Adoption Advocate No. 23: Continuum of Child Welfare Services to Promote Permanence for Children
Published April 2010 by Elisa Rosman, Ph.D. with Chuck Johnson
This article presents NCFA’s philosophy concerning the continuum of child welfare and supportservices as provided to children and families in need of social services, either domestically or interna-tionally. NCFA is a vocal and enthusiastic proponent of domestic and intercountry adoption as a viableoption for children without families to care for them, and we believe this continuum should be non-hier-archical; the continuum is not “one size fits all,” as different options may prove better for different children and families. This article provides a framework for government officials, policymakers, andchild welfare practitioners to use as a reference as they work to implement policies and practices thathave an impact on the child welfare continuum.
One can envisage a desirable hierarchy oflife environments that can be offered a child:
Nonetheless, the important thing is not to apply this range of measures mechanically or rigidly. Every child is different; his/her history and his/her personal and family situation are special (p. 4).2
While this ISS statement represents a more hierarchical approach than NCFA embraces, weinclude it here in our good faith opinion that the ISS supports timely decision-making in the best interest of each child in question, and that they doin fact consider international adoption a viable option and treat it as such.
Within the adoption community, the Families for Orphans Coalition (on whose Executive Committee NCFA serves) has also presented its own version of this continuum of services as itrelates to permanency planning:
NCFA fully supports the idea of a child welfare continuum, and believes that it represents our core beliefs as an organization. Our continuum, presented below, ensures that adoption, both domestic and intercountry, remains a viable option for children after family preservation or reunification is ruled out as a timely and appropriate option—and before a child is placed in long-term institutional or foster care. (We acknowledge that interim foster care may be a necessary part of the process for some children.) Drawing from resources outlined above, we present the child welfare continuum chart below.
While the list is presented as a step-by-step flow chart, the specific needs of children and families within each country may require deviation from this step-by-step formula. The implicit hierarchy presented in this chart is often referred to as the ”Principle of Subsidiarity,” with the firstchoice being the preservation of the birth family,followed by a permanent family-based option inthe birth country, followed by intercountry adoption.3 We want to stress that, in NCFA’s view, the appropriate action must always be taken in the best interest of the child, and the best action is one that shall result in a permanent, legal family for a child in every situation possible; the correct option for one child and family will not necessarily be best for another. Also, when options are less than clear, agencies can and should engage in concurrent planning to appropriately prepare for timely and effective decision-making for the benefit of the child.4 The importance of considering the needs of each individual child and family isalso emphasized in the United Nations’ Guidelines for the Alternative Care of Children(2009): “All decisions…should be made on a case-by-case basis, with a view notably to ensuring the child’s safety and security, and must be grounded in the best interests and rights of the child concerned” (p. 6-7).5
The concept of the child welfare continuumis clearly demonstrated in the advocacy work ofthe adoption community following the Haiti earthquake in January, 2010. Advocates are arguing for the child welfare system to be “built back better,” so that out of this tragedy a stronger childwelfare system can emerge. As Kathleen Strottman, Executive Director of the Congressional Coalition on Adoption Institute (CCAI) argues:
We can go about making plans to provide protection to orphan children in temporary shelters until they can be returned to their orphanages, or worse the streets, or we can take the recent out pouring of international support and use it to begin a new. Working together, we can help the people of Haiti to develop a child welfare system in which Haitian children are being raised in safe, loving and permanent families, not by institutions. Such a system could be built upon international best practices in preserving families, providing foster care, as well as promoting domestic and international adoption.6
We now present each stage of the continuum, followed by a review of research concerning childand family outcomes for each stage. While we believe that the continuum has international applicability, we specifically draw from the United States’child welfare system for most of the information and examples presented below.
Ideally, all families would have the personal and financial resources they need to stay together, and there would be no need for foster care or adoption services. Even for children in foster care, typically the “first choice” outcome is family reunification, when this is a realistic and viable option that can be accomplished in a timely manner. For fiscal year 2008 (the most recent year for which data is available), of the 463,000 children in foster care in the United States, 226,867 (49%) had reunification with parents or primary caretakers as their case goal. Furthermore, 148,340 children (52% of those who exited foster care in 2008) were reunified with parents or primary caretakers.7
The United Nation’s Guidelines for the Alternative Care of Children similarly maintains the importance of family preservation and reunification: “States should develop and implement consistent and mutually reinforcing family-oriented policies designed to promote and strengthen parents’ ability to care for their children (p. 11).”8
Research clearly indicates how to keep families together and reunify families successfully. In the area of family preservation, the Guidelines cited above mention specific support services thatcan help enable families to care for and protect their children, including parenting courses, the promotion of positive parent-child relationships, conflict resolution training, opportunities for employment, and other social services.
