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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
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3

The Effects of Institutionalization
and Living Outside of Family Care
on Children’s Early Development

Orphans and children living outside of family care are an extremely vulnerable population, often exposed to poverty, stigma, physical and sexual violence, and a lack of educational resources, according to research cited by Vesna Kutlesic (Cluver et al., 2013; Morantz et al., 2013).1 Other research indicates it is important to explore whether these children were first exposed to traumatic life events while living with their families, or subsequent to separation from their families to an out-of-family placement (e.g., an institution or foster care), or after ending up homeless and living on the street (Atwoli et al., 2014; Gray et al., 2015; Li et al., 2009; Whetten et al., 2014). Regardless of the timing of traumatic life events, Kutlesic emphasized the importance of building on the strengths of these children, eliminating stigma, and fostering their growth and well-being through their participation in evidence-based, multidisciplinary interventions aimed at improving their health, education, and psychosocial development.

Low- and middle-income countries (LMICs) are home to an estimated 132 million single and double orphans (cases in which either one or both parents are deceased), 95 percent of whom are over the age of 5 (UNICEF, 2015). Further research estimates that more than 8 million children around the world grow up in institutions (Csaky, 2009). Additionally, UNICEF estimates that there are tens of millions of street children who need care,

__________________

1 Vesna Kutlesic is director of the Office of Global Health at the Eunice Kennedy Shriver National Institute for Child Health and Human Development.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

and that this number is increasing (UNICEF, 2009). Caring for these vulnerable children therefore presents a complex problem that requires evidence-based solutions, a continuum of care, and placements for children with a diverse set of health, education, and psychosocial needs, said Kutlesic. Each model of care (institutionalization, family-based care, etc.) has its strengths and weaknesses, with primary goals being to provide a quality environment for children, opportunities for learning and growth, and protection from harm.

According to Kutlesic, when families are stressed and unable to care for a child or are at risk of harming a child, it is important to consider the child’s age, health, and developmental needs when determining an optimal living arrangement and support services. For children under age 2, research conducted by the Bucharest Early Intervention Project, the St. Petersburg–USA Orphanage Research Team, and others has focused on large hospital-style institutions employing shift workers with minimal interactions with residing infants and children, with results demonstrating powerful negative effects on the infant brain and other aspects of child development (Nelson et al., 2014; St. Petersburg–USA Orphanage Research Team, 2008). When these infants were later placed with trained, paid, and supervised foster parents, some brain and other developmental improvements have been observed, while others appear irreversible (Fox et al., 2011; St. Petersburg–USA Orphanage Research Team, 2008).

However, other studies of long-term outcomes of children placed in institutional care have found more nuanced positive outcomes, particularly among children over age 5 and those living in low-income countries (Embleton et al., 2014; Merz et al., 2013; Whetten et al., 2014). For example, the Positive Outcomes for Orphans study conducted in Cambodia, Ethiopia, India, Kenya, and Tanzania has found that children living in institutional settings scored as well or better than their counterparts in family-based care across measures such as physical and emotional well-being. According to Kutlesic, these data do not suggest that institutions are preferential to family settings. Rather the data suggest that children living in communities that are in the process of developing well-trained family and foster care placements have demonstrated positive psychosocial adjustment and developmental gains when placed in smaller institutions (such as group homes) that are well-organized and contain a strong educational component. She also cautioned that as part of reform projects aimed at the deinstitutionalization of children to family, foster care, and adoptive placements, it is important to have parallel efforts aimed at caregiver training, community health and social services, and strengthening the foster care system. These efforts reduce the risk of failed child placements and the unintended consequence of contributing to the growing numbers of street children, she said.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

Kutlesic closed by suggesting that in order for children who are not able to live with their families to be provided with the opportunity for optimal developmental outcomes, it is important to provide high-quality living environments that are tailored to the needs of individual children and include opportunities for learning and growth, well-trained caregivers, and appropriate adult-to-child ratios, regardless of placement setting.

