Research leaves little doubt that children living in orphanages and other institutions around the world are at higher risk of experiencing developmental setbacks that can have a lasting impact on their lives. The evidence is not lost on many of the nations that rely on orphanages to care for children without parents. But for them, it’s not a question of whether they should address the problem or even what can be done to solve it. What they struggle to answer is how to overcome challenges ranging from cultural to financial that stand in the way of implementing what science tells them will help improve the outcomes for millions of children in their orphanages.

"From a practice and policy standpoint, almost everybody agrees that the goal is to provide every child with a loving, committed family. We also have evidence that improving the environment within institutions can improve the outcomes of the children who remain there," said Christina Groark, Ph.D., co-director of the University of Pittsburgh Office of Child Development (OCD). “The issue for many nations is how to get there from where they are now. Developing a system of family alternatives is not an easy task.”

Interest in the development of such children rose after the fall of Romanian strongman Nicholae Ceausescu revealed the appalling conditions within the institutions where thousands of children had been raised without adequate nutrition, medical care, sanitation, or caretaking. The revelations led to a sharp increase in adoptions from orphanages worldwide, greater interest in studying the development of institutionalized children, and a willingness among more nations to explore alternatives to the orphanages they long relied upon to care for children without parents.

The challenges those nations face were among the topics addressed by 25 of the world’s leading experts on vulnerable children at a 2009 conference held at Leiden University in the Netherlands, which was convened by OCD and international colleagues to examine what is known about children’s development as well as policy and practice. Publications that emerged from the project detail the developmental deficits institutionalized children tend to exhibit, the conditions that contribute to them, what can be done to address the problem, and the obstacles that confront countries attempting to build a system of family-care alternatives.

Challenging alternatives

Studies report that exposure to substandard care in an institution can?have a lasting developmental impact on children, including problems forming healthy attachments?and deficits in neurological and?cognitive abilities and physical growth. And children who spend time in an institution during their first few years of life tend to be the most vulnerable.

Not surprisingly, the research also shows that in most cases it is better for children’s outcomes if they are able to be placed in a family environment outside of the institution or avoid spending any time in an institution whatsoever. For example, children adopted from orphanages show marked improvement in physical growth, attachment, and their cognitive and behavioral development, although the recovery is not always complete.

Children are also more likely to have long-term problems with behavior, executive function, and social skills if they are not able to leave the institution by a certain age. The age at which the “step” occurs varies depending on the severity of the orphanage experience and other factors. But studies suggest that when institutionalized children are adopted before the step occurs they tend to have rates of problems similar to children who have never lived in an institution.

In many countries, a child welfare system, and the professional infrastructure and family support that family alternatives to institutions require, either don’t exist or are underdeveloped. And in many cases, political, administrative, financial, and cultural challenges complicate the process of developing them.

Such factors make it difficult to recruit adoptive or foster parents. In some countries, for example, there is resistance among parents to raise someone else’s child based on religious beliefs, culture, social customs, or other factors. Also, financially strapped families are often less willing to adopt and many nations lack systems for providing them with financial assistance and other support that would encourage them to do so.

Most children in institutions throughout the world have at least one parent. There are many reasons why parents relinquish their children to institutions, including poverty, which plays a major role. Yet, many countries lack preventative interventions, such as basic services, assistance, and early family support programs, that could help reduce the number of families who give up their children to orphanages or other institutions.

Physical or mental disability also increases children’s likelihood of being institutionalized. In Central and Eastern Europe and the Commonwealth of Independent States, for example, children with disabilities are 46 times more likely to end up in an institution than those without disabilities. And in most countries, parents willing to adopt strongly favor typically functioning children, making it difficult to place institutionalized children with disabilities in alternative family settings.

The lack of professional services infrastructure to train, support, and provide services to families is yet another obstacle many countries face in trying to prevent children from entering orphanages or other institutions.

“One of the necessary components of having a comprehensive child welfare system is that you need a professional infrastructure,” Dr. Groark said. “You need social workers and psychologists who know how to deal with all of the risk factors that cause families in those countries to give up their children. Infrastructure like that isn’t developed overnight.”

There are signs of progress, however. For example, children are now adopted domestically at higher rates than in the past in some countries, such as Brazil and China. And in India, China, and a few other nations, more children who traditionally have been difficult to place are being taken into domestic family care.

Wholesale child welfare reform takes time. And the inescapable reality is that millions of children remain in orphanages and other institutions throughout the world, even in nations that are making progress toward building a professional child welfare system of family care alternatives.

Ukraine, for example, had the political will to create a child welfare system of family care alternatives and invested considerable resources to build it. After five years, 5,000 children had been placed in foster care. But another 45,000 children remained in orphanages.

There is hope for such children, however. Studies suggest conditions within orphanages and other institutions can be substantially improved, resulting in better developmental outcomes for both typically functioning children and those with disabilities. In St. Petersburg, Russia, for example, OCD and Russian researchers designed and implemented interventions and structural changes to create an environment of family-like care in Soviet-era orphanages, which for decades had emphad conformity, discipline, and a business-like, perfunctory approach to care that lacked the warmth and sensitivity that children raised in a typical family would be expected to receive.

Caregivers were trained and encouraged to be more warm, sensitive, and responsive in their interactions with the children. They were taught how to position and interact with children in their care who had disabilities. For the first time, primary caregivers were designated and their schedules adjusted to give children consistency in who was caring for them.

Key structural changes were also made. For example, the groupings of children were made smaller, which enabled caregivers to spend more time with individual children. And the groups included children of different ages, as well as children with disabilities.

Conditions improved significantly and the interventions continue today with local funding. Most importantly, children show substantial improvement across all developmental domains, including sizable increases in their developmental quotients, and improvement in their behavioral development, their engagement with caregivers, and even their physical growth. “They’ve maintained that intervention on their own budget for six years and it still works,” said OCD Co-director Robert McCall, Ph.D. “The care giving is better by measurement and the children’s development is still better by measurement.”