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1. Introduction Childhood is a developmental stage in which the importance of reciprocal emotional bonding between a child and his/her caregivers, for healthy physical, psychological, and social development has been known for centuries [1]. Orphans in group homes or institutions take more risks, have more threats to achievement, and have poorer peer influences [2]. Almost no systematic studies have been carried out during the past five decades about orphanages largely because nearly all orphanages in industrial nations have been replaced by adoption and foster care [3]. This solution, in Third World Countries, is unacceptable either religiously in some countries as Egypt, or has been considered an unrealistic solution in other countries as in Africa [3]. Although orphanages can provide a secure and positive alternative to abusive and unsafe family or community environments, they cannot provide individualized and family nurturing [4]. Research findings indicate that children in institutional care have more behavioral problems, such as aggressive behavior and have higher levels of depression and anxiety, compared to children that are reared in a family environment [5–7]. Several studies have shown that institutional care has negative effects, especially on young children; however, only a few studies have investigated the prevalence rate of problems among these children, the extent of care service needs, and risk and protective factors by collecting data from multiple informants. Early intervention immediately following institutional care placement is recommended [8–12].

young children; however, only a few studies have investigated the prevalence rate of problems among these children, the extent of care service needs, and risk and protective factors by collecting data from multiple informants. Early intervention immediately following institutional care placement is recommended [8–12]. 2. Methods This cross-sectional epidemiological study recruited 265 children (190 males and 75 females) of ages ranging from 6 to 12 years (X ± SD: 3.35 ± 0.9 years) residing in three orphanages in Cairo and who had lived with their caregivers for at least a month during the year 2011 through 2012. Psychiatric analysis was performed by 3 experienced psychiatrists. Excluded from the survey; children with visual and/or auditory deficits, children younger than 6 years, and those with chronic medical illnesses. Children from orphanage I were 81, orphanage II were 147, and orphanage III were 37. Children were divided into three groups according to age.

by 3 experienced psychiatrists. Excluded from the survey; children with visual and/or auditory deficits, children younger than 6 years, and those with chronic medical illnesses. Children from orphanage I were 81, orphanage II were 147, and orphanage III were 37. Children were divided into three groups according to age. Group 1: included 108 children of ages ranging from 6 to 8 years. Group 2: included 70 children of ages ranging from 8 to 10 years. Group 3: included 87 children of ages ranging from 10 to12 years. All children were subjected to the following. Sociodemographic Information Form: this form collected data about risk and protective factors regarding children and their families. Based on the information in each child's file, a social service specialist or a psychologist completed the form. Predictive factors, such as current age, age at first admission, history for admission, gender, place of residence prior to institutional care, the frequency of moving from one institution to another and death of mother/father were recorded.

hild's file, a social service specialist or a psychologist completed the form. Predictive factors, such as current age, age at first admission, history for admission, gender, place of residence prior to institutional care, the frequency of moving from one institution to another and death of mother/father were recorded. Child Behavior Checklist (CBCL/6–18): the CBCL is designed to obtain parents'/caregivers' reports of their children's problems. The CBCL was translated to Arabic and its reliability and validity has been established The test retest reliability was 0.84 for total problems and 0.88 for internal consistency. In the validity study, confirmatory factor analysis was conducted and 99% of the items were found to be significantly, positive, and sufficiently measure what they were designed to measure (P < 0.01) [13]. The CBCL includes items for rating competencies and 113 items for behavioral and emotional problems. Items are rated on a 3-pointscale as 0 = not true, 1 = sometimes true, and 2 = often true, based on the preceding 6 months. The following syndromes are scored from the CBCL: Internalizing group (anxious/depressed, withdrawn/depressed, or somatic complaints), externalizing group (rule breaking behavior, or aggressive behavior), social problems, thought problems, and attention problems. [14–16]. Semistructured Psychiatric Interview according to DSM IV. To detect presence of psychiatric disorders by a qualified psychiatrist.

