Institutional Care for Young Children: Review of Literature and Policy Implications

Impacts of early deprivation on behavioral and neural measures of executive function in early adolescence

Children reared in institutional settings experience early deprivation that has lasting implications for multiple aspects of neurocognitive functioning, including executive function (EF). Changes in brain development are thought to contribute to these persistent EF challenges, but little research has used fMRI to investigate EF-related brain activity in children with a history of early deprivation. This study examined behavioral and neural data from a response conflict task in 12-14-year-olds who spent varying lengths of time in institutional care prior to adoption (N = 84; age at adoption - mean: 15.85 months, median: 12 months, range: 4-60 months). In initial analyses, earlier- and later-adopted (EA, LA) youth were compared to a group of children raised in their biological families (non-adopted, NA). NA youth performed significantly more accurately than LA youth, with EA youth falling in between. Imaging data suggested that previously institutionalized (PI) youth activated additional frontoparietal regions, including dorsolateral prefrontal cortex, as compared to NA youth. In addition, EA youth uniquely activated medial prefrontal regions, and LA uniquely activated parietal regions during this task. A separate analysis in a larger group of PI youth examined whether behavioral or brain measures of EF varied with the duration of deprivation experienced. Duration of deprivation was negatively associated with activation of default mode network (DMN) regions. Overall, results suggest that there are lasting effects of deprivation on EF, but that those who are removed from institutional care earlier may be able to recruit additional neural resources as a compensatory mechanism.

The Placement of Children in Need of Out-of-Home Care: Forms of Care and Differences in Attachment Security and Behavioral Problems in the Italian Context

The current paper investigated differences in secure attachment levels and behavioral problems among four groups of children in out-of-home care in Italy: closed adoption (child and birth parents not in contact following adoption), open adoption (child and birth parents still in contact after placement), foster care (child living temporarily with relatives or unrelated foster parents) and institutional care (child in residential care for large groups of children). One hundred and thirty children aged 10-19 were included in this study. The Attachment Interview for Childhood and Adolescence and the Achenbach Youth Self-Report were employed to measure participants' secure attachment levels and behavioral problems. Both a multivariate analysis of covariance and measured variable path analysis were performed. Age, gender and time elapsed between the request for child protection and placement on out-of-home care were used as covariates. The results showed that adolescents in closed adoption had higher secure attachment scores than those in foster care and institutional care, while adolescents in open adoption scored significantly higher on problem behaviors than those in the other out-of-home care groups. Findings were discussed in terms of limitations and implications for future research.

Global priority for the care of orphans and other vulnerable children: transcending problem definition challenges

BACKGROUND

Tens of millions of children lack adequate care, many having been separated from or lost one or both parents. Despite the problem's severity and its impact on a child's lifelong health and wellbeing, the care of vulnerable children-which includes strengthening the care of children within families, preventing unnecessary family separation, and ensuring quality care alternatives when reunification with the biological parents is not possible or appropriate-is a low global priority. This analysis investigates factors shaping the inadequate global prioritization of the care of vulnerable children. Specifically, the analysis focuses on factors internal to the global policy community addressing children's care, including how they understand, govern, and communicate the problem.

METHODS

Drawing on agenda setting scholarship, we triangulated among several sources of data, including 32 interviews with experts, as well as documents including peer-reviewed literature and organizational reports. We undertook a thematic analysis of the data, using these to create a historical narrative on efforts to address children's care, and specifically childcare reform.

RESULTS

Divisive disagreements on the definition and legitimacy of deinstitutionalization-a care reform strategy that replaces institution-based care with family-based care-may be hindering priority for children's care. Multiple factors have shaped these disagreements: a contradictory evidence base on the scope of the problem and solutions, divergent experiences between former Soviet bloc and other countries, socio-cultural and legal challenges in introducing formal alternative care arrangements, commercial interests that perpetuate support for residential facilities, as well as the sometimes conflicting views of impacted children, families, and the disability community. These disagreements have led to considerable governance and positioning difficulties, which have complicated efforts to coordinate initiatives, precluded the emergence of leadership that proponents universally trust, hampered the engagement of potential allies, and challenged efforts to secure funding and convince policymakers to act.

CONCLUSION

In order to potentially become a more potent force for advancing global priority, children's care proponents within international organizations, donor agencies, and non-governmental agencies working across countries will need to better manage their disagreements around deinstitutionalization as a care reform strategy.

Trauma of separation: the social and emotional impact of institutionalization on children in a post-soviet country

BACKGROUND

In the former Soviet Union (fSU) region, which has the highest rate of institutional care worldwide, 'social orphans' -indigent children who have one or both parents living-are placed in publicly run residential institutions to receive education, food, and shelter. Few studies have focused on understanding the emotional effects of separation and life in an institutional environment on children who grow up with their families.