An issue brief from the Child Welfare Information Gateway also highlights key components of successful reunification.9 These include:
There are also ways to promote family reuni-fication system-wide. These include:
How can the success of family preservationand reunification be measured? For family reunification, the most obvious measure is whether or not the family is able to remain together in the long term. The available data for family reunification is not overwhelmingly positive. In a review of family reunification for The Future of Children, Wulczyn finds that nearly 30% of children who were reunified with their families in 1990 had reentered foster care within ten years. He provides an overview of programs and practices that show promise in promoting and sup porting successful reunification. These include programs that are comprehensive, theory-based (i.e., based on empirically proven theories and intervention strategies), culturally competent (i.e.,acknowledge cultural differences and norms), build on families’ inherent strengths, address children’s developmental needs, and provide ongoing aftercare.10
Another measure of family preservation iswhether fewer children are entering foster care inthe first place. One example of a community thathas successfully embraced family preservationand reunification is Alameda County inCalifornia. In that county, the number of youthentering the child welfare system decreased by40% from 2000 to 2007. According to CarolCollins, Assistant Agency Director at theDepartment of Children and Family Services,“One of our themes became ‘Let’s focus ourefforts on early intervention, prevention, andkeeping children safely at home’” (p. 19). Thecounty accordingly implemented the AnotherRoad to Safety (ARS) Initiative to target threecommunities and provide services via socialworkers. The social workers helped link familieswith support services such as medical care, devel-opmental assessments, job training, and basic lifenecessities. There was also a team to provideongoing support, which included psychologistsand developmental specialists. In 2003, AlamedaCounty implemented the Annie E. Casey Familyto Family Initiative, which focused on developingpartnerships within the community and stressingfamily involvement in decision-making. In addi-tion, the county applied for a Title IV-E waiver inorder to use funds to help keep children fromentering foster care in the first place.11
Domestic adoption typically occurs via private adoption (primarily infant adoption) or from the foster care system. The most recent and comprehensive data regarding the number of domestic adoptions in the United States, dating from 2002, can be found in NCFA’s Adoption Factbook IV. In that year, there were 76,013 unrelated domestic adoptions. Of those, 22,291 were infant adoptions, 56.5% were by public agencies, 22.4%were by private agencies, and 21.1% were by private individuals.12
From a research and policy perspective, it is important to investigate outcomes for adopted children: Do they fare better or worse than their non-adopted peers? Of course, it is difficult to generalize about such a diverse group of children, but recent data sheds some light on this issue.The National Survey of Adoptive Parents (NSAP) was conducted between April 2007 and June 2008 as an add-on to the National Survey of Children’s Health, specifically for families with adoptedchildren, and a Chartbook was recently published presenting data from the NSAP.13 It is the first survey to provide nationally representative information about adopted children and their families, and it includes interviews with families of 2,089 children, representing the nearly 1.8 million adopted children in this country.
NSAP data provides a generally positive picture of outcomes for domestically adopted children. Overall, their physical health is very good. 81% of parents who adopted children from foster care and 84% of parents who adopted via private domestic adoption report that their child’s healthis “excellent” or “very good.” As the table below shows, the authors did find that, while overall they are doing quite well, children adopted from foster care are more likely than children adopted privately to demonstrate certain problems in the areas of social and emotional well-being. This may result from the fact that children are typically adopted from foster care at an older age than children adopted domestically; additionally, these children may have suffered abuse and neglect andmay have been in several temporary placements prior to being placed in a permanent adoptive home. As the Chartbook authors explain: “As a group, the pre-adoptive experiences of children adopted from foster care—many of whom are adopted at older ages than children adopted from other domestic sources or internationally—are likely to make them more vulnerable than other adopted children” (p. 6). This points to the importance of timely decision making for children involved in the child welfare system.