Child Behavior Checklist (CBCL/6–18): the CBCL is designed to obtain parents'/caregivers' reports of their children's problems. The CBCL was translated to Arabic and its reliability and validity has been established The test retest reliability was 0.84 for total problems and 0.88 for internal consistency. In the validity study, confirmatory factor analysis was conducted and 99% of the items were found to be significantly, positive, and sufficiently measure what they were designed to measure (P < 0.01) [13]. The CBCL includes items for rating competencies and 113 items for behavioral and emotional problems. Items are rated on a 3-pointscale as 0 = not true, 1 = sometimes true, and 2 = often true, based on the preceding 6 months. The following syndromes are scored from the CBCL: Internalizing group (anxious/depressed, withdrawn/depressed, or somatic complaints), externalizing group (rule breaking behavior, or aggressive behavior), social problems, thought problems, and attention problems. [14–16]. Semistructured Psychiatric Interview according to DSM IV. To detect presence of psychiatric disorders by a qualified psychiatrist. 3. Statistical Analysis Data were presented as mean ± standard deviation (X ± SD) or percentage (%). The means of two groups were compared using student's t test. Data were tabulated and statistically analyzed with the statistical package for social sciences (SPPS) version 14 software. P values less than 0.05 were considered significant.

ysis Data were presented as mean ± standard deviation (X ± SD) or percentage (%). The means of two groups were compared using student's t test. Data were tabulated and statistically analyzed with the statistical package for social sciences (SPPS) version 14 software. P values less than 0.05 were considered significant. 4. Results Two hundred and seventy five children were identified as being eligible to participate in the study. Of these, caregivers of 10 children declined to participate. This left 265 participating children who were residing with 81 caregivers. More than half the children 71.7% had been in their current placement for less than 2 years; 74.71% of children had a female caregiver 64.52% had a stable caregiver for more than 6 months (Table 1). The range of total score was 31–69 (mean = 43.78); the highest scores were on externalizing, internalizing, and aggressive score and the least was somatic score (Table 2). The completed Child Behavior Checklist (CBCL) showed 11 Ratings on the questionnaire summarized as a total behavior problems score comprising all items on the checklist. Children had total behavior problems represent 61,13% of the studied group. The externalizing factors were higher than the internalizing ones (60% versus 58.86%); the most predominant problem was attention (43,77%) whereas somatic problem was the least (18.11%) (Table 3).

ms score comprising all items on the checklist. Children had total behavior problems represent 61,13% of the studied group. The externalizing factors were higher than the internalizing ones (60% versus 58.86%); the most predominant problem was attention (43,77%) whereas somatic problem was the least (18.11%) (Table 3). The psychiatric diagnosis of the whole sample (No. 265) as shown in (Table 4); enuresis (23.03%) was the commonest diagnosis on axis I and mental retardation (6%) on axis II. While on axis I attention deficit hyperactivity disorder (19.62%), oppositional defiant disorder (17.36%), sleep disorders (10.75%) followed by conduct disorder (9.81%) depression disorder (7.17%), separation anxiety disorder (7.17%), lastly no diagnosis on Axis I (35.47%), less than (1%) tics, dysthymia, and schizophrenia. Statistical correlation is shown between different psychiatric morbidity diagnoses and other variables including age differences, sex of caregiver, stability of caregiver reason for institutionalization, moves between institutions, and length of institutionalization (Tables 5(a) and 5(b)).

The psychiatric diagnosis of the whole sample (No. 265) as shown in (Table 4); enuresis (23.03%) was the commonest diagnosis on axis I and mental retardation (6%) on axis II. While on axis I attention deficit hyperactivity disorder (19.62%), oppositional defiant disorder (17.36%), sleep disorders (10.75%) followed by conduct disorder (9.81%) depression disorder (7.17%), separation anxiety disorder (7.17%), lastly no diagnosis on Axis I (35.47%), less than (1%) tics, dysthymia, and schizophrenia. Statistical correlation is shown between different psychiatric morbidity diagnoses and other variables including age differences, sex of caregiver, stability of caregiver reason for institutionalization, moves between institutions, and length of institutionalization (Tables 5(a) and 5(b)). 5. Discussion Lately, an increase in the number of orphanages in many of the Egyptian governorates was noticed as a response of the orientation that encourages the care for the orphans. Many child care professionals are still believing that orphanages are bad for children and they will fail to have a normal development both socially and psychologically [17]. Orphanage children are uniquely vulnerable to many psychosocial hazards of institutional care [18]. Fisher et al. [12], Vorriat et al. [19], Roy et al. [20], and MacLean [21], compared children in institutional care and children living with their families andere found that institutional care had negative effect on the emotional and behavioral development of children aged 6–12 years. This study of psychiatric and behavioral problems in orphans has revealed that the prevalence rate of total behavior problems was (61%), compared to other studies that used CBCL which detected the prevalence rate of behavior problems was nearly 20%–78% [22], and 33% [17]. In our study the main increase in score of CBCL was in the externalizing factors (hyperactive, aggressive, and delinquent) 60.1%. This denotes the overt aggressive and rebellious attitude of these orphans towards society as they grow up and become more aware of their real condition in the society. They live in conflict that they resolve by indulging in violence. Another cause of this was suggested to be the separation of a child from his/her parents at early ages and the related attachment problems that lead to externalization problems [23]. Cantone et a1. [24]. stated that the internalizing and externalizing factors represent a distinction between fearful inhibited over controlled behavior (internalizing) and aggressive antisocial uncontrolled behavior (externalizing). Other internalizing factors as depressed factor has shown a highly significant increase explained by being deprived of families and lacking the essential psychological support at this early stage of life. The change in total scores of CBCL in the followup was of no statistical significance.

