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J. Child Psychol. Psychiat. Vol. 40, No. 8, pp. 12311237, 1999Cambridge University Press

' 1999 Association for Child Psychology and PsychiatryPrinted in Great Britain. All rights reserved

00219630\99 $15.00j0.00

The Orphans of Eritrea: A Five-year Follow-up Study

Peter H. Wolff Gebremeskel Fesseha

The Childrens Hospital andHarvard Medical School, Boston, U.S.A.

Redd Barna, Asmara, Eritrea

A group of 47-year-old war orphans were examined for the first time while living in aninstitution (the Solomuna Orphanage) during a protracted war between Eritrea andEthiopia. At that time, they were compared to a group of refugee children living in a nearbycamp with one or both parents. The orphans exhibited significantly more behavioralsymptoms than the refugee children, but performed the cognitive tests at a more advancedlevel. Five years later, the orphans were re-examined; and they were compared tounaccompanied 912-year-children living in one of two residential settings that differedqualitatively in their social climate, principles of child care, and patterns of staffchildinteractions. Although the severity of their behavioral symptoms had diminished, theorphans still exhibited many symptoms of emotional distress. On the other hand, theyperformed the cognitive measures as well as, or better than, unaccompanied children whohad been protected from the terrors of war. The cross-sectional comparisons indicated thata residential setting that respects the individuality of children and promotes their closepersonal ties with at least one staff member can ameliorate many of the more seriouspsychological sequelae of having lost both parents and being exposed to the physical dangersof the war. The implications for war orphans in other Third World countries are discussed.

Keywords: War orphans, institutional care, rehabilitation.

Abbreviations: BSQ: Behavioral Symptom Questionnaire ; K-ABC: Kaufman AssessmentBattery for Children.

Introduction

Child development specialists in Western culturesgenerally concur that children who are placed in resi-dential care for extended periods at an early age are atincreased risk for cognitive retardation, psychiatric dis-orders, and antisocial behavior in later life. Therefore,they usually recommend that such children be restored totheir families, or placed for adoption and foster care asearly in life as possible (Bowlby, 1960; Goldfarb, 1945;Hodges & Tizard, 1989a; Spitz, 1951; Tizard & Hodges,1978).

On the assumption that adoption and foster care haveeliminated the need for orphanages, nearly all Westerninstitutions for the prolonged care of orphans were closed

over the past 30 years (Weisman, 1994; Wolkind &Rushton, 1994). However, residential care is often theonly hope of survival for hundreds of thousands ofchildren in war-torn Third World countries where fostercare and adoption are economically unrealistic, logistic-ally unfeasible, and culturally unacceptable options (Cliff& Noormahomed, 1993; Isiugo-Abanihe, 1985 ; Jensen &Shaw, 1993; Mollica, Pooler, Son, Murray, & Tor, 1997).The effects of growing up in an institutional setting, and

Requests for reprints to: Dr Peter H. Wolff, ChildrensHospital, 300 Longwood Avenue, Boston, MA 02115, U.S.A.(E-mail: wolffIp!a1.tch.harvard.edu)

the social climate in such institutions that will best serve

severely traumatized war orphans, are therefore stillpublic health issues of abiding importance.

This report summarizes the findings of a 5-year follow-up study of Eritrean war orphans (the Solomunaorphans) who were first examined while they were livingin a large orphanage during a 30-year war with Ethiopia.The orphanage was located in the most inaccessible basecamps of the Eritrean resistance struggle to reduce thechildrens exposure to constant aerial bombardment, butthe setting lacked most of the basic sanitary facilities.Fresh water and food were often in short supply, and thetemperature fluctuated between periods of extreme heatand cold.