Academically, children adopted domestically also seem to be doing well. For children adopted from foster care, 50% of parents rated their reading and language arts skills as “excellent” or “very good,” and 41% were rated “excellent” or “very good” in math. For children adopted privately, those percentages are 64% and 58%, respectively. As for being engaged in school, 61% of parents whose 6-to-17-year-old children were adopted from foster care report they are usually or always engaged in school. That figure is 74% for children adopted privately.
For these families, the parent/child relationship is generally strong as well. Seventy-five percent of parents with children adopted from foster care and 85% of parents with children adopted privately describe the parent/child relationship as “very warm and close.” Eighty-one percent of parents of children adopted from foster care and 93% of parents of children adopted privately report they would make the decision to adopt again.
UNICEF officially recognizes the importanceof intercountry adoption. As stated in their position on intercountry adoption: “For children who cannot be raised by their own families, an appropriate alternative family environment should be sought in preference to institutional care which should be used only as a last resort and as a temporary measure. Intercountry adoption is one of a range of care options which may be open to children, and for individual children who cannot beplaced in a permanent family setting in their countries of origin, it may indeed be the best solution. In each case, the best interests of the individual child must be the guiding principle in making a decision regarding adoption.”14
Despite this international validation, however, intercountry adoption among American families is decreasing. According to the Department of State, 12,753 children were adopted in 2009.15 As the graph below illustrates, adoptions have steadily decreased every year since their peak of 22,884 in 2004.
NCFA believes that intercountry adoption should remain a viable option as long as there are children in other countries who need families andparents in this country who are interested in adopting internationally. Dr. Elizabeth Bartholet of Harvard University recently addressed this issue before the Inter-American Commission on Human Rights at the Organization of AmericanStates.
In November 2009 the commission held a hearing on the human rights of unparented children. In her testimony, Dr. Bartholet argued that, in the area of intercountry adoption, human rights arguments have focused too heavily on the human rights of parents and the sovereignty rights of states. She argues that the human rights of unparented children must be considered as well:
We assert that children’s most fundamental human rights are to live and to grow up in a nurturing family so they can fulfill their human potential. These rights have been largely ignored in the debate surrounding unparented children and related International Adoption policies. We argue that unparented children have a right to be placed in families, either their original families, or if that is not feasible, then in the first available permanent nurturing families. This includes the right to be placed in international adoption if that is where families are available. We argue that children have a related right to be liberated from the conditions characterizing orphanages and most foster care.16
Of course, one of the primary arguments against intercountry adoption is the false perception that it is rife with fraud and exploitation. Dr.Bartholet acknowledges these concerns, as does NCFA, which is why our organization consistently calls for the enforcement of existing laws that identify and punish those involved in adoptionfraud and other illegal activities. However, along with NCFA, Dr. Bartholet also argues against other policies, such as moratoria on intercountry adoptions, which “simply punish unparented children by denying them adoptive homes.” NCFA also strongly supports international rules and regulations (such as the Hague Convention onIntercountry Adoption) that promote ethical intercountry adoption. We firmly believe that an ethicalintercountry adoption process is attainable inmost countries, and, certainly more often than not, is already the reality in many countries. For the vast majority of internationally adopted children, adoption provides loving permanent homes for children who have no family to care for them.“ To shut down intercountry adoption, as some of its more radical critics suggest, would harm far more children than it would help and is therefore not an appropriate response to the problems facing the institution.”17
The United States government also supports intercountry adoption as an option for childrenand families. In a statement celebrating National Adoption Month in November 2009, Michele Bond, Deputy Assistant Secretary for Overseas Citizens Services in the Bureau of Consular Affairs, affirmed America’s commitment to intercountry adoption: “Here at the State Department, we continue to work with other countries to develop and implement standards and procedures to help ensure that as many children as possible can find permanent, loving homes. We believe that intercountry adoption can be an important option for children in need, and that every childdeserves a loving home.”18
As in the case of children adopted domestically, it is difficult to generalize about outcomes for a group as large and diverse as internationally adopted children. Research is clear that multiple factors have an impact on outcomes for adopted children, including their country of origin, age at adoption, and length of time spent in an institution prior to adoption. However, the NSAP study mentioned above19 does provide some data specific to intercountry adoption as well.