ed behavior (externalizing). Other internalizing factors as depressed factor has shown a highly significant increase explained by being deprived of families and lacking the essential psychological support at this early stage of life. The change in total scores of CBCL in the followup was of no statistical significance. In our study, there was statistically significant increase in separation anxiety disorder in children with the lowest age. Offord et al. [25] and Miller et al. [26] had found that frequency and severity of antisocial behavior varied directly with age of adoption. According to the reports of multiple informants, institutionalization at younger ages, the conditions of previous living in another institutions, two or more moves between institutions, and recurrent physical illness increased the risk of emotional and behavioral problems [12, 27, 28]. Caregiver quality was the most important predictive factor for behavioral problems, which is compatible with previous studies [29]. One of the leading factors that ensure the mental health of children is the quality of the relationship with a caregiver, which is marked by confidence, support, continuity, and warmth. For this reason, caregiver training is identified as one of the most important preventive interventions.

e with previous studies [29]. One of the leading factors that ensure the mental health of children is the quality of the relationship with a caregiver, which is marked by confidence, support, continuity, and warmth. For this reason, caregiver training is identified as one of the most important preventive interventions. The most prevalent diagnosis was enuresis (23.03%); a finding very close to that was found by Abolmagd (22.9%) in orphans compared to (6.7%) of the school children [30]. On the other hand, El-Ray [31] has found that (41.1%) of orphans were diagnosed as enuretic. This is explained psycho analytically according to Garfinkel [32] as an expression of passive aggressive behavior, depression, and inability to resolve or contain high levels of anxiety. Meanwhile, Essen and Peckham [33] added that socioeconomic status and stressful life events characteristic of family dysfunction are also more frequently associated with enuresis. Some Egyptian surveys estimated nocturnal enuresis in Egyptian children by 1.9%, out of them, disturbances of home atmosphere was found in (61%) of enuresis children [34]. It is noticed that children in orphanages demonstrated aggression either passively through enuresis or explicitly as an overt aggressive behavior. Sleep disorders (10.57%) were present of all its types and it was noticed that one cause for it may be the hard program put for the children [35]. Current study demonstrated speech disorders affecting 1.5% of the sample possibly due to anxieties or lack of care in orphanages. Okasha et al. [36], showed that stammers have delayed milestones, aggression, instability and shyness. On the other hand,separation anxiety disorder and depression disorder were found in 7.17% and 7.17% of cases, respectively, which may be explained by various variables including all the children had lost one of their parent before the age of 11 years, all were from lower socioeconomic class which are known risk factors for the development of depression [37]. However, These rates are somewhat lower than those found by Fawzy and Fouad (21% and 58.5% resp.,) and far lower than those found in other countries, which is attributed possibly, in Egypt, to the sympathy, social support, and religious backgrounds [38].

ch are known risk factors for the development of depression [37]. However, These rates are somewhat lower than those found by Fawzy and Fouad (21% and 58.5% resp.,) and far lower than those found in other countries, which is attributed possibly, in Egypt, to the sympathy, social support, and religious backgrounds [38]. In Axis II, mental retardation was present in 6% of our cases, a figure which is nearer to that found by Abolmagd (12.1%) of orphan children versus (2.7%) of the control group [30] but far less than that found by El-Ray, who found that (24.4%) of orphans were mentally retarded [31]. This can be attributed to many possible factors as reported by Grantham-McGregor and Ani [39] including undernutrition, border line intelligent mother, physical or sexual abuse, and/or low previous socioeconomic standards.

ar less than that found by El-Ray, who found that (24.4%) of orphans were mentally retarded [31]. This can be attributed to many possible factors as reported by Grantham-McGregor and Ani [39] including undernutrition, border line intelligent mother, physical or sexual abuse, and/or low previous socioeconomic standards. 6. Conclusion In Egypt, orphanage harbors either true orphans or foundling abandoned by mothers after illegitimate pregnancies. This study showed that children living in orphanages are more prone to suffer from various psychiatric disorders and the stability of caregiver acts as a protective variable. Given the high prevalence of psychiatric morbidities in such institutions and to avoid its hazardous effect on the community, we recommend proper supervision of the orphanages by the supervising authorities, regular training courses for the caregivers to help improving their children caring skills, and psychiatric surveillance for the orphanages must be available and continuous for early detection and treatment of psychiatric disorders. Finally, More studies on orphanages should be carried out including bigger number with longer period of followup in other Egyptian governorates. Table 1 Sociodemographic characteristics of the studied children.