THE EFFECTS OF INSTITUTIONALIZATION ON BEHAVIORAL DEVELOPMENT

In 2003, the European Commission Daphne Program funded a survey to examine the risk of harm to children under the age of 3 years living in institutions across 54 European countries (Browne et al., 2006). Kevin Browne and his team focused on behavioral consequences of institutionalization compared to family-based care, primarily in western and central European countries of the European Union (EU).2 At the beginning of the study, survey results showed that some countries had no children in institutional care,3 compared to the Czech Republic which institutionalized six children per 1,000, the highest figure in Europe. At the time, 44,000 children under 3 years old were in institutions across Europe and Central Asia; 23,000 children under 3 were in institutions in the EU member states and could spend up to 18 hours per day in their cribs. Browne’s findings showed that institutions negatively affect a child’s social behavior and interaction with others, as well as negatively affecting the formation of emotional attachments. Additionally, being institutionalized was linked to poor cognitive performance and language deficits. To combat the detrimental effects of institutionalization on young children, UNICEF launched a deinstitutionalization campaign after the United Nations (UN) General Assembly released guidelines saying that no child under 3 years of age should be in institutional care.

In 2013, Browne said that while some countries significantly reduced the number of children under 3 in institutions during the previous decade, others increased their number, as evidenced by 46 out of 54 country responses to the survey. Increases were seen in Austria,4 Albania, Malta, Moldova, Croatia, Bosnia and Herzegovina, Poland, and Tajikistan (arranged in order of largest percent increase) despite significant investment from nongovernmental organizations (NGOs) (Browne and Chou,

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2 Kevin Browne is director of the Center for Forensic and Family Psychology at the University of Nottingham, United Kingdom.

3 Countries with no children in institutional care included Slovenia and the United Kingdom.

4 Browne hypothesized that the additional three children in Austrian institutions are refugee children from abroad rather than Austrian nationals.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

2015). Countries that significantly reduced the number of children in residential care were Belgium, Czech Republic, Slovakia, Spain, Romania, Finland, Belarus, Estonia, Russia, The Netherlands, and Bulgaria (arranged in order of largest percent decrease) (Browne and Chou, 2015). Browne highlighted an increase in foster care, stating that the majority of children are now in family-based care because countries have made efforts to reduce the numbers in institutional care. He noted that more work has to be done, however, and that several countries still lag behind in developing a legitimate family-based care system, notably Belgium, Italy, and Spain. Although the Czech Republic currently has high numbers of children in institutions compared to other countries in Europe, Browne commended the country’s efforts to reduce institutionalization by 22 children per 10,000 (Browne and Chou, 2015).

Reasons for institutionalization varied and have changed little since 2003, according to Browne’s research. In Western European countries, 4 percent of children were institutionalized because they were abandoned, another 4 percent were disabled, and 68 percent were abused and neglected. In Eastern Europe and Central Asia, children were more likely to be institutionalized because of disability (23 percent), abandonment (33 percent), and because they were abused or neglected (14 percent), according to Browne (2009). He noted that abandoned children, children with disabilities, and those from ethnic groups face more discrimination than children institutionalized for other reasons. In the Czech Republic and Slovakia, a significant proportion of children in institutions are of Romani origins and a significant number have disabilities. Browne also proposed that several societal influences have led to the development of institutional care, including

  • A lack of community nurses and social workers, who, according to research, are the best actors to prevent abandonment and violence in the community (Browne, 2009; Hamilton-Giachritsis and Browne, 2012)
  • A lack of home-based assessments of children in need and their families
  • A lack of free universal prevention services to reduce child abuse, neglect, and abandonment
  • Weak targeted interventions with families at high risk of child abuse, neglect, and abandonment
  • Slow development of high-quality foster care systems

In closing, Browne suggested the provision of high-quality foster care, community services for families in need, and daycare facilities for children with and without disabilities to reduce the number of children in

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

institutions. He recommended residential care only for children who may harm themselves or others, as well as an increased number of mother–baby units in institutions when community services do not exist.

THE BUCHAREST EARLY INTERVENTION PROJECT

According to Anne Berens,5 social policies under Nicolae Ceaușescu’s authoritarian rule of Romania from 1965 to 1989—such as a ban on contraception and a tax on families without children—coupled with widespread poverty led to rising fertility and high rates of child abandonment into state institutions. At the end of this regime in 1989, there were an estimated 170,000 children in institutions. It is in this historical context that researchers developed the Bucharest Early Intervention Project, a longitudinal study in Romania that began in 2000 with ongoing follow-up today. The project has three aims:

  1. Examine the effects of institutionalization on the brain and behavioral development of young children.
  2. Determine if observed negative effects can be remediated by placing children in high-quality foster care.
  3. Improve the welfare of Romanian children by establishing foster care as an alternative to institutionalization.