NSAP data suggests that, as a whole, internationally adopted children are faring quite well. In the area of physical health, 93% of children adopted internationally have parents who reported their health as being “excellent” or “very good”. Children adopted internationally are also doing well academically. Parents report that 73% ofchildren ages 6 to 17 are usually or always engaged in school. Sixty-three percent of parents of children ages 5 to 17 report that their child’s school performance is “excellent” or “very good” in language arts; 65% for math. These children are also very engaged with their families and communities: 64% eat meals with their families six or seven days a week, and 93% have participated in an organized activity.
Internationally adopted children and their families also enjoy quality family relationships. Forty-six percent of parents report that the parent/child relationship is “better than ever expected,” and 62% say that having their children in their lives is “better than they ever expected. ”Eighty-five percent of parents report that their relationship with their child is “very warm and close” and 91% report being not aggravated as parents. Overall, the research is clear that intercountry adoption benefits both children and parents.
Controversy Surrounding Intercountry Adoption
There are those who argue that intercountry adoption is too heavily favored and widely practiced, as well as those who argue that it isn’t favored enough. Those who argue that it is too heavily favored are, in essence, opposed to intercountry adoption in any form. They believe that an individual’s birth culture and nation should take precedence over a child’s right to a permanent family. As Jeneen Interlandi explained in a recent Newsweek article, opponents of intercountry adoption argue that “that taking orphaned children from their birth countries and raising them elsewhere robs those nations of their most valuable resource and leaves the adoptees with a hopelessly fractured ethnic identity, only to satisfy the capricious whims of wealthy Westerners. (The contentious term cultural genocide is sometimes employed.)”20
This is an untenable argument. Interlandi (who was herself adopted internationally) also argues that race and ethnicity should not be the deciding factors in any adoption. She claims that many white parents—her own included—are perfectly capable of successfully raising children from other races and cultures. She concludes: “In the end, what matters most is not where a child is from, but whether or not that child is well loved and well cared for by a responsible family—regardless of race or nationality. ”Those who argue that intercountry adoption isn’t favored enough object to it being considered only after family preservation and reunification efforts have failed. They fear that those who oppose intercountry adoption at every opportunity will ignore the need for timely action or create some sub-category of placement that falls short of real permanency.
We at NCFA believe that the child welfare continuum presented above is the correct order of social services. We by no means consider intercountry adoption a “last resort.” On the contrary, in the continuum presented in this article, intercountry adoption is considered a viable option and, in fact, a first-level option when other options higher on the continuum have failed to deliver permanency in a timely manner or are not likely to succeed based on circumstances. In all cases, intercountry adoption must be considered a viable option before a child is relegated to life in an institution or any other nonpermanent placement or care. NCFA believes that, by ensuring that intercountry adoption remains in proper perspective on the continuum of child welfare services, we are in fact preserving it as a positive option for many children who lack a family to care for them.
Avoiding Institutionalization for Children
All of these options along the child welfare continuum are needed in order to keep children out of institutional care and in the permanent care of a family. According to UNICEF, there are more than two million children currently living ininstitutions around the world.21 Save the Children believes that figure may be as high as 8 million.22 It is nearly undisputed that institutional care is not good for children. A report from the organization Every Child outlines the range of negative outcomes associated with institutionalization, including poor health, poor physical growth, hearing and vision problems, delays in the development of motor skills, reduced cognitive development, reduced social development, and abuse. Furthermore, Every Child estimates that institutional care is twice as expensive as community/group homes and up to eight times as expensive as providing vulnerable families with the support they need to stay together.
