Institutional Care Leads to Atypical Attachment, Developmental Delays in Children

Institutionalization was associated with developmental delays and atypical attachment patterns in children, according to results published in the Lancet Psychiatry. Rapid recovery of developmental milestones was observed with deinstitutionalization, and the study authors advocated policy recommendations that prioritize kinship networks, including adoption and foster care.

Millions of children spend their developmental years in institutional facilities, and care quality varies widely, with poor food quality and sanitation, as well as high staff turnover and child-to-caregiver ratios, representing systemic issues.

The review extracted data from 308 published studies on the institutionalization and deinstitutionalization of children around the world. The pooled cohort comprised 34,823 children from 68 countries. The most frequently represented countries were Russia (n=5638), Kenya (n=4444), China (n=3718), India (n=2546), Turkey (n=1852), and the United Kingdom (n=1583).

Random effects models were used to produce pooled estimates of the effects of institutionalization, and analyses were adjusted for between study heterogeneity. Effect sizes were modeled using Hedges’ g, with values ≥0.5 and ≥0.8 representing moderate to large effects, respectively. Global trends in institutionalization were also assessed using household survey data and nationwide estimates.

An estimated 5.09 to 6.10 million children from 137 countries were living in institutions, with many being described as orphanages. Study estimates suggest that 80 to 95% of children residing in institutions have a living parent. Reasons for institutional placement included poverty, disability, natural disasters, and parental health problems or death. Published data on institutions are scarce; facilities vary by size, staffing, region, specialty, and funding source. Most institutions have a child-to-staff ratio that precipitates some form of deprivation; high staff turnover and poor training are common.

Residency in institutions was associated with significant developmental delays. Figures varied widely, although delays in physical growth, brain development, cognition, and attention were most prominent (Hedges’ g range, 0.50 to 1.44). Effects of institutionalization on physical health (Hedges’ g, 0.29) and socioemotional development (Hedges’ g, 0.32) were less pronounced.

A dose-response relationship was observed between length of stay and developmental delays, with longer stays precipitating greater odds of atypical development. In 11 studies that assessed attachment (n=471), the proportion of children who formed a secure attachment with a caregiver was significantly lower than that of the general population (24% vs 62%; Hedges’ g, 0.76). Children in institutions were also significantly more likely to have dysregulated attachments compared to controls (57% vs 15%; Hedges’ g, 1.18).

In studies of deinstitutionalization, children displayed rapid improvement in physical health, brain growth, and cognitive development in the months after leaving an institution. Among children with prior exposure to severe deprivation, most were able to form secure attachments with new caretakers, including adoptive or foster parents. 

As study limitations, the investigators noted that caretaker reports may underestimate symptoms. Precise demographic data on children was also scarce, and results could not be adjusted for pre-institution exposures.

The study authors noted that reducing institutionalization will require concerted efforts to improve foster care and adoption programs. As part of a Lancet Group Commission, they proposed avoiding institutional care and implementing kinship families.


van Ijzendoorn MH, Bakermans-Kranenburg MJ, Duschinsky R, et al. Institutionalisation and deinstitutionalisation of children 1: a systematic and integrative review of evidence regarding effects on development [published online June 23, 2020]. Lancet Psychiatry. doi:10.1016/S2215-0366(19)30399-2