METHODS

Semi-structured qualitative interviews (N = 47) were conducted with 8- to 16-year-old children with a history of institutional care placement and their parents in Azerbaijan. Semi-structured qualitative interviews were conducted with 8- to 16-year-old children (n = 21) involved in the institutional care system in Azerbaijan and their caregivers (n = 26). Trained interviewers collected narratives about children's experiences prior to being separated from their families while living in an institution, as well as the impact of institutional placement on their emotional well-being. We applied thematic analysis with inductive coding.

RESULTS

Most of the children entered institutions around the school entry age. Prior to entering institutions, children had already experienced disruptions within their family environments and multiple traumatic events, including witnessing domestic violence, parental divorce, and parental substance abuse. Once institutionalized, these children may have had their mental health further impaired by a sense of abandonment, a strictly regimented life, and insufficiencies of freedom, privacy, developmentally stimulating experiences, and, at times, safety.

CONCLUSION

This study illustrates the emotional and behavioral consequences of institutional placement and the need to address accumulated chronic and complex traumatic experiences that occurred before and during institutional placement, which may affect emotion regulation and the familial and social relationships of children who lived in institutions in a post-Soviet country. The study identified mental health issues that could be addressed during the deinstitutionalization and family reintegration process to improve emotional well-being and restore family relationships.

Attachment dimensions and cortisol responses during the strange situation among young children adopted internationally

Children's attachments to their parents may help regulate their hypothalamic-pituitary-adrenal (HPA) axes. Prior research has largely focused on children with relatively consistent and low-risk caregiving histories, resulting in limited knowledge about the associations between attachment quality and HPA axis reactivity among children who have experienced early adversity. This study investigated whether dimensional measures of attachment quality were associated with HPA responses to the Strange Situation Procedure (SSP) among 64 children ages 11-33 months adopted internationally from institutional or foster care. Children who showed high levels of attachment avoidance exhibited a blunted cortisol response during the SSP. Conversely, children who sought proximity and contact with their adoptive parents exhibited an increase in cortisol reactivity during the SSP, followed by a return to baseline levels after the completion of the procedure. This association was independent of the previously reported association between parental insensitivity and blunted cortisol responses in this sample.

"I will commit to this child as much as I can for the time that they are with me:" A qualitative examination of how foster carer commitment relates to short-term foster care for young children following abuse and neglect

BACKGROUND

Foster carer commitment to the child has been shown to be of paramount importance in young children's recovery and development following abuse and neglect. In Dozier's definition of commitment in the US, there is a focus on both emotional investment in the child and committing to an enduring relationship with the child. How this relates to the routine practice of short-term, temporary, foster care has not been studied.

OBJECTIVE

This is the first qualitative study to explore the drivers of, and barriers to, commitment in short-term foster care within the broader aim of examining whether short-term care is meeting the needs of maltreated young children.

PARTICIPANTS & SETTING

Fourteen foster carers took part in research interviews and five focus groups were conducted with infant mental health professionals.

METHODS

Interviews and focus group data were subject to qualitative thematic analysis in order to identify patterns of commonality in relation to our research questions.

RESULTS

Three broad themes pertain to commitment and the meeting of young children's needs in short-term foster care: Influence, Timescales and Choice in the fostering role. These themes were found to house both drivers of, and barriers to, commitment in short-term care, which are influenced by systemic normalisations of fostering practices.

CONCLUSIONS

The emotional investment facet of commitment is more alive in the 'psyche' of short-term foster care than commitment to an enduring relationship. A long-term outlook for the child may be an undefined facet of commitment that is more akin with short-term placements.

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.

The Effectiveness of the Super Skills for Life (SSL) Programme in Promoting Mental Wellbeing among Institutionalised Adolescents in Malaysia: An Interventional Study

Background: Mental health issues have become more prevalent among institutionalised adolescents. Therefore an effective intervention programme is needed to improve their mental health. Objective: To evaluate the effectiveness of the Super Skills for Life (SSL) programme in improving the mental wellbeing of institutionalised adolescents and determine the factors associated with their mental wellbeing. Methods: A quasi-experimental study involving 80 female institutionalised adolescents divided into intervention and control groups was conducted. Intervention involved implementation of the SSL programme. The effectiveness of the programme was evaluated based on several outcome parameters. Results: Factors including age, number of family members, perceived social support and self-esteem had significant correlations with mental wellbeing of participants. The SSL programme significantly improved the anxiety and stress levels of participants. Conclusion: SSL programme exclusively improves the mental wellbeing in institutionalised adolescents.