6. Conclusion In Egypt, orphanage harbors either true orphans or foundling abandoned by mothers after illegitimate pregnancies. This study showed that children living in orphanages are more prone to suffer from various psychiatric disorders and the stability of caregiver acts as a protective variable. Given the high prevalence of psychiatric morbidities in such institutions and to avoid its hazardous effect on the community, we recommend proper supervision of the orphanages by the supervising authorities, regular training courses for the caregivers to help improving their children caring skills, and psychiatric surveillance for the orphanages must be available and continuous for early detection and treatment of psychiatric disorders. Finally, More studies on orphanages should be carried out including bigger number with longer period of followup in other Egyptian governorates. Table 1 Sociodemographic characteristics of the studied children. Number (n) Percent (%) Orphanage I 81 30.56 II 147 59.47 III 37 13.96 Gender Male 190 71.7 Female 75 28.3 Age (years) 6-7 108 40.75 8-9 70 26.41 10–12 87 32.82 Reasons for institutionalization Abandonment 146 55.09 Orphanage 64 24.15 Disturbed family 55 20.75 Moves between institution 1 150 56.6 2 97 36.6 3 18 6.8 Gender of caregivers Male 67 25.3 Female 198 74.7 Stability of caregivers Stable 171 64.5 Unstable 94 35.5 Length of institution Less than or equal to 2 years 190 71.7 More than 2 years 75 28.3 Table 2 Descriptive statistics for the child behavioral checklist.

.75 Moves between institution 1 150 56.6 2 97 36.6 3 18 6.8 Gender of caregivers Male 67 25.3 Female 198 74.7 Stability of caregivers Stable 171 64.5 Unstable 94 35.5 Length of institution Less than or equal to 2 years 190 71.7 More than 2 years 75 28.3 Table 2 Descriptive statistics for the child behavioral checklist. Minimum Maximum Mean Std. deviation Anxiety subscale 35 60 45.31 6.52 Withdrawal subscale 34 55 45.789 7.778 Thought problem 30 35 30.99 5.50 Somatic complains 30 33 31.15 6.60 Social problems 30 35 32.07 6.57 Attention 30 36 31.04 11.9 Aggression 31 69 48.98 9.87 Delinquent 30 61 40.18 7.41 Internalizing subscale 43 69 56.47 7.77 Externalizing subscale 31 69 49.356 8.60 Table 3 Children identified by the caregivers using CBCL to have behavioral problems. Problem Number (n) Percent (%) Total behavior problems 162 61.13 Externalizing problems 159 60 Internalizing problems 156 58.86 Attention problems 116 43.77 Social problems 110 41.5 Delinquent behavior 108 40.75 Aggressive behavior 101 38.11 Thought problems 96 36.3 Withdrawn 61 23 Anxious/depressed 53 20 Somatic complaints 48 18.11 Table 4 Psychiatric diagnoses of the orphans according to DSM IV.

roblems 159 60 Internalizing problems 156 58.86 Attention problems 116 43.77 Social problems 110 41.5 Delinquent behavior 108 40.75 Aggressive behavior 101 38.11 Thought problems 96 36.3 Withdrawn 61 23 Anxious/depressed 53 20 Somatic complaints 48 18.11 Table 4 Psychiatric diagnoses of the orphans according to DSM IV. Diagnoses Number (n) Percent (%) At least one diagnosis 171 64.53 More than one diagnosis 95 35.85 Enuresis 61 23.03 Nocturnal 52 19.62 Diurnal 2 0.75 Both 7 2.64 ADHD 52 19.62 Hyperactivity 36 13.58 Attention deficit 10 3.77 Both 6 2.26 Separation anxiety disorder 19 7.17 Oppositional defiant disorder 46 17.36 Speech disorders 4 1.51 Sleep disorders 28 10.57 Conduct disorder 26 9.81 Depression 19 7.17 Tics 2 0.78 Learning disorders 6 2.26 Dysthymia 2 0.78 Schizophrenia 1 0.38 Mental retardation 16 6 Table 5 (a) Psychiatric diagnoses of the orphans in relation to variables. (b) Psychiatric diagnoses of the orphans in relation to variables. (a) Variables Enuresis ADHD Separation anxiety disorder Oppositional defiant disorder Speech disorders Sleep disorders n P n P n P n P n P n P