Berens reported that in 2000 many political leaders questioned whether institutions were actually harmful for young children. Although baseline findings showed that children in institutions had significantly lower cognitive development scores than children who were not in institutions (Smyke et al., 2007), some believed that deficits among institutionalized children existed prior to institutionalization rather than developing due to residential care. For example, children placed in institutions may have been exposed to risk factors that led to placement in residential care such as exposure to fetal drugs and alcohol, or mothers who could not access prenatal care.

In response to these questions, Bucharest Early Intervention Project researchers designed a randomized control trial to control for environmental and background differences between children and examine the treatment effects incurred from high-quality foster care. When the project started, there was no national foster care system, only local initiatives largely supported by NGOs, said Berens. Therefore, researchers recruited and trained 58 foster families, the maximum amount possible based on funding from their grant.

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5 Anne Berens is the Julius B. Richmond Fellow at Harvard University in the United States.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

Researchers randomly assigned 136 children from state-run institutions into two groups (keeping siblings together): children who would move from an institution to foster families (foster care group) and those who would remain in institutions (institutional group). Sixty-eight children were assigned to the foster care group and 68 to the institutional group; 72 children from the community who had never been institutionalized comprised the control sample and were referred to as the “never institutionalized group.” According to Berens, the mean age of the sample prior to the intervention was 21.6 months and the mean age at placement into foster care was 22 months. Researchers conducted follow-up assessments at 30, 42, and 54 months, and 8 and 12 years. Age 16 follow-up was being conducted at the time of the meeting.

Bucharest Early Intervention Project researchers examined a wide range of outcomes: cognition, neurodevelopment (electroencephalogram [EEG], magnetic resonance imaging, and event-related potentials), psychopathology, physical development, social skills, attachment, language, temperament, autonomic and hypothalamic–pituitary–adrenal function, and genetics and epigenetics.6 In analyses of cognition, researchers found that the foster care group had significant improvements in intelligence quotient (IQ) at ages 30, 42, and 54 months compared to the institutionalized group (Fox et al., 2011). Taking into account the age at which a child was placed in foster care, data showed evidence of greater gains for IQ in younger children, particularly those placed before 24 months old (Nelson et al., 2007). Examining EEG patterns, researchers found that children placed into foster care after 24 months of age had brain activity indistinguishable from the institutionalized group, whereas children placed before 24 months had EEG patterns that were indistinguishable from the never institutionalized group (Vanderwert et al., 2010). The study also found high rates of psychiatric disorders—around 38 percent—in the institutionalized group and increased rates of behavioral difficulties such as attention deficit hyperactivity disorder, externalizing symptoms, and aggression (Humphreys et al., 2015).

Finally, Berens stated that timing effects were seen across a number of domains with evidence of greater recovery of the foster care group if placed before 12, 15, 20, and 24 months. In addition to IQ and brain function, differences were noted in language, social skills, inhibitory control, and attachment (Almas et al., 2012; Bos et al., 2010, 2011; McDermott et al., 2013; Vanderwert et al., 2010; Windsor et al., 2011) (see Figure 3-1). Importantly, Berens noted that positive effects in the foster care group

__________________

6 Berens focused her presentation on cognition, neurodevelopment, and psychopathology, and encouraged participants to visit the project website for a discussion of findings on the other measures: http://www.bucharestearlyinterventionproject.org.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
Image
FIGURE 3-1 Effect modification by age at foster care placement suggests multiple sensitive periods across developmental domains.
NOTE: ERN = error-related negativity; IQ = intelligence quotient.
SOURCES: Almas et al., 2012; Bos et al., 2010, 2011; McDermott et al., 2013; Nelson et al., 2007; Vanderwert et al., 2010; Windsor et al., 2011.

were true only for children who had stable placements; children who had disrupted foster care often fared worse than the institutionalized group.