The Assessment of Early Server Childhood Caries Status in Abandoned Institutionalized Children

Oral health is a critical indicator of children’s quality of life, which at this early age, depends exclusively on the attention, involvement, and guidance of parents or caregivers. Assessing carious damage and measuring the prevalence of early severe tooth decay in temporary teeth in children is obtained by calculating the dmft index, giving the sum of an individual’s decayed, missing, and filled teeth. The aim of our study was to conduct a clinical examination of the oral status of institutionalized children from Romania. We selected and included in the study 144 children, both boys and girls in equal number, with ages of five or six years old, from which 110 were eligible for the study and met the inclusion criteria. Of all children, 20.90% were five years old girls, 27.27% five years old boys, 26.36% six years old girls, and 25.46% six years old boys. Of all, 10,45% had more than three incisors presenting decays, equally affected by gender. Of the boys’ group, 20% of age six had more de two canines affected, and 26.7% of five years old girls had more than three affected canines. Of the five years boys’ group, 24.3% had more than three affected temporary molars, 44.9% of six years boys had more than five. Of the five years old girls, 33.3% had more than four temporary molars affected and, 56.6% of the six years old girls’ group had more than five molars presenting carious lesions. The dental status and dmft values were similar for five years old and six years old children and similar boys and girls. Due to the vulnerability of young children that consists not only in their inability to identify, express, and address their own needs but also the lack of parental support, lack of an optimal diet for age, and proper hygiene, they reach adolescence with an impaired dental status, inappropriate for their age.

The expected and the unexpected in recovery and development after abuse and neglect: The role of early foster carer commitment on young children's symptoms of attachment disorders and mental health problems over time

BACKGROUND

Whilst we know that foster care is better than institutional care for abused and neglected children, we know less about the specific qualities of foster care that are important for their development and recovery from maltreatment effects.

OBJECTIVE

This is the first study to investigate the effects of foster carer commitment on symptoms of Attachment Disorders (AD) and mental health problems in young children post-maltreatment.

PARTICIPANTS & SETTING

144 children, age 0-5, recently accommodated into foster care as part of an ongoing Randomised Controlled Trial.

METHODS

Children were assessed using the Disturbances of Attachment Interview and the Strengths and Difficulties Questionnaire, then followed up 15 months and 2.5 years thereafter. Commitment of the foster carer was measured by 'This Is My Baby' interview. Multiple regression was used to analyse the data.

RESULTS

Higher initial foster carer commitment, measured shortly after entry to care, was associated with a reduction in Reactive Attachment Disorder symptoms 15 months after placement, with a modest (non-significant) association persisting 2.5 years later. Initial commitment was not associated with symptoms of Disinhibited Social Engagement Disorder at any follow-up time point, nor with symptoms of mental health problems at 15 months. However, higher initial commitment was unexpectedly associated with higher mental health symptom scores at 2.5 years post-accommodation.

CONCLUSIONS

This study highlights the complex and non-linear development of children in committed foster care, underscoring the need to examine multiple time-points and to consider symptoms of Attachment Disorders separately from those of other mental health problems.

The importance of responsive parenting for vulnerable infants

The quality of the early caregiving context sets the stage for the developing child's long term developmental trajectory. Infants are born highly dependent on parents and other caregivers for critical input for developing brain and behavioral systems. When infants experience early adversity, they are at risk for difficulties regulating behavior, emotions, and physiology. Parenting interventions have been developed to enhance parental responsiveness, thereby enhancing child outcomes. One such program, Attachment and Biobehavioral Catch-up (ABC), is a home visiting intervention designed to enhance parenting nurturance and sensitivity. In this paper, we will consider the importance of parental sensitivity and developmental consequences of sensitive and insensitive care. We will then describe interventions that target parental responsiveness and intervention effectiveness, focusing primarily on ABC. Public policy recommendations related to the importance of parental responsiveness will then be discussed.

Child-parent cardiac transference is decreased following disrupted/absent early care

Parental input shapes youth self-regulation development, and a lack of sensitive caregiving is a risk factor for youth mental health problems. Parents may shape youth regulation through their influence over biological (including neural) and behavioral development during childhood at both micro (moment-to-moment) and macro (global) levels. Prior studies have shown that micro-level parent-child interactions shape youth's biology contributing to youth mental health. However, it remains unclear whether prior disrupted/absent care affects those moment-to-moment parent-youth interactions in ways that increase risk for youth psychopathology. In the current study, we calculated transfer entropy on cardiac data from parent-youth dyads where the youth had either been exposed to disrupted care prior to adoption or not. Transfer Entropy (TE) tracks information flow between two signals, enhancing quantification of directional coupling, allowing for the examination of parent-child and child-parent influences. Using this novel approach, we identified lower cardiac information transfer from youth-to-parents in dyads where the youth had been exposed to disrupted/absent early care. Moreover we showed that the degree to which the parent's physiology changed in response to youth's physiology was negatively related to the youth's mental health, representing a potential pathway for elevated mental health risk in populations exposed to disrupted/absent early care.