Four years before the beginning of the follow-up

studies, the Social Affairs Department of the provisionalEritrean government (EPLF) had become increasinglyconcerned that so many of the Solomuna orphans wereexhibiting major behavioral disorders and developmentaldelays. A preliminary survey at that time indicated thatover 25% of the 47-year-old children were at signifi-cantly increased risk for serious psychiatric illnesses(Wolff, 1986). The Department therefore asked severalexpatriate consultants to make recommendations howthe social climate of the orphanage might be improveddespite severe shortages in trained personnel and materialresources (Jareg, 1988; Wolff, 1986). The proposedrecommendations were fully implemented within less

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1232 P. H. WOLFF and G. FESSEHA

than a year; and the orphanage was transformed from animpersonal bureaucratic institution to a child-centeredresidential setting (see Wolff, Dawit, & Zere, 1995).

By 1990, all orphans who participated in the follow-upstudy were living as family units of mixed ages from 47years together with a housemother who slept and ate withthem and supervised their daily housekeeping routines.The staff had collective responsibility for all decisions

affecting the children; the children were expected toparticipate in the activities of the orphanage community;and child-care workers interacted freely with the childrento instil in them a sense of trust and self-confidence.

After the age of 7 years, the Solomuna orphans weretransferred to a large boarding school for 5000 students.The Zero School was also located in deep canyons toprotect students from aerial attack, and it had beenorganized according to the same child-centered principlesof collective responsibility as the Solomuna Orphanage.The orphans who participated in the follow-up studieshad therefore all spent their critical growth years in asocially and emotionally supportive environment.

Five years later, after the country was at peace, the

Solomuna orphans were re-examined while they wereeither still living in one of the government orphanages, orafter they had been placed with extended families withinthe preceding 6 months. This report describes the changesin emotional state and cognitive development of theSolomuna orphans over the 5-year interval; and itcompares their behavior with that of the most nearlyappropriate comparison groups available at the time.

Methods

Initial Assessment (1990)

Subjects. At the first examination, the sample consisted of

72 orphans aged 47 years (36 boys, 36 girls), including equalnumbers of children from each dormitory at the orphanage.They were compared to a group of 47-year-old refugee childrenliving with at least one parent in their own dwellings in a nearbyrefugee camp, where they were exposed to the same physicalhardships and threats of aerial bombardment.

Measures. All children were examined by a BehavioralSymptom Questionnaire (BSQ; Richman, Stevenson, &Graham, 1975) as well as by culture fair measures of cognitiveperformance (see below). In addition, their interactions withadult strangers were observed under free field conditions. Thecomparison of orphans and refugee children has been describedin detail in earlier reports (Wolff, Dawit, et al., 1995; Wolff,Tesfai, Eyasso, & Aradom, 1995), and only the main findingswill be summarized here.

Follow-up Studies (1996)

Subjects. When the Solomuna orphans were re-examined 5years later, the refugee children who had served as the initialcomparison group had all returned to their villages and couldno longer be traced. The orphans could also not be compared tonormal 912-year-old children who had grown up with theirown families under peacetime conditions, because the war hadonly ended 4 years earlier. Instead, the Solomuna orphans werecompared to unaccompanied children who had spent the war ininstitutions where they had not been exposed to active combat.The comparison groups were selected from two institutions that

differed qualitatively in their patterns of staffchild interactionand principles of governance (see below). Every fourth name onalphabetic lists was selected until 20 girls and 20 boys aged 912years in each institution had been identified. The mean age ofchildren in all three groups was 11:0 years (range 9 years 4months to 12 years 1 month).

Measures. The original BSQ was modified for the olderchildren, and completed by child-care counselors or surrogateparents who knew the children best. Eritrean members of the

research team, who had been trained in 1990 and retrained in1996, administered age-appropriate cognitive tests. The testsincluded:

(1) The Kaufman Assessment Battery for Children (K-ABC;Kaufman & Kaufman, 1983a), which divides cognitivefunctions into a sequential and a simultaneousinformation-processing style, replaced the Leiter Inter-national Scale that had been used as a measure of generalintelligence in 1990. The K-ABC correlates highly withthe WISC-R in Western industrial societies (Kaufman &Kaufman, 1983b). However, a number of the subtests ofthe K-ABC presuppose familiarity with Western popularculture and exposure to a conventional Western publicschool education. These were deleted for use in Eritrea. Inaddition, culturally inappropriate itemsin the othersubtestswere replaced by equivalent items appropriate for Eritreanchildren. The following subtests were administered:

(a) Hand movements, a modification of the Luria (1966) edge,fist, palm paradigm that asks children to perform asequence of taps on the table with the fist, hand, or palm inthe order demonstrated by the examiner (classified as ameasure of sequential processing).

