. Eighty percent (337/421) reported at least one HIV risk behaviour. HIV sexual risk behaviours were more common among children living in HIV-affected households compared to those not living in HIV-affected households and those with unknown household status (35.0% vs. 13.6% vs.10.8%, X2 = 9.25, p = 0.01). Children living in HIV-affected households had poorer mental health and elevated substance use (70.0% vs. 48.5%, X2 = 6.21, p = 0.05; 35.0% vs. 19.9%, X2 = 4.02, p = 0.1306, respectively). HIV-affected households may require specific interventions to support the health and well-being of children and adolescents.

Rates of out-of-home care among children in Canada: an analysis of national administrative child welfare data

INTRODUCTION

As a part of the public health approach to child welfare, data about children placed in out-of-home care are needed to assess population trends, understand drivers of social and health inequities, and examine outcomes for children and families. We analyzed administrative data from Canada to describe the population of children in out-of-home care, and estimate and compare rates of out-of-home care by province/territory, year, sex/gender, age group and placement type.

METHODS

We conducted a cross-sectional analysis of point-in-time data from all provinces and territories for the period 2013/2014 to 2021/2022. We used frequencies and percentages to describe the population of children (and youth up to age 21 years) in out-of-home care and estimated overall and stratified rates and rate ratios.

RESULTS

An estimated 61 104 children in Canada were in out-of-home care on 31 March 2022. The national rate of out-of-home care was 8.24 children per 1000 population. Rate variations by province/territory were substantial and changed over time. Rates were highest among males and children aged 1 to 3 and 16 to 17 years. Foster homes were the most common type of placement, although kinship homes accounted for an increasing share.

CONCLUSION

This analysis demonstrated that administrative data can be used to generate national indicators about children involved in the child welfare system. These data can be used for tracking progress towards health and social equity for children and youth in Canada.

Annual Research Review: Early intervention viewed through the lens of developmental neuroscience

The overarching goal of this paper is to examine the efficacy of early intervention when viewed through the lens of developmental neuroscience. We begin by briefly summarizing neural development from conception through the first few postnatal years. We emphasize the role of experience during the postnatal period, and consistent with decades of research on critical periods, we argue that experience can represent both a period of opportunity and a period of vulnerability. Because plasticity is at the heart of early intervention, we next turn our attention to the efficacy of early intervention drawing from two distinct literatures: early intervention services for children growing up in disadvantaged environments, and children at elevated likelihood of developing a neurodevelopmental delay or disorder. In the case of the former, we single out interventions that target caregiving and in the case of the latter, we highlight recent work on autism. A consistent theme throughout our review is a discussion of how early intervention is embedded in the developing brain. We conclude our article by discussing the implications our review has for policy, and we then offer recommendations for future research.

Resilience and associated factors in orphaned and separated adolescents in Kenya: Understanding the relationship with care environment and HIV risks

Orphans are at higher risk of HIV infection and several important HIV risk factors than non-orphans; however, this may be due to a combination of related social, psychological, and economic factors, as well as care environment, rather than orphan status alone. Understanding these complex relationships may aid policy makers in supporting evidence-based, cost-effective programming for this vulnerable population. This longitudinal study uses a causal effect model to examine, through decomposition, the relationship between care environment and HIV risk factors in orphaned and separated adolescents and youths (OSAY) in Uasin Gishu County, Kenya; considering resilience, social, peer, or family support, volunteering, or having one's material needs met as potential mediators. We analysed survey responses from 1105 OSAY age 10-26 living in Charitable Children's Institutions (CCI) (orphanages) and family-based care settings (FBS). Follow-up time was 7-36 months. Care in CCIs (vs. FBS) was associated with a decreased likelihood of engaging in forced, exchange, and consensual sex. Excess relative risks (ERR) attributable to the indirect pathway, mediation, or interaction were not significant in any model. Care environment was not statistically associated with differences in substance use. Our findings support the direct, unmediated, association between institutional care and HIV risk factors.

Sensory processing challenges as a novel link between early caregiving experiences and mental health

Early caregiving adversity (ECA) is associated with elevated psychological symptomatology. While neurobehavioral ECA research has focused on socioemotional and cognitive development, ECA may also increase risk for "low-level" sensory processing challenges. However, no prior work has compared how diverse ECA exposures differentially relate to sensory processing, or, critically, how this might influence psychological outcomes. We examined sensory processing challenges in 183 8-17-year-old youth with and without histories of institutional (orphanage) or foster caregiving, with a particular focus on sensory over-responsivity (SOR), a pattern of intensified responses to sensory stimuli that may negatively impact mental health. We further tested whether sensory processing challenges are linked to elevated internalizing and externalizing symptoms common in ECA-exposed youth. Relative to nonadopted comparison youth, both groups of ECA-exposed youth had elevated sensory processing challenges, including SOR, and also had heightened internalizing and externalizing symptoms. Additionally, we found significant indirect effects of ECA on internalizing and externalizing symptoms through both general sensory processing challenges and SOR, covarying for age and sex assigned at birth. These findings suggest multiple forms of ECA confer risk for sensory processing challenges that may contribute to mental health outcomes, and motivate continuing examination of these symptoms, with possible long-term implications for screening and treatment following ECA.

Maternal incarceration increases the risk of self-harm but not suicide: a matched cohort study

AIMS

Children of incarcerated mothers are at increased risk of experiencing multiple adversity such as poverty, mental illness and contact with child protection services (CPS), including being taken into out of home care (OOHC). However, little is known about whether these children are at increased risk of suicide or self-harm compared to children not exposed to maternal incarceration or about the factors that may contribute to this. We aimed to investigate differences in the risk of suicide and self-harm between children exposed to maternal incarceration and those not exposed and examine how socio-demographic factors, maternal mental illness and CPS contact (with or without OOHC) may affect these outcomes.

METHODS

We used a retrospective matched cohort study design, comparing 7674 children exposed to maternal incarceration with 7674 non-exposed children. We used multivariable Cox proportional hazards regression to compare the risk of suicide and self-harm between exposed and non-exposed groups, controlling for geographical remoteness, CPS contact and maternal mental illness.

RESULTS

There was no significant difference in the rate of suicide (rate ratio [RR] = 1.49; 95% confidence interval [CI]: 0.78, 2.87) or risk of suicide (adjusted hazard ratio [aHR] = 0.92; 95% CI: 0.43, 1.96) between the two groups. However, the exposed group had a significantly higher rate of self-harm (RR = 2.83; 95% CI: 2.50, 3.21) and a significantly higher risk of self-harm (aHR = 1.74; 95% CI: 1.45, 2.09) compared to those non-exposed. CPS contact with or without OOHC was independently associated with an increased risk of self-harm for both groups.

CONCLUSION

Children exposed to maternal incarceration are at an increased risk of self-harm and should be prioritized to receive targeted, multimodal support that continues after the mother's release from prison. The association between CPS contact and self-harm warrants further research.

Prevalence, incidence and chronicity of child abuse among orphaned, separated, and street-connected children and adolescents in western Kenya: What is the impact of care environment?

BACKGROUND

The effect of different types of care environment on orphaned and separated children and adolescents' (OSCA) experiences of abuse in sub-Saharan Africa is uncertain.

