Abstract
Policy makers struggling to protect the 153 million orphaned and separated children (OSC) worldwide need evidence-based research on the burden of potentially traumatic events (PTEs) and the relative risk of PTEs across different types of care settings. The Positive Outcomes for Orphans study used a 2-stage, cluster-randomized sampling design to identify 1,357 institution-dwelling and 1,480 family-dwelling orphaned and separated children in 5 low- and middle-income countries (LMICs) in sub-Saharan Africa and Asia. We used the Life Events Checklist developed by the National Center for Posttraumatic Stress Disorder to examine self-reported PTEs among 2,235 OSC ages 10-13 at baseline. We estimated prevalence and incidence during 36-months of follow-up and compared the risk of PTEs across care settings. Data collection began between May 2006 and February 2008, depending on the site. Lifetime prevalence by age 13 of any PTE, excluding loss of a parent, was 91.0% (95% confidence interval (CI) = 85.6, 94.5) in institution-dwelling OSC and 92.4% (95% CI = 90.3, 94.0) in family-dwelling OSC; annual incidence of any PTE was lower in institution-dwelling (23.6% [95% CI = 19.4, 28.7]) than family-dwelling OSC (30.0% [95% CI = 28.1, 32.2]). More than half of children in institutions (50.3% [95% CI = 42.5, 58.0]) and in family-based care (54.0% [95% CI = 50.2, 57.7]) had experienced physical or sexual abuse by age 13. Annual incidence of physical or sexual abuse was lower in institution-dwelling (12.9% [95% CI = 9.6, 17.3]) than family-dwelling OSC (19.4% [95% CI = 17.7, 21.3]), indicating statistically lower risk in institution-dwelling OSC (risk difference = 6.5% [95% CI = 1.4, 11.7]). Prevalence and incidence of PTEs were high among OSC, but contrary to common assumptions, OSC living in institutions did not report more PTEs or more abuse than OSC living with families. Current efforts to reduce the number of institution-dwelling OSC may not reduce incidence of PTEs in this vulnerable population. Protection of children from PTEs should be a primary consideration, regardless of the care setting.
Highlights
The appropriateness of institutional care for orphaned children has become a central question for international aid policy affecting many lowand middle-income countries (LMICs)
Annual incidence of physical or sexual abuse was lower in institution-dwelling (12.9% [95% confidence interval (CI) = 9.6, 17.3]) than family-dwelling orphaned and separated children (OSC) (19.4% [95% CI = 17.7, 21.3]), indicating statistically lower risk in institution-dwelling OSC
Prevalence and incidence of potentially traumatic events (PTEs) were high among OSC, but contrary to common assumptions, OSC living in institutions did not report more PTEs or more abuse than OSC living with families
Summary
The appropriateness of institutional care for orphaned children has become a central question for international aid policy affecting many lowand middle-income countries (LMICs). In the meta-analysis, differences between institutionalized and non-institutionalized children were not observed in 3 of the 4 countries ranking low on the Human Development Index, a widely accepted measure of health, education, and standard of living, suggesting that conclusions about what is broadly labeled ‘‘institution’’ may not hold for institutionalized orphans in LMICs. Yet the findings from the literature have led to a generalization that all institutional care is harmful to all children and have fueled international policies aimed at reducing the number of institutions and using them exclusively as a temporary option until family-based care can be reestablished.[6,7,8] At the same time, the numbers of street children are on the rise in these same countries. Policy makers struggling to protect the 153 million orphaned and separated children (OSC) worldwide need evidence-based research on the burden of potentially traumatic events (PTEs) and the relative risk of PTEs across different types of care settings
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