For millions of children worldwide, living in orphanages or other institutions where they are deprived of the warmth and attention of caring adults is not a benign experience, a growing body of scientific evidence suggests.

Those studies report that spending as little as six months in an institution where the care is extremely substandard can have a lasting developmental impact on children, including problems forming healthy attachments and deficits in neurological and cognitive abilities and physical growth. The research also suggests that the children who are the most vulnerable tend to be those whose experience in institutions comes early in life.

Such findings have implications for a broad range of nations, including nations where children in institutions are rare, such as the United States. While the studies may focus on institutionalized children, the factor found to most influence whether they experience developmental deficits is common among all nations, affluent or otherwise.

"It appears the quality of caregiver-child interactions is the most crucial," said Robert McCall, Ph.D., co-director of the University of Pittsburgh Office of Child Development (OCD). “And that can characterize children in all kinds of risk circumstances—from extreme poverty to neglectful and abusive families to homelessness.”

As many as 8 million children live in orphanages, hospitals or other residential institutions throughout the world. Although conditions vary from institution to institution and country to country, the quality of daily care many children receive is often less than sufficient in terms of promoting healthy development.

Several characteristics of institutions can affect the quality of care children receive. Among those most often found are high child-caregiver ratios, large group s, many different and changing caregivers, and the way caregivers perform their caregiving duties, which are often described as businesslike, perfunctory, and lacking the level of interaction, sensitivity and warmth a child would be expected to receive in a well-functioning family.

Developmental outcomes are also affected by other factors, including genetics, prenatal conditions, such as a mother’s drug or alcohol use, and low birth weight and other birth complications. Another factor can be children’s experience before they entered an institution, such as whether they were victims of abuse or neglect within their own family.

There is, however, substantial evidence to suggest that children’s experiences while in an institution significantly contribute to higher rates of developmental deficiencies. This evidence includes studies that show children improve in every domain after they leave an institution and are placed in some type of family care. Other studies, including OCD’s work in Russian orphanages, suggest that children’s development profoundly improves when interventions succeed in improving the institutional environment in which they live.

OCD and its international colleagues, with funding from the Society for Research in Child Development and Leiden University, convened 25 of the world’s leading experts on children deprived of permanent parents in a conference held at Leiden University, the Netherlands, in 2009. Publications that emerged from the project detail the developmental issues researchers have found among those children, particularly those who spend time in orphanages or other institutional environments.

Common issues

The past few decades have seen heightened interest in the development of children without permanent parents. Much of the research on developmental issues has involved institutionalized children, their development while in orphanages or institutions, as well as after they are removed from the institutions and placed with adoptive families and, in some cases, in foster care.

“This is an opportune topic. A fundamental question in research on child development is: What are the necessary and sufficient early experiences that children need to develop typically? And the other side of that is avoiding long-term developmental deficiencies.” Dr. McCall said.

“Most of the institutions in the world are not ideal environments for children. This represents a natural circumstance of children not getting what parent-reared children normally get and what the consequences of that are.”

Poor attachment is one of the most profound long-term developmental problems that have been found among some children who have spent time living in orphanages and other institutions around the world. Contributing to the problem is the fact that even in institutions that provide a relatively clean environment and adequate medical care and nutrition, children are exposed to many different caregivers who work rotating shifts and go about their duties in a businesslike manner that lacks the warmth, sensitivity, and attention a parent would be expected to provide—all of which makes forming stable child-caregiver relationships unlikely.

Three studies that assessed the attachment of institutionalized children to a favorite caregiver using the Strange Situation Procedure suggest that, on average, 73 percent of children exhibit insecure disorganized attachment behavior. In one study, OCD researchers and their St. Petersburg colleagues reported that as many as 85 percent of Russian orphanage children showed disorganized attachment behavior. Although interventions improved care and children’s outcomes, including attachment problems, 60 percent of the children were still classified as having attachment disorders.

Children in institutions are also more likely to show indiscriminately friendly behavior than children raised in families, who typically are apprehensive when they meet strangers. In some cases, institutionalized children who are later adopted continue to show indiscriminate friendliness toward strangers, even after they become attached to their adoptive parents.

The inadequate social-emotional and caregiver-child relationship environments often found in orphanages and other institutions around the world can also result in deficiencies in physical growth. Studies have found that institutionalized children tend to be underd even when they are provided with adequate nutrition and medical care.

Research suggests, however, that their growth tends to improve markedly when they leave the institution, particularly if they are adopted or placed in foster care before they the age of 1 or 2 years. OCD and St. Petersburg researchers also report that the growth of institutionalized children in Russia improved when the psychosocial environment of the orphanages improved.

Another concern is brain development, which studies suggest can be affected by the kind of deprived environment found in many orphanages or other institutions. Researchers report there is less metabolic, physiological, and neurochemical activity in the brains of mid-childhood-aged children who have lived in a severely deficient institution compared to children raised in families.

Also seen is abnormal development of parts of the brain associated with higher cognitive functions, memory, and emotion. Some studies find that impulse control, attention and social relations are mildly impaired among institutionalized children who were later adopted or placed in some other family-care situation.

Deficiencies in brain development may also be related to problems seen among some formerly institutionalized children in areas such as emotional regulation and executive functioning, which is a set of cognitive processes that is important to performing activities ranging from planning and organizing to paying attention to details and remembering details.

There is some good news for children fortunate enough to be adopted by parents able to give them a typical family environment. After they leave orphanages or other institutions they tend to show significant improvement in terms of their physical growth, attachment and cognitive and behavioral development.

Children adopted at later ages do not always completely catch up, however. For example, even after living for several years with their adoptive parents, some children may still be slightly underd, score slightly below expectations on general mental tests, have attachment difficulties, and problems with attention, rule following, planning and other activities related to executive functioning.

Studies suggest that children are the most vulnerable to experiencing development problems if they are exposed to deprived environments in orphanages or other institutions during their first few years of life.

For example, the frequency of long-term problems among children who are adopted from institutions tends to be different. Those who are adopted earlier in life are less likely to exhibit problems than those who are adopted at a later age.

And several studies that looked at children adopted at different ages during the first three years of life report that there seems to be an age-related step at which point long-term problems with behavior, executive function, and social skills are triggered. The age at which the step occurs varies depending on the severity of the orphanage experience and other factors. Children adopted before the step generally have rates of problems similar to children who have never been institutionalized. The rates of problems increase significantly when the step occurs among children who are living in institutions. But the rates of problems tend not to rise beyond that point, regardless of how much longer a child stays in the institution.

“You would think that the longer a child is in an institution the worse the outcomes. For some outcomes, that may be true to a certain extent, especially social outcomes and language. But for behavior and executive functioning problems, there seems to be a step function,” said Dr. McCall.

It is clear that the earlier children can be placed in a family-care situation outside of an institution the better. Studies also suggest that interventions resulting in warmer, more responsive, and developmentally friendly care improve the outcomes of children who remain in institutions. But such steps are beyond the reach of many nations that have underdeveloped child welfare or lack adequate community-based resources to meet the complex needs of children without parents. “We know what works scientifically and from the standpoint of practice,” said OCD Co-director Christina Groark, Ph.D. “It’s implementing it that is a challenge.”