Article Title: The Effects of Early Social-Emotional and Relationship Experience on the Development of Young Orphanage Children

Authors: The St. Petersburg—USA Orphanage Research Team

Abstract: Undertaken at orphanages in Russia, this study tests the role of early social and emotion experience in the development of children. Children were exposed to either multiple caregivers who performed routine duties in a perfunctory manner with minimal interaction or fewer caregivers who were trained to engage in warm, responsive, and developmentally appropriate interactions during routine care.  Engaged and responsive caregivers were associated with substantial improvements in child development and these findings provide a rationale for making similar improvements in other institutions, programs, and organizations.

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Article Title: Characteristics of children, caregivers, and orphanages for young children in St. Petersburg, Russian Federation

Authors: Rifkat J. Muhamedrahimov; Natalia V. Nikoforova; Oleg I. Palmov; Christina J. Groark; Robert B. McCall; Larry Fish

Abstract: This report provides baseline information on conditions in orphanages in the Russian Federation. This information addresses three major limitations in the literature on the development of children residing in substandard orphanages and those adopted from such environments. First, although there is an assumption that early exposure to substandard orphanages is associated with a variety of developmental delays during and after residency, there are essentially no comprehensive, empirical descriptions of what these early environments are like. This paper provides such information on the orphanage system in the Russian Federation and on a sample of children from 0–4 years of age residing in three orphanages in St. Petersburg. Second, because the orphanage environment is typically globally deficient, it is difficult to discern causal variables in developmental delays. In this report we attempt to show that the most salient deficiencies are in the social–emotional environment. Third, there are few empirical descriptions in the literature of the birth circumstances and characteristics of children residing in orphanages which make it difficult to untangle the relative contributions of poor perinatal circumstances and the orphanage environment in accounting for developmental delays. The results of this study show that a larger than expected number of orphanage children have poor perinatal circumstances, and most fall far below the average local Russian norms on physical, cognitive and psychosocial development.

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Article Title: Review: The consequences of early institutionalization: can institutions be improved? – should they?

Authors: Robert B. McCall


Background and scope

The focus of this review is on institutionalized children, one of the most inequitably and severely treated groups of children. Although institutions vary, many share some common characteristics, including large groups, high children:caregiver ratios, many and changing caregivers and caregiver-child interactions that lack warm, sensitive, contingently-responsive and child-directed behaviours. Resident children develop poorly physically, mentally and social-emotionally, but those adopted from institutions display substantial catch-up growth in many domains of development. If they are adopted at an early age, there have been no long-term consequences of institutionalization yet measured; but if institutionalization is prolonged, they display higher rates of long-term deficiencies and problems in many domains.


This review is based on a database search of the literature, focusing on the development of children while residents, and the development of post-institutionalized children who have been transitioned from institutions to family care. It also draws on the reports and findings of the St. Petersburg–USA Orphanage intervention.


A combination of theories pertaining to attachment (especially caregiver attachment to the infant–toddler), chronic stress and genetics may explain these outcomes. It appears that caregiver–child interactions are a major contributor to children’s outcomes and interventions in institutions that improve such interactions produce substantial increases in children’s physical, mental and social-emotional development, including for children with disabilities.


Deinstitutionalization and the creation of comprehensive professional child welfare systems emphasizing family care alternatives is a preferred goal, but this is likely to take many low-resource countries decades to develop. If substantial numbers of children remain in institutions despite best efforts to find families for them, improving the institutions might help to provide all the children with the best care possible under the circumstances.

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Article Title: Maintaining a Social-Emotional Intervention and Its Benefits for Institutionalized Children

Authors: Robert B. McCall, Christina J. Groark, Larry Fish, Rifkat J. Muhamedrahimov, Oleg I. Palmov and Natalia V. Nikiforova

Abstract: This article reports the maintenance of one of the largest interventions conducted in St. Petersburg (Russian Federation) orphanages for children birth to 4 years using regular caregiving staff. One orphanage received training plus structural changes, another training only, and a third business as usual. The intervention produced substantial differences between these institutions on the Home Observation for Measurement of the Environment (HOME) Inventory and on the Battelle Developmental Inventory scores for children. These institutional differences in HOME scores (= 298) and Battelle scores for children (= 357) departing the institutions for families in St. Petersburg and the United States were maintained for at least 6 years after the intervention project. This result may be associated with certain features of the intervention and activities conducted during the follow-up interval.