Enhancing diurnal cortisol regulation among young children adopted internationally: A randomized controlled trial of a parenting-based intervention

Children who have been adopted internationally commonly experience institutional care and other forms of adversity prior to adoption that can alter the functioning of the hypothalamic-pituitary-adrenal (HPA) axis. In particular, internationally adopted children tend to have blunted diurnal declines compared to children raised in their birth families. The Attachment and Biobehavioral Catch-Up (ABC) intervention was developed to enhance young children's biological and behavioral regulation by promoting sensitive parenting. The current study used a randomized controlled trial to assess whether ABC improved the diurnal functioning of the HPA axis among 85 children who had been adopted internationally when they were between the ages of 4 and 33 months (M = 16.12). Prior to the intervention, there were no significant differences in diurnal cortisol production between children whose parents were randomly assigned to receive ABC and children whose parents were randomly assigned to receive a control intervention. After the intervention, children whose parents had received the ABC intervention exhibited steeper declines in cortisol levels throughout the day than children whose parents had received the control intervention. These results indicate that the ABC intervention is effective in enhancing a healthy pattern of diurnal HPA axis regulation for young children who have been adopted internationally.

The Correlation between Oral Self-Harm and Ethnicity in Institutionalized Children

Oral self-harm was described in institutionalized children who share a lack of emotional attention; frequently these children experience feelings such as neglect, loneliness, isolation or lack of connection with the world. The aim of our paper was to conduct a cross-sectional study in order to assess the prevalence of this behavior and its correlation with ethnicity among children from three institutions located in the central part of Romania. We examined 116 children from three ethnic groups, Romanians, Hungarians and local Roma population aged between 10–14 years old. The oral soft tissues were evaluated by one dentist who recorded the lesions of lips, buccal mucosa, commissures and tongue; data were statistically analyzed at a level of significance of p < 0.05. We found oral self-harm lesions in 18.1% participants, with statistically significant higher odds in girls (p = 0.03). The results showed an association between ethnicity and the development of these lesions (Chi-square p = 0.04). The most frequent lesions were located at oral commissures (35.48%), buccal mucosa (29.03%) and upper lip (19.36%). Oral self-harm lesions have a high incidence among institutionalized children in Romania. Identification of these cases in early stages is important, as these conditions are known to be aggravated during adolescence and adulthood.

The persistent associations between early institutional care and diurnal cortisol outcomes among children adopted internationally

Young children in institutional care experience conditions that are incompatible with their needs for attachment relationships. As a result, early institutionalization is expected to have lasting effects on the regulation of the hypothalamic-pituitary-adrenocortical (HPA) axis. The current study tested whether early institutionalization has persistent consequences for diurnal HPA axis outcomes among 130 children who had been adopted internationally between the ages of 6 and 48 months. Daily cortisol samples were collected from children at two time points: shortly after adoption (average of 5.3 months after adoption) and approximately 3 years later (average of 39.2 months after adoption). Shortly after adoption, children who had experienced a long duration of institutional care had lower morning cortisol levels and more blunted declines in cortisol across the day than children who experienced minimal or no institutional care. Three years later, children who had experienced a long duration of institutionalization continued to exhibit low morning cortisol levels and also exhibited low bedtime cortisol levels. Altogether, these results support the idea that early adversity results in the downregulation of the HPA axis and suggest that the effects of institutionalization on HPA axis functioning may persist several years after children are adopted into highly enriched families.

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

Early adversity and children's regulatory deficits: Does postadoption parenting facilitate recovery in postinstitutionalized children?

Children reared in orphanages typically experience the lack of stable, reliable caregivers and are at increased risk for deficits in regulatory abilities including difficulties in inhibitory control, attention, and emotion regulation. Although adoption results in a radical shift in caregiving quality, there remains variation in postadoption parenting, yet little research has examined postadoption parenting that may promote recovery in children experiencing early life adversity in the form of institutional care. Participants included 93 postinstitutionalized children adopted between 15 and 36 months of age and 52 nonadopted same-aged peers. Parenting was assessed four times during the first 2 years postadoption (at 2, 8, 16, and 24 months postadoption) and children's regulation was assessed at age 5 (M age = 61.68 months) and during kindergarten (M age = 71.55 months). Multiple parenting dimensions including sensitivity/responsiveness, structure/limit setting, and consistency in routines were examined. Both parental sensitivity and structure moderated the effect of preadoption adversity on children's emotion regulation while greater consistency was associated with better inhibitory control and fewer attention problems. Results support the notion that postadoption parenting during toddlerhood and the early preschool years promotes better regulation skills following early adversity.