A recent report from Save the Children urges governments to reduce the use of institutional care, arguing that it can have a long-term negative impact on all children, and that it is particularly damaging for children under the age of three.24 Karen Bos, in her testimony before the Inter-American Commission on Human Rights, explained the detrimental effects of institutionalization on child development. According to Bos, children in institutions receive inadequate input (i.e., stimulation), resulting in the “under-development of some brain circuits and the mis-wiring of others.” She identifies the long-term impact as follows:
Children raised in institutions are known to experience a range of problems, including impairments in physical, cognitive, language, and social-emotional functioning. Specifically, these children often show growth stunting, impaired intellectual development, language delays, attachment problems, depression and anxiety, aggressive behavior problems, and inattention/hyperactivity.25
The negative impact of institutionalization is well-documented by researchers who are part of the Bucharest Early Intervention Project (BEIP). For this project, researchers created a foster care system in Bucharest, and then randomly assigned 136 children to either stay in institutions or move into foster care. They also studied a comparison group of 72 typically developing children who had never been institutionalized. The children were assessed at 9 months, 18 months, 30 months, 42 months, and 54 months, with plans to assess them through age 8. In one of the most recently published studies from BEIP, the authors examined attention and emotion expression in both groups at 30 and 42 months of age. At 42 months, the foster care group showed significantly higher levels of attention than the institutionalized group, as well as higher levels of positive affect (i.e., positive mood). The authors conclude: “Institutionalized, socially deprived children, when placed into family environments, showed rapid increases in both expressed positive affect and attention in social episodes that were designed to be enjoyable for infants and young children.”26
In a 2007 study that focused on assessing cognitive skills, BEIP researchers measured the children’s developmental quotients and IQs at 42 and 54 months of age. At both points, the children in foster care scored significantly higher than their institutionalized counterparts. The authors also find that the children fare better the younger they are moved from institutionalization to foster care.27
The research clearly shows that it is not good for children to be raised in institutions. And yet, in many countries, in the absence of intercountry adoption, institutionalization is the only option left.
Conclusion and Recommendations
NCFA believes that our continuum of child welfare services outlined above should serve as a guideline for the child welfare and adoption communities. We want to stress the fact that we do not believe this continuum to necessarily be hierarchical; planning and evaluating options for a child can be concurrent, and different options may better serve different children and families indifferent situations. It is essential that a case-by-case determination be made for every child, but throughout all planning, the issue of timeliness is very important. What is clear is that institutionalization is not an acceptable outcome for any child, and that “every tool in the toolbox” must be tried to achieve the permanency that is in the best interests of all children.
A continuum that does not consider timeliness in assessing realistic options or allow for the possibility of intercountry adoption goes against all that research has shown to be good for children. Furthermore, the continuum we present does not require trying one option for a time and, if it fails, continuing down the line until an option is found that finally works. If family reunification and/or preservation is not a timely or realistic possibility for a given child, then no time should be wasted at that point on the continuum. In other cases, when options are less clear, agencies can and should engage in concurrent planning to appropriately prepare for timely and effective decision-making for the benefit of the child.
In order for the continuum to function effectively, governments, agencies, and child welfare advocates must commit to working together for whichever solution is in the best interest of a particular child. As important as homeland and culture are, the notion that preserving only these things at the expense of permanency undermines what children need in order to be safe and loved – a permanent family. If family preservation or reunification is determined to be in a child’s best interest and is a realistic and timely option, then that must be worked for whole heartedly. If domestic or intercountry adoption is found to be in the child’s best interest, then all resources must be put towards attaining one of these goals as efficiently as possible. Only in this way can everyone concerned with the welfare and safety of children effectively employ a continuum of services aimed at creating good outcomes for all children.