OBJECTIVE

Our two primary objectives were 1) to compare recent child abuse (physical, emotional, and sexual) between OSCA living in institutional environments and those in family-based care; and 2) to understand how recent child abuse among street-connected children and youth compared to these other vulnerable youth populations.

PARTICIPANTS AND SETTING

This project followed a cohort of OSCA in Uasin Gishu County, Kenya (2009-2019). This analysis includes 2393 participants aged 18 years and below, 1017 from institutional environments, 1227 from family-based care, and 95 street-connected participants.

METHODS

The primary outcome of interest was recent abuse. Multiple logistic regression was used to estimate the odds of recent abuse at baseline, follow-up, and chronically for each abuse domain and adjusted odds ratios (AOR) between care environments, controlling for multiple factors.

RESULTS

In total, 47 % of OSCA reported ever experiencing any kind of recent abuse at baseline and 54 % in follow-up. Compared to those in family-based care, street-connected participants had a much higher reported prevalence of all types of recent abuse at baseline (AOR: 5.01, 95 % CI: 2.89, 9.35), in follow-up (AOR: 5.22, 95 % CI: 2.41, 13.98), and over time (AOR: 3.44, 95 % CI: 1.93, 6.45). OSCA in institutional care were no more likely than those in family-based care of reporting any recent abuse at baseline (AOR: 0.85 95 % CI: 0.59-1.17) or incident abuse at follow-up (AOR: 0.91, 95 % CI: 0.61-1.47).

CONCLUSION

OSCA, irrespective of care environment, reported high levels of recent physical, emotional, and sexual abuse. Street-connected participants had the highest prevalence of all kinds of abuse. OSCA living in institutional care did not experience more child abuse than those living in family-based care.

The Relationship Between Spirituality and Resilience and Well-being: a Study of 529 Care Leavers from 11 Nations

Research has found that individuals who were separated from parental care and experienced alternative care settings during childhood are more likely to have poor outcomes as adults. This highlights the importance of understanding factors that are related to resilience and well-being for care leavers. A growing body of research has supported the importance of spirituality in our understanding of resilience and well-being. However, little work to date has examined the relationship of spirituality to outcomes in care leavers. The current study investigated the relationships between spirituality, resilience, well-being, and health in a sample of 529 care leavers from 11 nations. It also examined how different themes of spirituality were related to specific outcome variables. Data revealed that spirituality was significantly associated with higher life satisfaction, better mental and physical health, and more resilience even when accounting for current age, gender, age at separation, Human Development Index scores, and childhood adversity. Furthermore, findings indicate that different themes of spirituality are related to specific outcome variables, even when accounting for demographic information. Findings indicate that spirituality may play an important role in resilience and well-being for care leavers. Implications and limitations are discussed.

Case report: Improving quality of care in Kazakhstan institutions

This project is a community case study implemented by local professionals and caregivers to improve the quality of caregiving in two Kazakhstan institutions for infants and toddlers. Local professionals first received comprehensive training by an international team experienced in relevant research-based practices, and then the locals trained institutional staff. Over nearly 2 years, one institution progressively implemented changes in three wards and the other institution in one ward. The changes attempted to make the institution more family-like (e.g., smaller groups and fewer and more consistent caregivers) and caregivers behave more parent-like (e.g., more warm, sensitive, responsive interactions and relationships) without changing nutrition or medical care. Of the 45 children given some exposure to the emerging new wards, 11 experienced the fully revised wards for at least 4 months during their first 2 years of life. They displayed substantial increases in their physical growth, especially those entering in their first year of life, in contrast to the unchanging developmental patterns of 165 children who were reared in the two institutions before the ward changes were made. Physical growth is a commonly used standard of developmental well-being in institutions. Research shows it is sensitive to infants' psychosocial environment, and improvements in physical growth are related to children's cognitive and social-emotional development. Although this pilot community case study had only a few infants fully exposed to the complete ward changes and lacked characteristics of a research experiment, these results are consistent with children's developmental improvements reported in larger scientific studies of similar interventions. This project is an example of how some research-based practices are likely to be implemented in communities in the future. Specifically, it shows that local communities can successfully improve the rearing conditions within institutions, which improve the children's development, and may contribute to the success of their subsequent foster placement and adoption.

Effect of care environment on educational attainment among orphaned and separated children and adolescents in Western Kenya

Background

There are approximately 140 million orphaned and separated children (OSCA) around the world. In Kenya, many of these children live with extended family while others live in institutions. Despite evidence that orphans are less likely to be enrolled in school than non-orphans, there is little evidence regarding the role of care environment. This evidence is vital for designing programs and policies that promote access to education for orphans, which is not only their human right but also an important social determinant of health. The purpose of this study was to compare educational attainment among OSCA living in Charitable Children’s Institutions and family-based settings in Uasin Gishu County, Kenya.

Methods

This study analyses follow up data from a cohort of OSCA living in 300 randomly selected households and 17 institutions. We used Poisson regression to estimate the effect of care environment on primary school completion among participants age ≥ 14 as well as full and partial secondary school completion among participants age ≥ 18. Risk ratios and 95% confidence intervals were estimated using a bootstrap method with 1000 replications.

Results

The analysis included 1406 participants (495 from institutions, 911 from family-based settings). At baseline, 50% were female, the average age was 9.5 years, 54% were double orphans, and 3% were HIV-positive. At follow-up, 76% of participants age ≥ 14 had completed primary school and 32% of participants age ≥ 18 had completed secondary school. Children living in institutions were significantly more likely to complete primary school (aRR: 1.18, 95% CI: 1.10–1.28) and at least 1 year of secondary school (aRR: 1.28, 95% CI: 1.18–1.39) than children in family-based settings. Children living in institutions were less likely to have completed all 4 years secondary school (aRR: 0.79, 95% CI: 0.43–1.18) than children in family-based settings.

Conclusion

Children living in institutional environments were more likely to complete primary school and some secondary school than children living in family-based care. Further support is needed for all orphans to improve primary and secondary school completion. Policies that require orphans to leave institution environments upon their eighteenth birthday may be preventing these youth from completing secondary school.

Family Composition and Stability for Orphans: A Longitudinal Study of Well-Being in 5 Low- and Middle-Income Countries

Objectives: Many orphaned children in low- and middle-income countries live with family. Yet, their household composition and its stability are not well-characterized, nor is impact of stability on longer-term outcomes.

Methods: We used the longitudinal, multi-country Positive Outcomes for Orphans cohort to describe adult family living with orphans. Stability was measured by changes in presence of six familial relations over time, and related to three outcomes: 1) incident abuse, 2) cognitive functioning, 3) emotional difficulties. Associations were estimated using generalized linear models fit with generalized estimating equations. For abuse, Poisson regression estimated risk ratios. For continuous scores of cognitive functioning and emotional difficulties, linear models estimated mean differences (MDs) with 95% confidence intervals.

Results: Among 1,359 orphans, 53–61% reported living with their mother each year; 7–13% with father; nearly 60% reported ≥1 change in composition over follow-up. Compared to 0 changes, difficulties increased with 1 change [MD: 0.23 (−0.33, 0.79)], 2 changes [MD: 0.57 (0.00, 1.16)] and ≥3 changes [MD: 0.73 (0.18, 1.29)]. No associations were found with abuse or cognitive functioning.