Habilidades Sociais e Problemas de Comportamento de Crianças sob Acolhimento Institucional

Resumo Este estudo realizou uma caracterização do repertório de habilidades sociais e problemas de comportamento de crianças em situação de acolhimento institucional, que foi comparada à média normativa brasileira. Participaram 36 crianças, ambos os gêneros, na faixa etária de 6 a 12 anos e 19 cuidadores, como avaliadores do repertório das crianças, utilizando-se o Inventário de Habilidades Sociais, Problemas de Comportamento e Competência Acadêmica para Crianças (SSRS). Os resultados mostraram que: (a) a amostra de crianças apresentou escores significativamente abaixo da norma em habilidades sociais, com mais da metade delas classificada com repertório deficitário e médio inferior em habilidades sociais, tanto na autoavaliação quanto na avaliação do cuidador; (b) a amostra apresentou repertório altamente comprometido em problemas de comportamento, sendo mais frequentes os do tipo externalizantes. Discute-se a importância e urgência de intervenções voltadas para a promoção de habilidades sociais das crianças institucionalizadas, de modo a prevenir e superar problemas em seu desenvolvimento.

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.

Obscure Dichotomy of Early Childhood Trauma in PTSD Versus Attachment Disorders

There are two competing schools of thoughts involving children who have experienced early childhood trauma. One posture's nosology focuses on the post-traumatic stress responses; the other focuses on the deviant behaviors that ensue from pathogenic care in early childhood. This author sought to review the literature from a holistic perspective, embracing both diagnostic positions. Seventy-three articles addressing childhood trauma and the ensuing emotional or behavioral disturbances were evaluated, mostly empirical-including 16 that specified posttraumatic stress disorder (PTSD), 21 that specified attachment disorders, and 37 that included potential overlaps between both trauma derivatives. An additional 138 studies were reviewed but not included herein because those focused on broader issues. Statistical data, financial and emotional impacts, and the effects of disrupted attachments were addressed-including both children with secure attachments and those with compromised attachments. The critical effect of both positive and negative parental responses was evaluated, as well as correlations or overlaps in the diagnostic criteria and symptom manifestations of the children and any apparent gaps in the current research. The literature details that the prognosis and course of treatment vary significantly between the two etiologies-apparently at least in part due to possible clinician bias in conceptualizations of the two populations. There are clear overlaps in the diagnostic criteria that strongly suggest comorbidity between the disorders, however, which is especially critical to analyze in the future, since there are solid, empirical, evidence-based treatment protocols for PTSD, but not for attachment disorders resulting from pathogenic caregiver maltreatment.

Comparing Long-Term Placement Outcomes of Residential and Family Foster Care: A Meta-Analysis

This study presents findings from three separate meta-analyses investigating differences between children placed in residential care and in family foster care with regard to three outcomes: internalizing behaviors, externalizing behaviors, and perception of care. Based on publications from the last 20 years, a total of 23 studies were included. The total sample consisted of 13,630 children in care, with 7,469 from foster care and 6,161 from residential care. The results from this study indicated that children in foster care had consistently better experiences and less problems across the three outcomes as compared to children in residential care. Analyses did not reveal evidence of publication bias, and sensitivity analyses also suggested that results were not influenced by individual studies. Additionally, moderation analyses revealed that the differences between foster and residential care could vary depending on certain factors such as the publication year, the gross domestic product of the country, and the length of care. The implications of differences in outcomes between the two placements are discussed.

Effects of Institutionalization and Parental Living Status on Children's Self-Esteem, and Externalizing and Internalizing Problems in Rwanda

The negative effects of institutionalization on children's wellbeing and psychological adjustment have been extensively documented. Throughout the world, particularly in developing countries, many children in residential child care institutions known as orphanages have parents, and it is not clear how this situation affects the psychological adjustment of institutionalized children. This study aimed at investigating specifically whether institutionalization impacts negatively children's psychological adjustment defined in terms of externalizing and internalizing behavior problems and self-esteem and whether having living parents or not has an additional influence. Children were recruited in Rwanda from seven registered institutions and six primary schools. Ninety-six institutionalized children (48 orphans, who lost at least one parent, and 46 non-orphans, who had both parents living) and 84 non-institutionalized children, who lived in a family (28 orphans and 56 non-orphans) aged 9 to 16 participated. The caregivers or parents assessed externalizing and internalizing behavior problems using the Child Behavior Checklist. Children completed the Coopersmith Self-Esteem Inventory. Controlling for gender, age, and residential area, analyses of covariance revealed that institutionalized children had significantly more externalizing behavior problems than had non-institutionalized children. In addition, non-orphans had more externalizing behavior problems than had orphans, regardless of whether they lived in an institution or not. There were no group differences in internalizing behavior problems, but there was a significant main effect of the parental living status (orphans vs. non-orphans) and a significant interaction effect between parental living status and institutionalization on self-esteem. Self-esteem of non-orphans in families was significantly higher than self-esteem of the other groups. This should be considered when making the decision to place a child in an institution, especially when her or his parents are still living, and when developing supportive programs for children without adequate parental care.