1 The Pew Commission on Children in Foster Care. (2004). Fostering the future: Safety, permanence and well-being for children infoster care.Washington, DC: The Pew Commission on Children in Foster Care. Available athttp://pewfostercare.org/research/docs/FinalReport.pdf 2 International Social Service. (1999). The rights of the child in internal and intercountry adoption. Retrieved from:http://www.crin.org/docs/ISS_ICA_ENG.pdf 3Save the Children. (2010). International Adoption Policy Brief. Retrieved fromhttp://www.crin.org/docs/International%20Adoption%20FEBB%20edit%2018_01_10.pdf 4In concurrent planning, alternate permanencies goals are pursued at the same time. For further information, see: Child WelfareInformation Gateway. (2005). Concurrent planning: What the evidence shows. Retrieved from:http://www.childwelfare.gov/pubs/issue_briefs/concurrent_evidence/ 5SOS Children’s Villages International & International Social Services. (2009). Guidelines for the alternative care of children: AUnited Nations framework. Retrieved from http://www.sos-childrensvillages.org/focus-areas/children-and-family/family-based-child-care/pages/guidelines-for-the-alternative-care-of-children.aspx 6Strottman, K. (2010, February 23). Orphan children of Haiti deserve a future [Web log post]. Retrieved fromhttp://ccainstitute.wordpress.com/?blogsub=confirming#subscribe-blog 7U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth andFamilies, Children’s Bureau. (2009). The AFCARS Report. Retrieved fromhttp://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report16.htm 8SOS Children’s Villages International & International Social Services. (2009). Guidelines for the alternative care of children: A United Nations framework. Retrieved from http://www.sos-childrensvillages.org/focus-areas/children-and-family/family-based-child-care/pages/guidelines-for-the-alternative-care-of-children.aspx 9Child Welfare Information Gateway. (2006). Family reunification: What the evidence shows. Retrieved from http://www.childwel-fare.gov/pubs/issue_briefs/family_reunification/family_reunification.pdf 10Wulczyn, F. (2004). Children, families, and foster care. The Future of Children, 14, 95-113. 11Parks, Y. (2009). Children and families first: A chronicle of the Alameda County Social Services Agency Foster Care System.Retrieved from http://www.casey.org/Resources/Publications/pdf/Alameda_ChildrenFamiliesFirst_FIN_LO.pdf 12Placek, P. (2007). National adoption data. In T.C. Atwood, L.A. Allen, and V.C. Ravenel (Eds.), Adoption Factbook IV, (pp. 3-69).Washington, D.C.: National Council for Adoption. 13Vandivere, S., Malm, K., & Radel, L. (2009). Adoption USA: A Chartbook based on the 2007 National Survey of Adoptive Parents.Washington, D.C.: The U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning andEvaluation. 14UNICEF. (nd). Statement: UNICEF’s position on Inter-country adoption.Retrieved fromhttp://www.unicef.org/media/media_41118.html 15United States Department of State. (nd). Total adoptions to the United States. Retrieved fromhttp://www.adoption.state.gov/news/total_chart.html 16Bartholet, E. (2009). Inter-American Commission on Human Rights, Organization of American States, Hearing on Human Rightsof Unparented Children and Related International Adoption Policies, 137th Ordinary Period of Sessions. Retrieved fromhttp://www.law.harvard.edu/programs/about/cap/ia/testimonyfullnov09.pdf 17Zappala, M & Johnson, C. (2009). A case for ethnical intercountry adoption. Adoption Advocate, 11, p. 1. 18Office of the Spokesman, U.S. Department of State. (2009, November 20). Briefing by Deputy Assistant Secretary of State forConsular Affairs Michele Bond on National Adoption Day[Press briefing]. Retrieved fromhttp://www.state.gov/r/pa/prs/ps/2009/nov/132215.htm 19Vandivere, S., Malm, K., & Radel, L. (2009). Adoption USA: A Chartbook based on the 2007 National Survey of Adoptive Parents.Washington, D.C.: The U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning andEvaluation. 20Interlandi, J. (2010). The case for international adoption [Online exclusive]. Newsweek.Retrieved fromhttp://www.newsweek.com/id/234343/page/1 21UNICEF. (2009). Progress for children: A report card on child protection. Retrieved from:http://www.unicef.org/publications/files/Progress_for_Children-No.8_EN_081309.pdf 22 International Save the Children Alliance (2003). A last resort: The growing concern about childrenin residential care. London, Save the Children UK. 23 Carter, R. (2005). Family matters: A study of institutional childcare in Central and Easter Europe and the former Soviet Union.Retrieved from http://www.crin.org/docs/Family%20Matters-A%20Study%20of%20Institutional%20Childcare%20in%20Central.pdf 24 Csaky, C. (2009). Keeping children out of harmful institutions: Why we should be investing in family-based care. London: Savethe Children. 25Bos, K. (2009). Inter-American Commission on Human Rights , Organization of American States, Hearing on Human Rights ofUnparented Children and Related International Adoption Policies, 137th Ordinary Period of Sessions. Retrieved fromhttp://www.law.harvard.edu/programs/about/cap/ia/testimonyfullnov09.pdf 26Geera, M.M., Marshall, P.J., Fox, N.A., Zeanah, C.H., Nelson, C.A., Smyke, A.T., & Guthrie, D. (2009). The effects of foster careintervention on socially deprived institutionalized children's attention and positive affect: Results from the BEIP Study. Journal ofChild Psychology and Psychiatry, 50(3), 246-253. 27Nelson, C.A., Zeanah, C.H., Fox, N.A., Marshall, P.J., Smyke, A.T., Guthrie, D. (2007). Cognitive recovery in socially deprivedyoung children: The Bucharest Early Intervention Project. Science, 318, 1937-1940.
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