Conclusion: Orphan well-being may be improved through supports stabilizing household composition or targeting emotional resilience.

Growth in self-regulation over the course of adolescence mediates the effects of foster care on psychopathology in post-institutionalized children: a randomized clinical trial

Children reared in institutions experience severe psychosocial deprivation, with lasting consequences for social and emotional development. This study evaluated growth trajectories of self-regulation from ages 8 to 16 among institutionally-reared children randomized to foster care (foster care group; FCG) or to remain in institutional care (care as usual group; CAUG), compared to a never-institutionalized group (NIG). We then tested a developmental pathway by which growth in self-regulation reduces general psychopathology at 16 for FCG versus CAUG. FCG experienced modest growth in self-regulation over adolescence and "caught up" to NIG by age 16. The beneficial effect of foster care on psychopathology operated through growth in self-regulation; part of this effect was further mediated by reduced peer difficulties for FCG. Findings reveal that the effects of foster care on self-regulation emerge over adolescence and that growth in self-regulation is a mechanism by which foster care mitigates the impact of institutionalization on psychopathology.

Sex-Related Difference in the Association Between Child Neglect and the Accuracy of Body Weight Perception Among Chinese Primary Schoolchildren

Introduction: Body weight perception (BWP) directly determines weight management behaviors. Although child neglect is a well-established risk factor for managing body weight, little is known about its association with the accuracy of BWP. This study aimed to assess the cross-sectional and longitudinal associations between child neglect and BWP accuracy in primary schoolchildren, and explore how these differ based on the sex of the child. Methods: The sample included 1,063 primary schoolchildren (557 boys and 506 girls, aged 8-10 years) from a two-wave observational study between 2018 and 2019 in Wuhan, China. Child neglect and BWP were investigated using self-administered questionnaires. The accuracy of BWP was defined by comparing the BWP and actual body weight, and it was categorized into three groups-consistent, underestimated, and overestimated. Multinomial logistic regression analysis was conducted with fitting child neglect as the independent variable and the accuracy of BWP as the dependent variable. Results: The prevalence of weight misperception was ~44% at baseline (underestimation 40%; overestimation 4%) in Chinese primary schoolchildren. In the cross-sectional analysis, children with a higher level of neglect were more likely to misperceive their body weight. Moreover, there was an apparent sex-related difference that boys who experienced a higher level of neglect significantly reported more underestimation, while girls reported more overestimation. There was no significant longitudinal association between child neglect and the change in BWP accuracy. Conclusions: This study revealed that a higher level of neglect was significantly associated with underestimated BWP in boys and overestimated BWP in girls. The mechanisms of sex-related difference and whether child neglect is involved in the change in BWP, merit further investigations.

Association of Care Environment With HIV Incidence and Death Among Orphaned, Separated, and Street-Connected Children and Adolescents in Western Kenya

IMPORTANCE

In 2015, there were nearly 140 million orphaned children globally, particularly in low- and middle-income regions, and millions more for whom the street is central to their everyday lives. A total of 16.6 million children were orphaned because of deaths associated with HIV/AIDS, of whom 90% live in sub-Saharan Africa. Although most orphaned and separated children and adolescents in this region are cared for by extended family, the large number of children requiring care has produced a proliferation of institutional care. Few studies have investigated the association between care environment and physical health among orphaned and separated youths in sub-Saharan Africa.

OBJECTIVE

To examine the association of care environment with incident HIV and death among orphaned and separated children and adolescents who were living in charitable children's institutions, family-based settings, and street settings in western Kenya over almost 10 years.

DESIGN, SETTING, AND PARTICIPANTS

The Orphaned and Separated Children's Assessments Related to Their Health and Well-Being (OSCAR) project was an observational prospective cohort study conducted in Uasin Gishu County, Kenya. The cohort comprised 2551 orphaned, separated, and street-connected children from communities within 8 administrative locations, which included 300 randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 charitable children's institutions (institutional settings), and a convenience sample of 100 children who were practicing self-care on the streets (street settings). Participants were enrolled from May 31, 2010, to April 24, 2013, and were followed up until November 30, 2019.

EXPOSURES

Care environment (family-based, institutional, or street setting).

MAIN OUTCOMES AND MEASURES

Survival regression models were used to investigate the association between care environment and incident HIV, death, and time to incident HIV or death.

RESULTS

Among 2551 participants, 1230 youths were living in family-based settings, 1230 were living in institutional settings, and 91 were living in street settings. Overall, 1321 participants (51.8%) were male, with a mean (SD) age at baseline of 10.4 (4.8) years. Most participants who were living in institutional (1047 of 1230 youths [85.1%]) or street (71 of 91 youths [78.0%]) settings were double orphaned (ie, both parents had died). A total of 59 participants acquired HIV infection or died during the study period. After adjusting for sex, age, and baseline HIV status, living in a charitable children's institution was not associated with death (adjusted hazard ratio [AHR], 0.26; 95% CI, 0.07-1.02) or incident HIV (AHR, 1.49; 95% CI, 0.46-4.83). Compared with living in a family-based setting, living in a street setting was associated with death (AHR, 5.46; 95% CI, 2.30-12.94), incident HIV (AHR, 17.31; 95% CI, 5.85-51.25), and time to incident HIV or death (AHR, 7.82; 95% CI, 3.48-17.55).

CONCLUSIONS AND RELEVANCE

In this study, after adjusting for potential confounders, no association was found between care environment and HIV incidence or death among youths living in institutional vs family-based settings. However, living in a street setting vs a family-based setting was associated with both HIV incidence and death. This study's findings suggest that strengthening of child protection systems and greater investment in evidence-based family support systems that improve child and adolescent health and prevent youth migration to the street are needed for safe and beneficial deinstitutionalization to be implemented at scale.

Telepsychiatry Consultation for Primary Care Treatment of Children and Adolescents Receiving Child Protective Services in Chile: Mixed Methods Feasibility Study

Background

Children and adolescents living under the supervision of child protective services have complex mental health care needs. The scarcity and uneven distribution of specialized mental health teams in Chile may limit the provision and quality of care for this vulnerable population. Telepsychiatry can address such health inequities.

Objective

The objective of this study was to evaluate the feasibility of a telepsychiatry consultation program for primary health care (PHC) treatment of children and adolescents living under the supervision of child protective services.

Methods

We developed a telepsychiatry consultation program for two rural PHC clinics located in central Chile (Valparaíso Region) and evaluated its implementation using a mixed methods study design. The program consisted of videoconferencing mental health consultation sessions scheduled twice per month (each 90 minutes long), over a 6-month period, delivered by child and adolescent psychiatrists based in Santiago, Chile. We described the number of mental health consultation sessions, participant characteristics, perceived usefulness and acceptability, and experiences with the telepsychiatry consultation program.

Results

During the 6-month study period, 15 videoconferencing mental health consultation sessions were held. The telepsychiatry consultation program assisted PHC clinicians in assigning the most adequate diagnoses and making treatment decisions on pharmacotherapy and/or psychotherapy of 11 minors with complex care needs. The intervention was perceived to be useful by PHC clinicians for improving the resolution capacity in the treatments of this patient population. Limitations such as connectivity issues were resolved in most sessions.