Impact of Emergency Shelter Utilization and Kinship Involvement on Children's Behavioral Outcomes

Youth in child welfare often experience emergency shelter care, a type of congregate setting, while a permanent placement is arranged. The present longitudinal study explored the impact of initial emergency shelter placement on long-term externalizing behavior (i.e., aggression, delinquency) and internalizing symptom (i.e., anxiety, depression) trajectories, and whether kinship involvement moderated the effect of shelter placement on behavioral outcomes. The sample consisted of 282 youths (55.3% male) with an average age of 9.90 years ( SD = 2.37); 36.9% experienced an emergency shelter placement. Data were collected from the Illinois Department of Children and Family Services. Caseworkers completed the Child and Adolescent Needs and Strengths, which measured youths' behavioral outcomes. Results suggested that shelter care was not associated with externalizing behavior trajectories. However, shelter care was associated with internalizing symptoms among children with less kinship involvement. Results from this study suggest that best practices for shelter care should leverage kinship involvement.

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.

Social touch during development: Long-term effects on brain and behavior

In this paper, our goal is to explore what is known about the role of social touch during development. We first address the neural substrates of social touch and the role of tactile experience in neural development. We discuss natural variation in early exposure to social touch, followed by a discussion on experimental manipulations of social touch during development and "natural experiments", such as early institutionalization. We then consider the role of other developmental and experiential variables that predict social touch in adults. Throughout, we propose and consider new theoretical models of the role of social touch during development on later behavior and neurobiology.

Children and adolescents in institutional care versus traditional families: a quality of life comparison in Japan

BACKGROUND

A good quality of life (QOL) is important for the physical and mental well-being of all children. However, young people who live in an institutional setting may face different challenges than those who are raised in a traditional family. While a few quantitative studies of institutionalized children's QOL have been conducted, no research has investigated the QOL of young people living in Children's Homes (CHs) in Japan. This research compared the QOL of children and adolescents in Japan who live in CHs with that of children and adolescents living in traditional families.

METHODS

A cross-sectional study was conducted in July 2016 with 204 students (grades three through nine), 47 of whom lived in a CH, and 157 of whom lived in a traditional family. Ages ranged from 8 to 15 years (CH: 55.8% Female, 44.2% Male; Traditional: 54.1% Female, 45.9% Male). Participants answered the kid-Kinder Lebensqualität Fragebogen (Translated from German: Children's quality of life questionnaire; KINDL®) Japanese Version, which covers six subscales of QOL; they filled in the questionnaires at home. Analysis of variance was used to compare QOL between the two samples.

RESULTS

The total QOL score for all students (combined elementary school students and junior high school students) from CHs was statistically significantly lower than that for students from traditional families. Scores for the subscales, emotional well-being and family, were also significantly lower for CH young people than for those in traditional families. While elementary pupils in CHs reported lower QOL than those in traditional families, no significant differences in QOL were seen between junior high school students from CHs and their peers from traditional families.

CONCLUSIONS

The findings presented support previous research showing that the QOL of elementary school students living in CHs is significantly lower than that of their peers in traditional families. However, this difference was not observed among junior high school students. This contrast suggests that QOL changes with age. Future research is needed to evaluate the determinants of QOL among all generations and family contexts.

Measuring movement into residential care institutions in Haiti after Hurricane Matthew: A pilot study

BACKGROUND

Governments have an ethical imperative to safeguard children in residential care institutions at all times, including in the aftermath of an emergency. Yet, a lack of accurate data about how the magnitude and characteristics of this population may change due to an emergency impedes leaders' ability to formulate responsive policies and services, mobilize resources and foster accountability. The purpose of this study was therefore to determine the feasibility of evaluating movement of children into residential care following an emergency.

METHODS

The pilot study took place in Les Cayes commune in the Sud Department of Haiti in April 2017. Six months prior to the pilot, the area was severely affected by Hurricane Matthew, with widespread devastation to property, livestock and livelihoods. Using a two-stage process, the team created a comprehensive list of residential care institutions in Les Cayes. At each facility, the data collectors attempted to administer four separate tools: a group count tool, a record review tool, interviews with staff, and interviews with children 10 years of age and older.