LUMOS FOUNDATION’S MODEL OF DEINSTITUTIONALIZATION IN MOLDOVA

Irina Malanciuc presented Lumos Foundation’s successful deinstitutionalization model in Moldova. Formerly part of the Soviet Union, Moldova is a young country—24 years old—with a population of over 3.5 million people, a fifth of whom are children (up to age 18).7,8 According to Malanciuc, the country is very poor with an underdeveloped economy.9 Due to high rates of poverty, parents often leave children in care of relatives and neighbors and go in search of work in other countries. Based on the study carried out by Lumos in its pilot regions in Moldova, it was estimated that 20 percent of children live without their parents (Lumos, 2009). There are many children with disabilities who live in institutions and who are victims of neglect and abuse.

__________________

7 Irina Malanciuc is country director for the Lumos Foundation, Moldova.

8 Figures provided by the National Bureau of Statistics of the Republic of Moldova. See http://www.statistica.md/newsview.php?l=en&idc=168&id=4779 (accessed February 10, 2016) for more information.

9 The data from the World Bank indicate that the gross domestic product per capita in Moldova slightly exceeded USD 2,200 in 2014. See http://data.worldbank.org/indicator/NY.GDP.PCAP.CD/countries/MD?display=graph (accessed February 10, 2016) for more information.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

Based on a study conducted by the Moldovan government with support from UNICEF, in 2007 Moldova had more than 11,000 children living in 67 residential institutions (Evans, 2013). Of these children, more than 60 percent were older than 12 years old (Evans, 2013). According to Malanciuc, this fact helped the authorities understand that through prevention of institutionalization, support of children who leave residential care because they exceed the age limit, and reintegration of children into families, it was possible to change the system. With an aim to reduce the number of children in institutions by 50 percent by 2012, as targeted in the National Strategy and Action Plan on the residential child care system reform for 2007–2012, Lumos Moldova joined the efforts of authorities and NGOs to decrease the number of children placed in residential care and implemented Lumos’ 10-step model for deinstitutionalization, as presented in Box 3-1.

By implementing the National Strategy and Action Plan, the number of children in institutions in Moldova decreased by 62 percent by 2012. Through the development of social services, the creation of alternatives to institutional care, family support, community-based services, and intersectorial coordination at the central and local levels, Lumos Moldova, in partnership with UNICEF, Hope and Homes for Children, and Every Child, reduced the number of children in institutions to fewer than 3,000 by the end of 2014. A large part of this decrease was due to the development of inclusive education, said Malanciuc. In 2010, only 8 percent of children with disabilities were enrolled in mainstream education; in 2014, this number climbed to 50 percent.10 Also, most children returned to their families, who were involved in the deinstitutionalization process from the beginning.

Lumos supported the development of a normative framework for child protection and the creation of new social and educational services. The foundation assisted authorities in closing six residential institutions from its pilot regions, reintegrating children into their families, and supporting graduates. Despite reducing the number of children in institutions in Moldova, Malanciuc did note some challenges, namely that Moldova still has children under age 3 living in institutions and that as of 2014, more than half of remaining children in institutions have disabilities and special education needs. Additionally, she highlighted a lack of services for those who leave care. Through creating care opportunities for these children and increasing the number of staff in areas such as social protection and education, Malanciuc is hopeful that the deinstitutionalization process will continue.

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10 Data is estimated based on figures provided by the National Bureau of Statistics of the Republic of Moldova. See http://www.statistica.md/public/files/publicatii_electronice/Educatia/Educatia_RM_2015.pdf (accessed February 10, 2016) for more information.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

TRANSFORMING CHILD CARE SYSTEMS: A CZECH POLICY PERSPECTIVE

Katerina Slesingerova suggested three reasons why transforming the child care system can be a difficult task.11 First, while most people agree that children need protection, they do not agree on how this should be

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11 Katerina Slesingerova is head of the Department for the Protection of Children’s Rights at the Ministry of Labor and Social Affairs in the Czech Republic.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

provided. Many times, scientific evidence supporting a path forward is filtered through personal values and beliefs. Second, Slesingerova said children cannot vote for policies that directly affect their lives. Finally, in the Czech Republic, more than half of public funding goes to institutional care; less than 9 percent goes to prevention, and about 40 percent goes to the foster care system.