(b) Number recall, a modification of the digit span (forward)task of the Wechsler scale (sequential processing).

(c) Word order, a short-term verbal memory task. Childrenare asked to point to a series of silhouettes of commonobjects in the same order as the examiner has named them(sequential processing).

(d) Gestalt closure, a task modified after Mooney and Ferguson(1951). Children had to identify and name ambiguous andincomplete inkblot drawings of familiar object (simultan-eous processing); and

(e) Triangles, a modified version of the standard blockdesign item of the Wechsler Intelligence test (simultaneousprocessing).All children were also tested by:

(2) The Standard Raven Progressive Matrices (Raven, 1958)that replaced the Colored Matrices used in 1990;

(3) The short form of the Token Test (McNeal & Prescott,1978), also used in 1990; and

(4) The Gardner Picture Vocabulary test (Gardner, 1990),also used in 1990.

Statistical EvaluationsNone of the measures had been standardized for Eritrean

children. Therefore, raw test scores were converted to ranks (bythe RANK procedure of the SAS Procedure Manual (SAS\STAT, 1992), and rank scores were entered as dependentmeasures in a General Linear ANOVA model (SAS\STAT,1992), or used for nonparametric comparisons (Siegel, 1956).

Direct Observations

In addition, each group was observed under free fieldconditions for peer interactions and responses to strangers.

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1233ERITREAN ORPHANS

Results

Follow-up Studies

First examination (1990). The BSQ revealed substantialindividual differences in frequency of behavioralsymptoms among the Solomuna orphans. Some childrendemonstrated remarkable resilience, while others were atsignificantly increased risk for psychiatric illnesses. How-

ever, it was not possible to ascertain the reasons for themarked individual differences in symptom frequency,because many of the children had been discovered bychance as they wandered aimlessly in the countryside insearch of food and shelter. Therefore, almost nothing wasknown about their family circumstances or their lifeexperiences before they came to the orphanage; in somecases even their names, ages, and village of origin wereunknown.

Group comparisons indicated that the Solomunaorphans showed significantly more behavioral symptomson the BSQ than refugee children; sleep disturbances,eating disorders, and aggressive interactions with peersaccounted for most of the group differences (Wolff,

Tesfai, et al., 1995). The group differences in emotionalstate were illustrated more graphically by free fieldobservations. Any (black or white, female or male) adultstranger who entered the compound immediatelyattracted groups of 1015 Solomuna orphans who clungdesperately to any of the strangers accessible body parts.Children who could not latch onto an arm, a leg, or theface, fought bitterly among themselves, while the moresuccessful children refused to let go until they werephysically separated by a child-care counselor. In sharpcontrast to the behavior of the orphans, the refugeechildren only waved their hand and shouted hellowhen strangers entered their camp, and they neverattempted to make any physical contact.

Despite the striking differences in social-emotionalstate, the Solomuna orphans outperformed the refugeechildren on nearly all cognitive measures (Wolff, Tesfai,et al., 1995). Child-care counselors attributed these groupdifferences to the implementation of peer teaching in allof the orphanage dormitories ; and to the deliberate effortof child-care counselors to engage the children in livelyconversations. Such a relation between children andadults was not consistent with the cultural traditions offamilies living in the refugee camps.

Second examination (1996). Only 40 of the originalgroup of 72 Solomuna orphans could still be traced in1996. The other 32 had either died during the intervening

Table 1Developmental Stability of Cognitive Measurea: Solomuna Orphans

Measures: 1990

Measures : 1996 Leiter Raven Token Naming

K-ABC 2.64** 1.84* 0.14 0.29Raven 3.08*** 2.36** 0.08 1.53*Token 1.85* 0.43 0.01 0.22Naming 1.35 0.44 2.10* 0.82

a Wilcoxon Signed Rank statisticz scores.*p .05; **p .01; ***p .001.

