The POFO Research Team thanks Fox, Nelson and Zeanah for their comments. The Bucharest Early Intervention Project (BEIP), among others, has indeed clearly demonstrated that infants and young children exposed to neglect and deprivation suffer deficits in both IQ and in the ability to form social relationships. These children are also found to be of smaller stature and at an increased likelihood of having psychiatric disorders. Your BEIP work is ground-breaking particularly in the ways that you demonstrated these changes in brain images, and showed how improving care early in life can remediate most of the negative effects of deprivation.

Where our research differs is in the interpretation that institutional care equals exposure to neglect and deprivation, and that family care equals loving care and provision of the basic needs of children.

We believe that you are referring to Denise Grady’s New York Times article in your second paragraph. Our article, cited therein, “A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6–12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations,” and to which your comment responds, does not claim that institutional care is not harmful. Instead, it demonstrates great variation in outcomes among community and institution based children, and that orphaned or abandoned (OAC) children aged 6-12 living in 83 randomly selected institutions from 6 sites across 5 countries, at the aggregate level, appear to be doing as well as, or better than, randomly selected OAC of the same ages living in family settings, Street children were not included in the study.

The appropriate comparison depends greatly on the intent of the study. If the goal is to assess differences between orphaned and non-orphaned children then the comparison referred to is indeed the correct one. However, the issue of orphaning and abandonment vs. non-orphaning and remaining with family is not the principal issue of interest. For policies under discussion about whether children should be moved from institutional care settings into community care, the comparisons presented in our paper are more relevant.

The POFO study results are only for children ages 6 to 12; this study does not include or apply to younger children. Just as study results concerning children over the age of 6 do not necessarily apply to younger children, the same is true in reverse: studies of children aged 2 and under, for example, may not extend to older children. Assessing care settings for the 6-12 age range is important; For children in the new OAC epidemic across southern and eastern Africa, the rate of being orphaned or abandoned rises with each year of age (e.g., children at the age of 6 are more likely to become OAC than younger children). Just as the needs of children change with age, it is possible that solutions may differ for younger and older children.

We want to be very clear on the interpretation of these research findings. The study found institutions where children were not doing well and institutions where children were doing well; the same was true in family settings. Blanket policies that discourage the use of institutions and promote the idea that all children should be moved out of such settings as quickly as possible may result in the endangerment of children. Just as it would be quite dangerous to move children from family settings where they are doing well to institutions, it is also possible that the reverse is true; moving children who are doing well in institutions to family settings that are not able to provide adequate care may be harmful.

As we see in all countries, poverty is a major contributor to not being able to provide adequate care, but there are many other reasons, including mental illness, substance abuse, not wanting the child (or any children), and not valuing children who have been orphaned or abandoned due to cultural or personal beliefs. We must continue to search for ways to care for these children in permanent and stable family settings. However, for the foreseeable future there are millions of children who do not have family settings that can provide adequate care. It is critical that we do not limit options for these children.

We, as a scientific community, have assumed in our research that institutions all have rather similar characteristics, most of these being harmful. Additionally, we have not done an adequate job at defining what an “institution” is. The policies addressing these issues are frequently based on hearsay and not evidence-based research. A key conclusion of “A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6–12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations” is that we need to first understand the characteristics of caregiving that result in child wellbeing and only then focus on where such care can be delivered in financially feasible and culturally appropriate ways. By neglecting the great heterogeneity in the structure and delivery of institutional care in existence, we run the risk of limiting innovative, caring, financially feasible and sustainable, and culturally appropriate care options that may be valid options for OAC who do not have a family that can provide adequate care.