Conclusions

The telepsychiatry consultation program was feasible and potentially useful to support PHC clinicians in the management of institutionalized children and adolescents with complex psychosocial care needs living in a poorly resourced setting. A larger scale trial should assess clinical outcomes in the patient population. Regulations and resources for this service model are needed to facilitate sustainability and large-scale implementation.

The impact of care environment on the mental health of orphaned, separated and street-connected children and adolescents in western Kenya: a prospective cohort analysis

Introduction

The effect of care environment on orphaned and separated children and adolescents’ (OSCA) mental health is not well characterised in sub-Saharan Africa. We compared the risk of incident post-traumatic stress disorder (PTSD), depression, anxiety and suicidality among OSCA living in Charitable Children’s Institutions (CCIs), family-based care (FBC) and street-connected children and youth (SCY).

Methods

This prospective cohort followed up OSCA from 300 randomly selected households (FBC), 19 CCIs and 100 SCY in western Kenya from 2009 to 2019. Annual data were collected through standardised assessments. We fit survival regression models to investigate the association between care environment and mental health diagnoses.

Results

The analysis included 1931 participants: 1069 in FBC, 783 in CCIs and 79 SCY. At baseline, 1004 participants (52%) were male with a mean age (SD) of 13 years (2.37); 54% were double orphans. In adjusted analysis (adjusted HR, AHR), OSCA in CCIs were significantly less likely to be diagnosed with PTSD (AHR 0.69, 95% CI 0.49 to 0.97), depression (AHR 0.48 95% CI 0.24 to 0.97), anxiety (AHR 0.56, 95% CI 0.45 to 0.68) and suicidality (AHR 0.73, 95% CI 0.56 to 0.95) compared with those in FBC. SCY were significantly more likely to be diagnosed with PTSD (AHR 4.52, 95% CI 4.10 to 4.97), depression (AHR 4.72, 95% CI 3.12 to 7.15), anxiety (AHR 4.71, 95% CI 1.56 to 14.26) and suicidality (AHR 3.10, 95% CI 2.14 to 4.48) compared with those in FBC.

Conclusion

OSCA living in CCIs in this setting were significantly less likely to have incident mental illness, while SCY were significantly more, compared with OSCA in FBC.

Amygdala Allostasis and Early Life Adversity: Considering Excitotoxicity and Inescapability in the Sequelae of Stress

Early life adversity (ELA), such as child maltreatment or child poverty, engenders problems with emotional and behavioral regulation. In the quest to understand the neurobiological sequelae and mechanisms of risk, the amygdala has been of major focus. While the basic functions of this region make it a strong candidate for understanding the multiple mental health issues common after ELA, extant literature is marked by profound inconsistencies, with reports of larger, smaller, and no differences in regional volumes of this area. We believe integrative models of stress neurodevelopment, grounded in "allostatic load," will help resolve inconsistencies in the impact of ELA on the amygdala. In this review, we attempt to connect past research studies to new findings with animal models of cellular and neurotransmitter mediators of stress buffering to extreme fear generalization onto testable research and clinical concepts. Drawing on the greater impact of inescapability over unpredictability in animal models, we propose a mechanism by which ELA aggravates an exhaustive cycle of amygdala expansion and subsequent toxic-metabolic damage. We connect this neurobiological sequela to psychosocial mal/adaptation after ELA, bridging to behavioral studies of attachment, emotion processing, and social functioning. Lastly, we conclude this review by proposing a multitude of future directions in preclinical work and studies of humans that suffered ELA.

Toxic stress, health and nutrition among Brazilian children in shelters

Background

Living in a shelter is an adverse experience that generates toxic stress. This situation can cause the dysregulation of the hypothalamic-pituitary-adrenal axis and exert a negative impact on health.The aim of the present study was to determine the association between toxic stress and social, clinical and nutritional characteristics in children at welfare institutions in a city of northeastern of Brazil.

Methods

An analytical, cross-sectional study was conducted with male and female children up to 60 months of age who live in shelters. Hair cortisol was used for the assessment of stress (immunoassay). The anthropometric data collected were height for age, body mass index for age, arm circumference for age, and head circumference for age (expressed in z-scores). We also evaluated food intake using markers proposed by the Brazilian Dietary and Nutritional Vigilance Surveillance System as well as the occurrence of dental caries and anemia.

Results

Sixty-three children one to 60 months of age participated in the present study. Asthma was the most frequent disease (11.1%). The prevalence of short stature, anemia and dental caries in the sample was 22.2, 22.2 and 9.4%, respectively. Cortisol levels ranged from 0.93 pg/mg to 391.29 pg/mg (median: 6.17 pg/mg). Higher cortisol levels were found in children with illnesses (p = 0.012) and those who had been hospitalized after being admitted to the institutions (p = 0.001).

Conclusions

The majority of children had unhealthy eating behavior. The cortisol concentrations found in the present study were suggestive of dysregulation of the hypothalamic-pituitary-adrenal axis. Hypercortisolism was associated with illness and hospitalization.

Better Language - Faster Helper: The Relation Between Spontaneous Instrumental Helping Action and Language Ability in Family-Reared and Institutionalized Toddlers

Background

Prosocial behavior is the key component of social and interpersonal relations. One of the elements of prosociality is helping behavior, which emerges already in early childhood. Researchers have identified several domains of helping behavior: instrumental helping, comforting another person, and sharing resources with others. The development of helping behavior can depend on a number of factors: children's age, the social situation of development, communication skills, and the ability to understand the feelings and needs of another person.

Objective

In Study 1, the main goal was to determine the effects of age and cognitive, language, and motor development on instrumental helping skills in early childhood. The goal of Study 2 was to estimate the effects of rearing in an adverse social environment by comparing the capacity for instrumental helping in family-raised and institutionalized children.

Design

The authors examined toddlers' (N = 198) ability to initiate spontaneous helping and the factors that may influence it. Cognitive, language, and fine motor skills were measured by the Bayley Scales of Infant and Child Development, 3rd edition. Children's instrumental helping behavior was assessed according to the procedure presented by Warneken and Tomasello, with a few modifications.

Results

Study 1 demonstrated that children's ability to initiate helping was dependent on their age: the non-helpers were significantly younger than the helpers. Children's language skills also played a significant role in their helping behavior. The children with higher language skills helped the adult more often and more quickly. Study 2 demonstrated that institutional placement per se was not related to toddlers' ability to initiate helping. Language ability was associated with helping behavior both in institution- and family-reared toddlers.

Conclusion

Instrumental helping in early childhood is related to children's age, language skills, and rearing conditions.