RESULTS

Out of 27 known institutions in Les Cayes, 22 institutions consented to participate in the research. Within these 22 institutions, the prevalence of new arrivals to residential care since Hurricane Matthew varied significantly across the four tools, ranging from 0.69% according to the aggregated child interviews to 20.96% according to the aggregated staff interviews. Record availability and quality was very poor and child participation was difficult to arrange due to travel and scheduling constraints.

INTERPRETATION

Robust measurement of new arrivals to residential care institutions was not feasible in Haiti following Hurricane Matthew. Moreover, many of the challenges encountered are likely to be encountered in humanitarian emergencies in other settings. Therefore, the research team does not recommend scale-up of these methods in most humanitarian settings. Alternative approaches that incorporate household survey methods to ascertain movement into residential care based on reports from caregivers may be more realistic in places with poor pre-existing governance systems and weak registries and records for residential care institutions.

Parenting predicts Strange Situation cortisol reactivity among children adopted internationally

The functioning of the hypothalamic pituitary adrenal (HPA) axis can be altered by adverse early experiences. Recent studies indicate that children who were adopted internationally after experiencing early institutional rearing and unstable caregiving exhibit blunted HPA reactivity to stressful situations. The present study examined whether caregiving experiences post-adoption further modulate children's HPA responses to stress. Parental sensitivity during naturalistic parent-child play interactions was assessed for 66 children (M age = 17.3 months, SD = 4.6) within a year of being adopted internationally. Approximately 8 months later, children's salivary cortisol levels were measured immediately before as well as 15 and 30 min after a series of brief separations from the mother in an unfamiliar laboratory setting. Latent growth curve modeling indicated that experiencing more parental sensitivity predicted increased cortisol reactivity to the stressor. Although half the families received an intervention designed to improve parental sensitivity, the intervention did not significantly alter children's cortisol outcomes. These findings suggest that post-adoption parental sensitivity may help normalize the HPA response to stress among children adopted internationally.

Peer Problems Among Postinstitutionalized, Internationally Adopted Children: Relations to Hypocortisolism, Parenting Quality, and ADHD Symptoms

Seventy-eight postinstitutionalized (PI) children adopted at ages 17-36 months were assessed 2, 8, 16, and 24 months postadoption on measures of cortisol and parenting quality, and compared to same-aged children adopted from foster care (FC, n = 45) and nonadopted children (NA, n = 45). In kindergarten (M_age  = 6.0 years), teachers, parents, and trained observers completed measures of peer relationships and attention deficit hyperactivity disorder (ADHD) symptoms. PI children had more peer problems and ADHD symptoms according to teachers and observers than NA children with FC children in between, whereas both PI and FC children were at significantly greater risk of hypocortisolism (i.e., blunted cortisol diurnal rhythm and reactivity). Hypocortisolism and ADHD symptoms mediated the association between preadoption adversity and peer difficulties. Higher postadoption parenting quality was protective.

Inhibited attachment disordered behavior in institutionalized preschool children: links with early and current relational experiences

Inhibited attachment disordered behavior (IADB) is characterized by difficulty in establishing an attachment relationship with a primary caregiver; is associated with persistent social and emotional problems; and is observed most frequently in contexts of pathological care such as institutional rearing. Here, we seek to enhance understanding of the conditions that give rise to IADB among institutionalized children by examining prior family experiences of neglect and deprivation and concurrent relational experiences at the institution. The sample is comprised of 146 children, between 36 and 78 months. IADB was assessed using a semi-structured interview administered to the child's primary caregiver. Results revealed that both pre-institutionalization experiences (e.g. parental abandonment) and current relational ones (e.g. low quality of child-caregiver relationship) predicted IADB. Findings are discussed in light of the need to promote conditions which foster the establishment and maintenance of the child's selective attachment to a caregiving figure.

Estimating the number of children in formal alternative care: Challenges and results

Given the relatively large body of literature documenting the adverse impacts of institutionalization on children's developmental outcomes and well-being, it is essential that countries work towards reducing the number of children in alternative care (particularly institutional care), and, when possible, reunite children with their families. In order to do so, reliable estimates of the numbers of children living in such settings are essential. However, many countries still lack functional administrative systems for enumerating children living outside of family care. The purpose of this paper is to provide a snapshot of the availability and coverage of data on children living in residential and foster care from some 142 countries covering more than 80 per cent of the world's children. Utilizing these country-level figures, it is estimated that approximately 2.7 million children between the ages of 0 and 17 years could be living in institutional care worldwide. Where possible, the article also presents regional estimates of the number of children living in residential and foster care. This work represents an important step to systematically identify and compile sources of data on children in alternative care and provides updated global and regional estimates on the magnitude of the issue. Its findings contribute to raising awareness of the urgent need to strengthen the capacity of countries to improve national systems for counting, monitoring and reporting on these vulnerable children.