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Article Title: Inhibitory Control and Working Memory in Post-Institutionalized Children

Authors: Emily C. Merz, Robert B. McCall, Amanda J. Wright, Beatriz Luna

Abstract: Inhibitory control and working memory were examined in post-institutionalized (PI) children adopted into United States families from Russian institutions. The PI sample originated from institutions that were less severely depriving than those represented in previous studies and approximated the level of psychosocial deprivation, which is characterized by adequate physical resources but a lack of consistent and responsive caregiving. PI children (N = 75; 29 male) ranged in age from 8–17 years (M = 12.97; SD = 3.03) and were grouped according to whether they were adopted after 14 months or before 9 months. A non-adopted comparison group (N = 133; 65 male) ranged in age from 8–17 years (M = 12.26; SD = 2.75). PI children adopted after 14 months of age displayed poorer performance on the stop-signal and spatial span tasks relative to PI children adopted before 9 months of age after controlling for age at assessment. The two PI groups did not differ in their performance on a spatial self-ordered search task. Older-adopted PI children also showed poorer spatial span task performance compared to non-adopted children, but younger-adopted PI children did not. Task performance was significantly associated with parent-rated hyperactive-impulsive behavior in everyday contexts. These findings suggest that exposure to prolonged early institutional deprivation may be linked with inhibitory control and working memory difficulties years after adoption.

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Article Title: Potential Selective Responding in a Parent Questionnaire Study of Post-Institutionalized Children

Authors: Brandi N. Hawk, Amanda Wright, Megan M. Julian, Johana M. Rosas, Emily C. Merz & Robert B. McCall

Abstract: This study assesses selective responding in a single wave of data collection and a four-wave study. Participants were 121 parents of post-institutionalized children, identified as “never responders,” “previous responders,” or “wave 4 responders.” Parents evaluated their adopted child’s family, school, peer, and behavioral adjustment. Children (47% male) were 2 to 20 years old (M = 10.79, SD = 4.59) and adopted between 5 and 54 months of age (M = 15.49, SD = 9.94). Within a single wave of data collection, no evidence suggested that selective responding contributes much bias. Over a multi-wave study, however, results may under-represent adjustment difficulties.

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Study Title: Structure, caregiver–child interactions, and children’s general physical and behavioral development in three central American institutions

Authors: Groark, Christina J.; McCall, Robert B.; McCarthy, Stephanie K.; Eichner, Joan C.; Gee, Amy D.

Abstract: This article describes structural characteristics and caregiver–child interactions (N = 34) in three Central American institutions for infants and young children (N = 79) and relates differences in these characteristics to differences in children’s physical, behavioral, and cognitive development. Generally, the institution with the smallest group size, fewest children per caregiver, and a few consistent caregivers had children with the best physical, behavioral, and cognitive development; this institution also had many temporary volunteers who played with the children. Differences in the quality of caregiver–child interactions were not directly related to children’s development, but the potential benefit of high-quality interactions may have been minimized by a high children:caregiver ratio in one institution, and the presence of volunteers to play with children may have compensated for and/or minimized the display of higher-quality interactions by staff caregivers in another institution. (PsycINFO Database Record (c) 2013 APA, all rights reserved)

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Study Title: Attachment security as a mechanism linking foster care placement to improved mental health outcomes in previously institutionalized children

Authors: Katie A. McLaughlin, Charles H. Zeanah,Nathan A. Fox, Charles A. Nelson


Background:  Children reared in institutions experience elevated rates of psychiatric disorders. Inability to form a secure attachment relationship to a primary caregiver is posited to be a central mechanism in this association. We determined whether the ameliorative effect of a foster care (FC) intervention on internalizing disorders in previously institutionalized children was explained by the development of secure attachment among children placed in FC. Second we evaluated the role of lack of attachment in an institutionalized sample on the etiology of internalizing disorders within the context of a randomized trial.