Neurodevelopmental effects of childhood malnutrition: A neuroimaging perspective

Approximately one in five children worldwide suffers from childhood malnutrition and its complications, including increased susceptibility to inflammation and infectious diseases. Due to improved early interventions, most of these children now survive early malnutrition, even in low-resource settings (LRS). However, many continue to exhibit neurodevelopmental deficits, including low IQ, poor school performance, and behavioral problems over their lifetimes. Most studies have relied on neuropsychological tests, school performance, and mental health and behavioral measures. Few studies, in contrast, have assessed brain structure and function, and to date, these have mainly relied on low-cost techniques, including electroencephalography (EEG) and evoked potentials (ERP). The use of more advanced methods of neuroimaging, including magnetic resonance imaging (MRI) and functional near-infrared spectroscopy (fNIRS), has been limited by cost factors and lack of availability of these technologies in developing countries, where malnutrition is nearly ubiquitous. This report summarizes the current state of knowledge and evidence gaps regarding childhood malnutrition and the study of its impact on neurodevelopment. It may help to inform the development of new strategies to improve the identification, classification, and treatment of neurodevelopmental disabilities in underserved populations at the highest risk for childhood malnutrition.

Development and Health of Adults Formerly Placed in Infant Care Institutions - Study Protocol of the LifeStories Project

A growing volume of research from global data demonstrates that institutional care under conditions of deprivation is profoundly damaging to children, particularly during the critical early years of development. However, how these individuals develop over a life course remains unclear. This study uses data from a survey on the health and development of 420 children mostly under the age of three, placed in 12 infant care institutions between 1958 and 1961 in Zurich, Switzerland. The children exhibited significant delays in cognitive, social, and motor development in the first years of life. Moreover, a follow-up of a subsample of 143 children about 10 years later revealed persistent difficulties, including depression, school related-problems, and stereotypies. Between 2019 and 2021, these formerly institutionalized study participants were located through the Swiss population registry and invited to participate once again in the research project. Now in their early sixties, they are studied for their health, further development, and life-course trajectories. A mixed-methods approach using questionnaires, neuropsychological assessments, and narrative biographical interviews was implemented by a multidisciplinary team. Combining prospective and retrospective data with standardized quantitative and biographical qualitative data allows a rich reconstruction of life histories. The availability of a community sample from the same geographic location, the 1954-1961 cohort of the Zurich Longitudinal Studies, described in detail in a paper in this issue (Wehrle et al., 2020), enables comparison with an unaffected cohort. This article describes the study design and study participants in detail and discusses the potential and limitations of a comparison with a community sample. It outlines a set of challenges and solutions encountered in the process of a lifespan longitudinal study from early childhood into the cusp of old age with a potentially vulnerable sample and summarizes the lessons learned along the way.

Psychosocial deprivation and receptive language ability: a two-sample study

Background

The quality of early caregiving experiences is a known contributor to the quality of the language experiences young children receive. What is unknown is whether, and if so, how psychosocial deprivation early in life is associated with long-lasting receptive language outcomes.

Methods

Two prospective longitudinal studies examining early psychosocial deprivation/neglect in different contexts (i.e., deprivation due to institutional care or deprivation experienced by children residing within US families) and receptive language as assessed via the Peabody Picture Vocabulary Test (PPVT) were used to assess the magnitude of these associations. First, 129 participants from the Bucharest Early Intervention Project, a randomized controlled trial of foster care as an alternative to institutional care in Romania, completed a receptive language assessment at age 18 years. Second, from the USA, 3342 participants from the Fragile Families and Child Wellbeing Study were assessed from infancy until middle childhood.

Results

Children exposed to early institutional care, on average, had lower receptive language scores than their never institutionalized counterparts in late adolescence. While randomization to an early foster care intervention had no long-lasting association with PPVT scores, the duration of childhood exposure to institutional care was negatively associated with receptive language. Psychosocial deprivation in US families was also negatively associated with receptive language longitudinally, and this association remained statistically significant even after accounting for measures of socioeconomic status.

Conclusion

Experiences of psychosocial deprivation may have long-lasting consequences for receptive language ability, extending to age 18 years. Psychosocial deprivation is an important prospective predictor of poorer receptive language.

Trial registration

Bucharest Early Intervention Project ClinicalTrials.gov Identifier: NCT00747396

Non-parental care in childhood and health up to 30 years later: ONS Longitudinal Study 1971-2011

BACKGROUND

Children who spend time in non-parental care report worse health later in life on average, but less is known about differences by type of care. We examined whether self-rated health of adults who had been in non-parental care up to 30 years later varied by type of care.

METHODS

We used longitudinal data from the office for National Statistics Longitudinal Study. Participants were aged <18 and never-married at baseline of each census year from 1971 to 2001. Separately for each follow-up period (10, 20 and 30 years later), multi-level logistic regression was used to compare self-rated health outcomes by different care types.

RESULTS

For combined census years, sample sizes were 157 896 dependent children with 10 years of follow-up, 166 844 with 20 years of follow-up and 173 801 with 30 years of follow-up. For all follow-up cohorts, longitudinal study members who had been in care in childhood, had higher odds of rating their health as 'not good' vs. 'good'; with highest odds for residential care. For example, 10-year follow-up odds ratios were 3.5 (95% confidence interval: 2.2-5.6) for residential care, 2.1 (1.7-2.5) for relative households and 2.6 (2.1-3.3) for non-relative households, compared with parental households after adjustment for childhood demographics. Associations were weakest for 10-year, and strongest for 20-year, follow-up. Additional adjustment for childhood social circumstances reduced, but did not eliminate, associations.

CONCLUSION

Decades after children and young people are placed in care, they are still more likely to report worse health than children who grew up in a parental household.

Anna's Story: How a Ukrainian Orphan's Acquisition of English as a Second Language Transformed Her Life

This article presents a case study of an adult Ukrainian orphan, Anna, who acquired English as a second and accessed U.S. higher education despite the fact that adopted children or aged out orphans face a unique constellation of educational and psychological challenges in language learning. This article presents Anna's story in her own voice and advocates for the specialized needs of the underserved, often voiceless thousands of older orphans in war-stricken Ukraine. This article suggests that access to institutional agents and social capital played a key role in Anna's success. Of interest to researchers, the article postulates common, current language learning theory perhaps may not fully explain the distinct processes of language acquisition by institutionalized, language-delayed children. The article also offers tangible lessons for educators of victims of trauma, and would thus be of interest to practitioners as well as researchers in the areas of language acquisition and educational psychology.

Moderating the Risk for Attention Deficits in Children with Pre-Adoptive Adversity: The Protective Role of Shorter Duration of out of Home Placement and Children's Enhanced Error Monitoring

Early institutional-deprivation has been found to increase risk for inattention/hyperactivity (ADHD). Notably, studies suggest that children with a history of adversity evidencing an enhanced ERP (the error-related-negativity; ERN) may be protected against attention problems. However, such protective effects of the ERN have been studied in children whom typically experienced residential instability. It is unknown whether error-monitoring is similarly protective for children with stable post-deprivation placements. The present study examined the protective effect of the ERN in a sample of children who experienced at least 3-years of stable, relatively enriched caregiving after being internationally-adopted as infants/toddlers from institutional-care. We included two groups of children adopted internationally before age three, one group adopted from institutional-care (PI:n = 80) and one comparison group adopted from foster-care (FC;n = 44). A second comparison group consisted of non-adopted children (NA;n = 48) from demographically comparable families. At five-years of age, we assessed child ADHD symptoms (parent-report) and behavioral performance and neural correlates of error-monitoring (Go/No-Go task). PI children displayed lower Go/No-Go accuracy relative to FC children, and higher levels of ADHD symptoms relative to NA controls. In both FC and PI groups, longer duration of pre-adoptive out-of-home placement was associated with inattention, especially for children with deficits in error-monitoring. Enhancing cognitive control in the form of error monitoring might be a useful intervention target to protect children from some of the negative outcomes associated with adverse early care. Furthermore, results underscore that regardless of type of pre-adoptive care, we should aim to place children in stable/permanent homes as early as possible.