Diagnoses Number (n) Percent (%) At least one diagnosis 171 64.53 More than one diagnosis 95 35.85 Enuresis 61 23.03 Nocturnal 52 19.62 Diurnal 2 0.75 Both 7 2.64 ADHD 52 19.62 Hyperactivity 36 13.58 Attention deficit 10 3.77 Both 6 2.26 Separation anxiety disorder 19 7.17 Oppositional defiant disorder 46 17.36 Speech disorders 4 1.51 Sleep disorders 28 10.57 Conduct disorder 26 9.81 Depression 19 7.17 Tics 2 0.78 Learning disorders 6 2.26 Dysthymia 2 0.78 Schizophrenia 1 0.38 Mental retardation 16 6 Table 5 (a) Psychiatric diagnoses of the orphans in relation to variables. (b) Psychiatric diagnoses of the orphans in relation to variables. (a) Variables Enuresis ADHD Separation anxiety disorder Oppositional defiant disorder Speech disorders Sleep disorders n P n P n P n P n P n P Gender Male 45 0.108 37 0.732 13 0.388 32 0.786 4 0.286 22 0.623 Female 16 15 6 14 0 6 Age (years) 6–8 33   18   12   18   2   14 8–10 12 0.0368 19 0.055 1 0.0001* 21 0.641 1 0.844 6 0.399 10–12 16   15   6   7   1   6 Reason of institutionalization Abandonment 30   30   14   26   3   13 Orphanage 14 0.732 13 0.5 2 0.0001* 14 0.348 1 0.577 1 0.0001* Disturbed family integrity 17   9   3   6   0   14 Moves between institutions 1 27   39   8   24   4   12 2 28 0.546 13 0.0857 9 0.355 15 0.331 0 0.001* 10 0.449 3 6   0   2   7   0   6 Sex of caregiver Male 13 0.202 15 0.936 7 0.584 4 0.941 1 0.0001* 5 0.601 Female 84 37 12 42 3 23 Stability of caregiver Stable >6 months 42 0.972 37 0.935 15 0.453 32 0.914 1 0.0001* 19 0.593 Unstable 20 15 4 14 3 9 Length of institutionalization Less than 2 years 37 0.357 43 0.793 15 0.366 37 0.968 1 0.017* 22 0.623 More than 2 years 24 9 4 9 3 6

15 0.936 7 0.584 4 0.941 1 0.0001* 5 0.601 Female 84 37 12 42 3 23 Stability of caregiver Stable >6 months 42 0.972 37 0.935 15 0.453 32 0.914 1 0.0001* 19 0.593 Unstable 20 15 4 14 3 9 Length of institutionalization Less than 2 years 37 0.357 43 0.793 15 0.366 37 0.968 1 0.017* 22 0.623 More than 2 years 24 9 4 9 3 6 P < 0.05 Significant, *Significant, n: number, ADHD: attention deficit hyperkinetic disorder. (b) Variables Conduct disorders Depression Tics Learning disorders Dysthymia Schizophrenia n P n P n P n P n P n P Gender Male 38 0.907 16 0.360 1 0.001* 4 0.004* 1 0.001* 0 0.0001* Female 8 3 1 2 1 1 Age (years) 6–8 11   10   0   3   0   0 8–10 12 0.279 5 0.923 1 0.844 0 0.623 2 0.0001* 1 0.661 10–12 3   4   1   3   0   0 Reason for institutionalization Abandonment 10   6   1   3   2   1 Orphanage 11 0.620 8 0.290 1 0.619 2 0.086 0 0.094 0 0.391 Disturbed family integrity 5   5   0   1   0   0 Moves between institutions 1 16   8   0   1   1   0 2 6 0.492 7 0.357 2 0.279 2 0.216 0 0.546 1 0.923 3 4   4   0   1   0   0 Sex of caregiver Male 3 0.538 7 0.584 0 0.0001* 1 0.0001* 2 0.125 0 0.215 Female 23 12 2 5 1 1 Stability of caregiver Stable >6 months 17 0.507 10 0.575 2 0.123 3 0.018* 0 0.003* 0 0.235 Unstable 9 9   0 3 2 1 Length of institutionalization Less than 2 years 19 0.489 13 0.387 0 0.0001* 4 0.043* 1 0.001* 0 0.007* More than 2 years 7 6 2 2 1 1 P < 0.05 significant, *Statistically significant.