As in Moldova, Slesingerova said that the child care system is divided among three ministries: the Ministry of Education, which is responsible for children’s homes; the Ministry of Health, which manages baby homes; and the Ministry of Labor and Social Affairs, which is responsible for child protection, social work, foster care, and a social security system. This split means that if savings are incurred in institutional care, the money is not reallocated to preventive care or services for families because responsibility for provision of those services lies with another ministry. Slesingerova noted that some changes are occurring to address this limitation such as discussions between the Ministry of Education and the Ministry of Social Affairs to unify administration of the institutions under one ministry. She emphasized that child care systems do not operate in isolation; they interact with other systems, which requires coordination from the lowest to the highest levels in the country. She added that no child care system is perfect, but that change can continue to be made according to new evidence.

BREAKOUT SESSION ON CHILDREN LIVING OUTSIDE OF FAMILY CARE

In addition to the panel presentations, the workshop featured a session in which workshop participants separated into four groups to discuss best practices for reaching children living at the margins of society. According to Browne, who reported out for the breakout session on children living outside of family care, Malanciuc presented a video by the Lumos Foundation titled, “Children Need Families, Not Orphanages” (narrated by the founder, J. K. Rowling), which highlights the science of developmental and psychological effects institutionalized care has on young children, reasons for institutionalization, and how institutionalized care can be prevented by diverting resources to community services. Malanciuc also highlighted “gatekeeping” practices in Moldova in which a committee gathers to discuss potential outcomes of a child’s placement into foster care, kinship care, or institutional care. Only after the committee agrees that the placement is in the child’s best interest is the child moved. Malanciuc also discussed the practice of placing social workers in maternity units with a high number of births per year in Moldova to reduce abandonment. With this practice, abandonment of children in maternity units dropped by 41 percent, she said (UNICEF, 2005).

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

Sevdzhihan Eyubova of the Karin Dom Foundation in Bulgaria highlighted a program the foundation implements in partnership with the Tulip Foundation and the Oak Foundation to prevent the institutionalization of children with disabilities.12 Specifically, she said the program is aimed at enhancing the capacity for parents to raise their children with disabilities at home, as well as the capacity of organizations in Bulgaria to encourage a family-centered approach to caring for these children. According to Eyubova, there are two sources of encouragement for parents to institutionalize their children: relatives and medical staff. To curb guidance from medical staff to parents to abandon children, Karin Dom placed psychologists in Bulgarian hospitals to support doctors and nurses. Psychologists offered support to staff delivering children with disabilities and talked through alternatives to institutional care.

Workshop participants also discussed foster care. Topics covered included how to promote good foster care through training, support, and diversification, and the various types of foster care such as short-term foster care, long-term foster care, and emergency foster care. Although breakout group participants attempted to determine if institutional care or foster care is preferable, some participants determined they could not make a fair comparison as they would be comparing apples to oranges.

__________________

12 See https://karindom.org.

Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×

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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Suggested Citation:"3 The Effects of Institutionalization and Living Outside of Family Care on Children's Early Development." National Academies of Sciences, Engineering, and Medicine. 2016. Reaching and Investing in Children at the Margins: Summary of a Joint Workshop by the National Academies of Sciences, Engineering, and Medicine; Open Society Foundations; and the International Step by Step Association (ISSA). Washington, DC: The National Academies Press. doi: 10.17226/23491.
×
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Next: 4 The Effect of Discrimination and Social Exclusion on Young Romani Children »
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The United Nations Sustainable Development Goals for 2015-2030 strive for a world that is "just, equitable, and inclusive," in which everyone receives care, education, and opportunities to thrive. Yet many children are living on the margins of society, face multiple disadvantages, and are excluded from full participation in all that life has to offer. To examine the science, economics, and politics of investing in the health, education, nutrition, and social protection of children at the margins, the National Academies of Sciences, Engineering, and Medicine held a workshop in Prague, Czech Republic in November 2015. Held in partnership with the Open Society Foundations and the International Step by Step Association, the workshop convened a diverse group of stakeholders from around the world for 2 days of discussion. This report summarizes the presentations and discussions from the workshop.

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