Psychosocial Stress and Adversity: Effects from the Perinatal Period to Adulthood

Early exposure to stress and adversity can have both immediate and lasting effects on physical and psychological health. Critical periods have been identified in infancy, during which the presence or absence of experiences can alter developmental trajectories. There are multiple explanations for how exposure to psychosocial stress, before conception or early in life, has an impact on later increased risk for developmental delays, mental health, and chronic metabolic diseases. Through both epidemiologic and animal models, the mechanisms by which experiences are transmitted across generations are being identified. Because psychosocial stress has multiple components that can act as stress mediators, a comprehensive understanding of the complex interactions between multiple adverse or beneficial experiences and their ultimate effects on health is essential to best identify interventions that will improve health and outcomes. This review outlines what is known about the biology, transfer, and effects of psychosocial stress and early life adversity from the perinatal period to adulthood. This information can be used to identify potential areas in which clinicians in neonatal medicine could intervene to improve outcomes.

Association of childhood out-of-home care status with all-cause mortality up to 42-years later: Office of National Statistics Longitudinal Study

Background

The adverse life-long consequences of being looked-after as a child are well recognised, but follow-up periods for mortality risk have mostly ended in young adulthood and mortality suggested to differ by age of placement, gender and cohort in small samples.

Methods

Data on 353,601 Office for National Statistics Longitudinal Study (LS) members during census years 1971–2001, and Cox proportional hazards regression models with time-varying covariates (age as the timescale), were used to examine whether childhood out-of-home care was associated with all-cause mortality until the end of 2013. After adjusting for baseline age and age², gender, born outside the United Kingdom, number of census observations in childhood and baseline census year we tested whether mortality risk varied for those in care by age, gender and baseline census year, by separate assessment of interaction terms. Supplementary analyses assessed robustness of findings.

Results

Adults who had been in care at any census (maximum of two) had an adjusted all-cause mortality hazard ratio 1.62 (95% CI 1.43, 1.86) times higher than adults who had never been in care. The excess mortality was mainly attributable to deaths categorised as self-harm, accidents and mental & behavioural causes. Mortality risk was elevated if the LS member was initially assessed in 1981 or 2001, compared to 1971. There was no significant variation in mortality risk for those in care by age or gender. The main findings were consistent irrespective of choice of comparison group (whole population, disadvantaged population), care placement (residential, non-residential) and age at death (all ages, adulthood only).

Conclusions

In this large, nationally representative study of dependent children resident in England and Wales, those who had been in care during childhood had a higher risk of mortality long after they had left care on average, mainly from unnatural causes. No differences by age or gender were found. Children in care have not benefitted from the general decline in mortality risk over time.

Prevalence and number of children living in institutional care: global, regional, and country estimates

BACKGROUND

Children living in institutionalised settings are at risk of negative health and developmental outcomes, as well as physical and emotional abuse, yet information on their numbers is scarce. Therefore, the aim of our study was to estimate global-level, regional-level, and country-level numbers and percentages of children living in institutional care.

METHODS

In this estimation study, we did a systematic review of peer-reviewed publications and a comprehensive review of surveys and unpublished literature to construct a dataset on children living in institutional care from 136 countries between 2001 and 2018. We applied a wide range of methods to estimate the number and percentages of children living in institutional care in 191 countries in 2015, the year the Sustainable Development Goals were adopted. We generated 98 sets of estimates for each dataset, with possible combinations of imputation methods for countries with different available data points. Of these 98 sets, we report here five types of global-level estimates: estimates with the highest values, those with the lowest values, those with median values, those with uncertainty levels, and those derived from methods with the smallest root-mean-square errors (RMSE).

FINDINGS

Global estimates of children living in institutions in 2015 was highly sensitive to the methods and data used, ranging from 3·18 million to 9·42 million children, with a median estimate of 5·37 million. When selecting the method with the lowest RMSE, the global estimate was 4·21 million, whereas with negative binomial regression with bootstrapping, the global estimate was 7·52 (95% CI 7·48-7·56) million. We also observed large variations in country-level estimates. Compared with other regions, estimates in south Asia, sub-Saharan Africa, and Latin America had larger variations in values when switching between estimation methods. High-income countries had the highest average prevalence of institutionalisation, whereas low-income countries had the lowest average prevalence. Estimates from the full data with the smallest RMSE method showed that south Asia had the largest estimated number of children living in institutions (1·13 million), followed by Europe and central Asia (1·01 million), east Asia and Pacific (0·78 million), sub-Saharan Africa (0·65 million), Middle East and North Africa (0·30 million), Latin America and the Caribbean (0·23 million), and North America (0·09 million). North America consistently had the lowest estimates among all regions.

INTERPRETATION

Worldwide, institutional care places millions of children at elevated risk of negative health and developmental outcomes, highlighting the need for deinstitutionalisation. However, there is considerable uncertainty regarding the number of children living in institutions. To improve estimates of the size of this population, we need to standardise the definition of institutional care and improve data collection, particularly in countries with large child populations.

FUNDING

Lumos Foundation.

Factors Contributing to Maternal-Child Separation in Port-Au-Prince, Haiti

Background

The Haitian orphanage sector receives more than 70 million United States Dollars (USD) in foreign aid annually and continues grow; there are over 500 orphanages in Port-Au-Prince alone. An estimated 80% of the 30,000 children living in Haitian orphanages have at least one living parent.

Objectives

This research seeks to identify factors contributing to maternal-child separation in Port-Au-Prince to understand motivations and attitudes surrounding maternal-child separation. We hypothesized that poverty, health status, and current state of the family unit are influential in the mother's decision to separate from her child.

Methods

From June to August 2017, a chain referral sampling study was conducted in Port-Au-Prince and the surrounding metropolitan area. Seventy interviews were conducted with (1) Mothers - separated (n = 8) and non-separated (n = 48) - and (2) Community leaders exposed to maternal-child separation (n = 18). The semi-structured interview consisted of questions about (1) exposure to maternal-child separation, (2) circumstances surrounding maternal-child separation, and (3) factors contributing to maternal-child separation. Additionally, all mothers completed a survey including demographic information and multiple validated surveys: Maternal Postpartum Quality of Life, Patient Health Questionnaire (PHQ-9), and PTSD Checklist (PCL) to address quality of life, depression, and PTSD, respectively.

Findings

This study found separation to be associated with poor economic means compounded with other factors, most notably access to education, ability to care for disabled children, insufficient support, and poor maternal mental health. Additional themes identified include negative stigma towards maternal-child separation and sparse education surrounding family planning. Quantitative findings revealed separated mothers experienced significantly higher rates of PTSD compared to non-separated, small but statistically worse quality of life, and no difference in rates of major depression.