National estimation of children in residential care institutions in Cambodia: a modelling study

OBJECTIVES

The primary objective of this study was to collect baseline data on the number of children living in residential care institutions in Cambodia. The secondary objective was to describe the characteristics of the children (eg, age, sex, duration of stay, education and health). The data were intended to guide recent efforts by the Government of Cambodia to reduce the number of children living in residential care institutions and increase the number of children growing up in supportive family environments.

SETTING

Data were collected in Cambodia across 24 sites at the commune level. Communes-administrative divisions roughly equivalent to counties-were selected by the National Institute of Statistics using a two-stage sampling method.

DESIGN

Government lists and key informant interviews were used to construct a complete roster of institutions across the 24 communes. All identified institutions were visited to count the number of children and gather data on their basic characteristics. The rate of children in residential care in the selected communes was calculated as a percentage of total population using a Poisson model. This rate was applied to all districts in Cambodia with at least one reported residential care institution.

PARTICIPANTS

A total of 3588 children were counted across 122 institutions. A child living in a residential care institution was defined as anyone under the age of 18 years who was sleeping in the institution for at least four nights per week during the data collection period.

RESULTS

There are an estimated 48 775 children living in residential care institutions in Cambodia. The vast majority of children have a living parent and are school-aged. More than half are between 13 and 17 years of age.

CONCLUSIONS

Nearly 1 of every 100 children in Cambodia is living in residential care. This raises substantial concerns for child health, protection and national development.

Promoting psychosocial adaptation of youths in residential care through animal-assisted psychotherapy

The goal of this study was to examine the influence of animal-assisted psychotherapy (AAP) on the psychosocial adaptation of a group of adolescents in residential care who had suffered traumatic childhood experiences and who presented with mental health problems. This study recruited 63 youths (mean age=15.27, SD=1.63) who were divided into two groups: a treatment group of 39 youths (19 female and 20 male; mean age=15.03, SD=0.51) and a control group of 24 (five female and 19 male; mean age=15.67, SD=1.63). The youths who underwent the AAP program had higher school adjustment in comparison to their peers who did not receive treatment. Their hyperactive behavior decreased, and they showed better social skills, more leadership, and fewer attention problems. They also showed a more positive attitude toward their teachers in comparison to controls. No differences were observed in other variables associated with clinical symptoms or personal adjustment. These results suggest that AAP can be effective with teenagers who have suffered childhood traumas and who present with problems of psychosocial adaptation.

"I Want to be There When He Graduates:" Foster Parents Show Higher Levels of Commitment than Group Care Providers

Group care is a frequent placement for adolescents placed in out of home care when their birth parents' care is deemed unsafe. In the present study, we assessed whether foster parents show greater commitment to children than group care providers. Given that group care represents a number of living arrangements, we considered both shift care (where staff work shifts and do not live with the children) and cottage care (where staff live for extended periods of time with the children in a group living context). Commitment was assessed using the This Is My Child Interview (adapted for adolescents). Thirty-one foster parents, 18 shift workers, and 28 cottage care providers were interviewed. As predicted, foster parents showed higher levels of commitment than both shift care workers and cottage care providers, and the associations held when children's externalizing behaviors and the number of children the caregivers had cared for were controlled. The results suggest that foster care promotes greater commitment among caregivers than other out of home placements, and add to other findings that favor foster care as the out of home placement of choice for adolescents.

Factors related to the cortisol awakening response of children working on the streets and siblings, before and after 2 years of a psychosocial intervention

The study objective was to observe the cortisol awakening response (CAR) pattern before and after a psychosocial intervention with children from dysfunctional families who had at least one child working on the streets, and to verify factors related to it. Two hundred and eleven children between 7 and 14 years old were selected and 191 were included, 178 were re-evaluated 2 years after, of whom 113 had cortisol measures completed. Besides cortisol, they were evaluated at baseline and at end point regarding: abuse/neglect, mental health symptoms, exposure to urban violence and family environment. There was no significant difference between the CAR area under the curve (AUC) before and after the intervention. Two regression analysis models were built to evaluate factors related to the CAR before and after intervention. Before the intervention, working on the streets (vs. not) was related to a greater cortisol increase after awakening, at follow-up, having suffered physical punishment (vs. not) was related to a flattened cortisol response. The intervention was not associated with changes in the magnitude of the CAR AUC, though the CAR was associated with psychosocial stressors pre- and post-intervention. Effective interventions for children at risk that might shape a physiological cortisol response are still needed.