Methods:  A sample of 136 children (aged 6–30 months) residing in institutions was recruited in Bucharest, Romania. Children were randomized to FC (n = 68) or to care as usual (CAU; n = 68). Foster parents were recruited, trained, and overseen by the investigative team. Attachment security at 42 months was assessed using the Strange Situation Procedure, and internalizing disorders at 54 months were assessed using the Preschool Age Psychiatric Assessment.

Results:  Girls in FC had fewer internalizing disorders than girls in CAU (OR = 0.17, p = .006). The intervention had no effect on internalizing disorders in boys (OR = 0.47, p = .150). At 42 months, girls in FC were more likely to have secure attachment than girls in CAU (OR = 12.5, p < .001), but no difference was observed in boys (OR = 2.0, p = .205). Greater attachment security predicted lower rates of internalizing disorders in both sexes. Development of attachment security fully mediated intervention effects on internalizing disorders in girls.

Conclusion:  Placement into FC facilitated the development of secure attachment and prevented the onset of internalizing disorders in institutionalized girls. The differential effects of FC on attachment security in boys and girls explained gender differences in the intervention effects on psychopathology. Findings provide evidence for the critical role of disrupted attachment in the etiology of internalizing disorders in children exposed to institutionalization.

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Study Title: Validity of Evidence-Derived Criteria for Reactive Attachment Disorder: Indiscriminately Social/Disinhibited and Emotionally Withdrawn/Inhibited Types

Authors: Mary Margaret Gleason, M.D., Nathan A. Fox, Ph.D.,Stacy Drury, M.D., Ph.D., Anna Smyke,Ph.D., Helen L. Egger, M.D., Charles A. Nelson III, Ph.D., Matthew C. Gregas, Ph.D., Charles H. Zeanah, M.D.



This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD).


As part of a longitudinal intervention trial of previously institutionalized children, caregiver interviews and direct observational measurements provided continuous and categorical data used to examine the internal consistency, criterion validity, construct validity, convergent and discriminant validity, association with functional impairment, and stability of these disorders over time.


As in other studies, the findings showed distinctions between the two types of RAD. Evidence-derived criteria for both types of RAD showed acceptable internal consistency and criterion validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42, and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%), respectively. Signs of indiscriminately social/disinhibited RAD showed little association with caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%), and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally withdrawn/inhibited RAD was moderately associated with caregiving at the first three time points and strongly associated with attachment security. Signs of this type of RAD were associated with depressive symptoms, although two of the five children with this type of RAD at 54 months did not meet criteria for major depressive disorder. Signs of both types of RAD contributed independently to functional impairment and were stable over time.


Evidence-derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited RAD define two statistically and clinically cohesive syndromes that are distinct from each other, shows stability over 2 years, have predictable associations with risk factors and attachment, can be distinguished from other psychiatric disorders, and cause functional impairment. Clinical trial registration information—The Bucharest Early Intervention Project, URL:, unique identifier: NCT00747396.


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Study Title: The effects of severe psychosocial deprivation and foster care intervention on cognitive development at 8 years of age: findings from the Bucharest Early Intervention Project

Authors: Nathan A. Fox, Alisa N. Almas, Kathryn A. Degnan, Charles A. Nelson, Charles H. Zeanah


Background:  Previous reports from the Bucharest Early Intervention Project suggested that children removed from institutions and placed into intervention displayed gains in IQ relative to children randomized to remain in institutional care.

Method:  The current report presents data from the 8-year follow-up of these children. One hundred and three of the original 136 children in the study were tested with the WISC IV.

Results:  Results reveal continued benefit from the intervention even though many of the children in both the intervention and control groups were no longer residing in their initial placements. Gains in IQ were particularly evident for those children who remained with their intervention family. There were also modest timing effects such that children placed earlier displayed higher scores on the WISC processing speed subscale. Early placement was also a significant predictor of a profile of stable, typical IQ scores over time.

Conclusion:  These data suggest the continued importance of early intervention and the negative effects of severe psychosocial deprivation on the development of IQ scores across early childhood.


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