Conclusion

This research finds economic means to be insufficient in predicting maternal-child separation, with access to education being the most salient contributing factor mentioned after economics. Findings from this study will inform development of programming focusing on education, family planning, and social support in Port-Au-Prince.

Early childhood development: an imperative for action and measurement at scale

Experiences during early childhood shape biological and psychological structures and functions in ways that affect health, well-being and productivity throughout the life course. The science of early childhood and its long-term consequences have generated political momentum to improve early childhood development and elevated action to country, regional and global levels. These advances have made it urgent that a framework, measurement tools and indicators to monitor progress globally and in countries are developed and sustained. We review progress in three areas of measurement contributing to these goals: the development of an index to allow country comparisons of young children’s development that can easily be incorporated into ongoing national surveys; improvements in population-level assessments of young children at risk of poor early development; and the production of country profiles of determinants, drivers and coverage for early childhood development and services using currently available data in 91 countries. While advances in these three areas are encouraging, more investment is needed to standardise measurement tools, regularly collect country data at the population level, and improve country capacity to collect, interpret and use data relevant to monitoring progress in early childhood development.

A systematic scoping review of hygiene behaviors and environmental health conditions in institutional care settings for orphaned and abandoned children

BACKGROUND

Adequate hygiene behaviors and environmental health conditions are fundamental to children's health, development, and well-being. They are especially important in institutional care settings for orphaned and abandoned children, a particularly vulnerable population whose basic needs are often not met.

OBJECTIVES

We systematically reviewed the evidence about hygiene behaviors and environmental health conditions in institutional care settings for children and associated health outcomes; interventions to improve these behaviors, conditions, and outcomes; and obstacles to improvement.

METHODS

PubMed, Web of Science, Scopus, and EBSCOhost were searched for studies in the peer-reviewed and grey literature. Studies were included if they reported primary data on one or more environmental health condition or hygiene behavior in an institutional care setting for orphaned and abandoned children.

RESULTS

Forty-five publications reporting on over 500 institutions in 29 countries were included. The most documented concern was poor personal hygiene behaviors followed by inadequate water and sanitation infrastructure and overcrowding. Protozoan, helminthic, viral infections, and diarrheal illness among institutionalized children were the most commonly documented associated health outcomes.

DISCUSSION

More studies documented the status of hygiene and environmental health in children's institutions than interventions to improve behaviors and conditions. Insufficient finances and expertise or involvement of caregivers are reported barriers to implementing improvements in children's institutions. The development of guidelines for essential environmental health standards in orphanages, monitoring of facility conditions, accountability for facility deficiencies, and implementation research to identify improvement opportunities would contribute to and promote the health and development of orphaned and abandoned children worldwide.

"A child who is hidden has no rights": Responses to violence against children with disabilities

BACKGROUND

There is an urgent need to understand how best to prevent and respond to violence against children with disabilities as they are at a high risk for violence because they are marginalized, isolated, and targeted and have little power within their communities.

OBJECTIVE

Guided by social-ecological theory, this study explores responses to violence against children with disabilities, including preventative measures and treatment of victims in the West African countries of Guinea, Niger, Sierra Leone, and Togo.

PARTICIPANTS

Participants were recruited using purposive and snowball sampling from the following three groups: disability stakeholders including representatives from local, national, and international organizations and governments; community members including parents, teachers, and leaders; and children with disabilities.

METHODS

A qualitative study design guided data generation, that included document analysis, semi-structured interviews, and focus groups across the four countries. In total, 419 people participated. Of those participants, 191 took part in an interview and the rest participated in one of 55 focus groups.

FINDINGS

Responses to disability-based violence are driven at the mesosystem and exosystem levels. Prevailing views indicated that national level policies and laws are not always considered part of solutions, communities are leading responses to violence, and children with disabilities are hidden at home or in institutions for both their own and their family's safety. Conclusions The findings can inform development of prevention and intervention programs that will protect children with disabilities from violence in contexts with high levels of disability stigma, social conflict, violence, and poverty.

Institutional caregiver experiences in child care

ABSTRACT Objective: to know the experience of institutional caregivers in child care. Method: qualitative research that used the Attachment Theory and the Symbolic Interactionism. Fifteen caregivers were interviewed, in 2015, in a child care institution based in a municipality in the south of Brazil. Data were analyzed through content analysis. Results: two categories emerged from the study: Embracing the children in the institution; Helping children adapt to institutionalization. Institutionalization imposes several social ills, such as abandonment and violence. These must be faced by caregivers, generating sadness and revolt. In addition, institutionalization leaves a mark on the child’s life, which belongs to no one, nor has his individuality and subjectivity preserved. Conclusion and Implications for practice: it is necessary to provide caregivers psychological support and Permanent Education so that they are supported in the work, improving the conditions of care offered to the child.

Future Directions in the Study and Treatment of Parent-Child Separation

Children require adult caregivers to survive and thrive. In the absence of committed and nurturing care, children face increased risk for a number of difficulties, including internalizing and externalizing psychopathology, cognitive and language deficits, and social difficulties. Recent changes in the U.S. immigration system have resulted in a large number of children removed from their parents, drawing increased scrutiny to the impact of parent-child separation and best practices for caring for children who have been separated. Drawing from work on children exposed to institutional care, as well as research on children separated from caregivers due to validated abuse and neglect, it is clear that children belong in families that are safe and supportive and that some forms of substitute care (i.e., institutional or group-based care) are insufficient to meet children's needs. However, it is difficult to know the specific impact of parent-child separation on child outcomes given that stressors often cluster and pre-separation experiences and post-separation placements also contribute to the experience of separation from a parent and subsequent functioning. Attempts to parse the specific contributions of each separation-related stressor, examining sensitive periods in the impact of separation, studying the mechanisms by which separations affect children, and consideration of the broader social and political context are useful future directions for moving this area of study forward. We must also more fully probe the roles that caregivers play in child development. Lastly, we must endeavor to cease practices of removing children from loving and capable caregivers and, when necessary, provide support to parents and children who have experienced separation.

Effects of early institutionalization on emotion processing in 12-year-old youth

We examined facial emotion recognition in 12-year-olds in a longitudinally followed sample of children with and without exposure to early life psychosocial deprivation (institutional care). Half of the institutionally reared children were randomized into foster care homes during the first years of life. Facial emotion recognition was examined in a behavioral task using morphed images. This same task had been administered when children were 8 years old. Neutral facial expressions were morphed with happy, sad, angry, and fearful emotional facial expressions, and children were asked to identify the emotion of each face, which varied in intensity. Consistent with our previous report, we show that some areas of emotion processing, involving the recognition of happy and fearful faces, are affected by early deprivation, whereas other areas, involving the recognition of sad and angry faces, appear to be unaffected. We also show that early intervention can have a lasting positive impact, normalizing developmental trajectories of processing negative emotions (fear) into the late childhood/preadolescent period.

Global services and support for children with developmental delays and disabilities: Bridging research and policy gaps

Pamela Collins and colleagues explain the research and policy approaches needed globally to ensure children with developmental delays and disabilities are fully included in health and education services.

Biological embedding of childhood adversity: from physiological mechanisms to clinical implications

BACKGROUND

Adverse psychosocial exposures in early life, namely experiences such as child maltreatment, caregiver stress or depression, and domestic or community violence, have been associated in epidemiological studies with increased lifetime risk of adverse outcomes, including diabetes, heart disease, cancers, and psychiatric illnesses. Additional work has shed light on the potential molecular mechanisms by which early adversity becomes "biologically embedded" in altered physiology across body systems. This review surveys evidence on such mechanisms and calls on researchers, clinicians, policymakers, and other practitioners to act upon evidence.

OBSERVATIONS

Childhood psychosocial adversity has wide-ranging effects on neural, endocrine, immune, and metabolic physiology. Molecular mechanisms broadly implicate disruption of central neural networks, neuroendocrine stress dysregulation, and chronic inflammation, among other changes. Physiological disruption predisposes individuals to common diseases across the life course.

CONCLUSIONS

Reviewed evidence has important implications for clinical practice, biomedical research, and work across other sectors relevant to public health and child wellbeing. Warranted changes include increased clinical screening for exposures among children and adults, scale-up of effective interventions, policy advocacy, and ongoing research to develop new evidence-based response strategies.

Parenting, the other oldest profession in the world - a cross-sectional study of parenting and child outcomes in South Africa and Malawi

BACKGROUND

Parenting quality is important in child development. In the presence of HIV poverty and life stress, parenting may be challenged and child development affected.

METHODS

This study examines cross-sectional associations of situational factors such as poverty, mental health, HIV status, living with a biological parent, and stigma with good parenting and child outcomes (n=989; age=4-13 years) within the Child Community Care study (South Africa and Malawi). A parenting measure was created from 10 variables comprising 6 child and 4 parent ratings. These were highly correlated. Total parenting score was generated on a 10 point continuous scale, with a good parenting cut off then defined as >=8 out of a possible 10.

RESULTS

Five factors were associated with good parenting. Positively associated with good parenting were being the biological parent of the child, parental mental health and dwelling in households with multiple adults. Poverty and stigma were negatively associated with good parenting. Using multiple mediation analysis, a positive direct effect of good parenting was found on child self-esteem, child behaviour and educational risks with a partial mediation via child depression and trauma.

CONCLUSIONS

These data highlight possible intervention points. Influences on parenting could be seen through being the biological parent, parental mental health, poverty and stigma. In these challenging environments, health, nutrition, mental health, education, and treatment to keep parents alive are all clearly identified as potential pathways to ensure child well-being.

Child violence experiences in institutionalised/orphanage care

Institutions are not necessarily good environments for children. In the face of challenges such as HIV, Ebola, poverty, conflict and disaster the numbers have grown rather than reduced. Some countries have closed institutions down -driven by findings that cognitive developmental delay is associated with institutional care. Yet insight into abuse and violence within institutionalised settings is neglected. Maltreatment -violence and abuse -may be an issue. This systematic review series addresses violence and abuse experiences in institutionalised care, exploring firstly the frequency of abuse/violence in institutions, secondly any interventions to reduce such violence or abuse and thirdly the perpetrators of such violence or abuse. The final systematic review updates the findings on cognitive delay associated with institutionalised care. With a violence lens, cognitive delay may well be considered under the umbrella of neglect. Maltreatment and abuse may be a driver of cognitive delay. The keyword search covered several electronic databases and studies were included for data abstraction if they met adequacy criteria. Eight studies were identified on the prevalence of abuse in institutions and a further three studies reported on interventions. Only one study was identified documenting peer on peer violence in institutions. Sixty-six studies were identified examining cognitive development for institutionalised children. All but two of these record cognitive deficits associated with institutionalisation. Only two asked about violence or abuse which was found to be higher in institutionalised children. Overall the abuse experiences of children in institutions are poorly recorded, and in one study violence was associated with high suicidal attempts. The major intervention pathway for ameliorating cognitive challenge seems to be placement out of the institutions which shows benefits and redresses some cognitive outcomes - yet not a total panacea. The single study providing training and monitoring of harsh punishment and maltreatment showed immediate and decided reductions. This data suggest, despite the paucity of studies, violence and abuse, by commission or omission is prevalent in institutions, has an effect on child well-being and is amenable to intervention. Simple training or more complex structures to place children within conducive alternative environments (or to avoid institutionalised placements in the first place) seem to be the main pathway of intervention.

Early childhood development coming of age: science through the life course

Early childhood development programmes vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential. There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Equitable early childhood policies and programmes are crucial for meeting Sustainable Development Goals, and for children to develop the intellectual skills, creativity, and wellbeing required to become healthy and productive adults. In this paper, the first in a three part Series on early childhood development, we examine recent scientific progress and global commitments to early childhood development. Research, programmes, and policies have advanced substantially since 2000, with new neuroscientific evidence linking early adversity and nurturing care with brain development and function throughout the life course.

Out-of-Home Placement for Children and Adolescents With Disabilities-Addendum: Care Options for Children and Adolescents With Disabilities and Medical Complexity

Children and adolescents with significant intellectual and developmental disabilities and complex medical problems require safe and comprehensive care to meet their medical and psychosocial needs. Ideally, such children and youth should be cared for by their families in their home environments. When this type of arrangement is not possible, there should be exploration of appropriate, alternative noncongregate community-based settings, especially alternative family homes. Government funding sources exist to support care in the community, although there is variability among states with regard to the availability of community programs and resources. It is important that families are supported in learning about options of care. Pediatricians can serve as advocates for their patients and their families to access community-based services and to increase the availability of resources to ensure that the option to live in a family home is available to all children with complex medical needs.

Civic engagement among orphans and non-orphans in five low- and middle-income countries

BACKGROUND

Communities and nations seeking to foster social responsibility in their youth are interested in understanding factors that predict and promote youth involvement in public activities. Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in resource-poor settings. Understanding whether and how OSC are engaged in civic activities is important for community and world leaders who need to provide care for OSC and ensure their involvement in sustainable development.

METHODS

The Positive Outcomes for Orphans study (POFO) is a multi-country, longitudinal cohort study of OSC randomly sampled from institution-based care and from family-based care, and of non-OSC sampled from the same study regions. Participants represent six sites in five low-and middle-income countries. We examined civic engagement activities and government trust among subjects > =16 years old at 90-month follow-up (approximately 7.5 years after baseline). We calculated prevalences and estimated the association between key demographic variables and prevalence of regular volunteer work using multivariable Poisson regression, with sampling weights to accounting for the complex sampling design.

RESULTS

Among the 1,281 POFO participants > =16 who were assessed at 90-month follow-up, 45 % participated in regular community service or volunteer work; two-thirds of those volunteers did so on a strictly voluntary basis. While government trust was fairly high, at approximately 70 % for each level of government, participation in voting was only 15 % among those who were > =18 years old. We did not observe significant associations between demographic characteristics and regular volunteer work, with the exception of large variation by study site.

CONCLUSION

As the world's leaders grapple with the many competing demands of global health, economic security, and governmental stability, the participation of today's youth in community and governance is essential for sustainability. This study provides a first step in understanding the degree to which OSC from different care settings across multiple low- and middle-income countries are engaged in their communities.