5 years, or were lost to follow-up for other reasons. A posthoc comparison indicated that there had been no signifi-cant differences on any of the outcome measures betweenorphans who could and could not be traced, except thatthe children who were lost to follow-up had performedslightly better on the picture vocabulary test.

The total number of behavioral symptoms exhibited bythe Solomuna orphans had decreased slightly between

1990 (meanl8.8) and 1996 (meanl5.8; zl2.3, p.05 by matched t-test comparisons), but over the sameperiod the behavioral symptoms had undergone extensivedevelopmental changes. When the orphans were 47years old, the most common symptoms were enuresis,sleep disturbances, eating disorders, and aggressive inter-actions with peers and adults (Wolff, Tesfai, et al., 1995).By the age of 912 years these symptoms had disappearedalmost entirely, and mood disturbances of depressionand anxiety were now the prevalent symptoms. Since verysimilar developmental changes in symptom type are alsotypical of home-reared Western children, no clinicalsignificance could be attributed to the slight decrease inoverall symptom frequency (Shaffer, 1994; Skuse, 1994).

On the other hand, the individual differences insymptom frequency that had been noted in 1990 remainedremarkably stable over the 5-year interval. Orphans whoin 1990 had scored in the upper 33% for symptomfrequency (meanl14.5) still scored in the upper 33 % in1996 (meanl8.1). Orphans who had scoredin the lowest33% in 1990 (meanl3.5) were still in the lowest 33 % in1996 (meanl3.6; zl3.4, p .001; Mann-Whitney Utest). A rank order comparison for total number ofsymptoms at the two times of testing similarly indicatedthat individual differences in symptom frequency hadremained stable over time (zl3.4, p .001, Wilcoxonmatched pairs comparison ; Siegel, 1956).

Cognitive development. Despite the differences in

cognitive tests at the two times of testing, rank orders forcognitive performance had also remained stable (seeTable 1). All Solomuna orphans in the follow-up samplewere now attending public schools; and all but one ofthem were performing academically in the upper third oftheir classes. Classroom teachers also reported that mostof the Solomuna orphans were well behaved and co-operative in the classroom.

Group Comparisons (1996)

The comparison of Solomuna orphans and un-accompanied children living in the two other residential

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Table 2Group Comparisons9- to 12-year-old Children: Behavioral Symptoms (by Ranks)

Solomuna(S)

OrphanageA

OrphanageB

Source Mean (SD) Mean (SD) Mean (SD) F(2)

All symptoms 5.9 (4.2) 9.3 (6.3) 1.6 (3.2) 42.6****a

Symptom typesSleep 0.9 (1.0) 0.5 (1.0) 0.2 (0.7) 6.4**bEating 0.2 (0.4) 0.1 (0.5) 0.1 (0.5) 0.7Social peers 1.1 (1.0) 1.4 (1.0) 0.4 (0.8) 7.7**cSocial adults 0.7 (0.8) 0.9 (1.1) 0.0 (0.3) 9.4**cLanguage 0.4 (0.9) 1.2 (1.7) 0.1 (0.3) 13.7***dMood disorders 4.5 (4.2) 5.7 (5.0) 0.8 (0.2) 23.5****c

*p .05; **p .01; ***p .001; ****p .0001.a : ASB; b: SAlB; c: SlAB; d: ASlB.

settings gave a more objective picture of the currentpsychological state of the Solomuna orphans. As in-dicated, the comparison groups were drawn from two

institutions that differed greatly in their quality of child-care, social climates, and principles of governance.

Orphanage A accommodated 450 children aged 517years. The director made most decisions affecting thechildren and rarely, if ever, consulted his staff. Theyounger children all slept together in one large dormitorywith one child-care worker, but child-care workers wereassigned to a different dormitory each week so that thechildren had little opportunity to form close personal tieswith any one staff member. Older orphans lived inseparate dormitories,grouped according to chronologicalage, and no child-care worker slept with them. Staffmembers supervised the children at meal times, but didnot eat with them. Most daily activities were regulated by

explicit rules and well-defined schedules, but there werefew organized after-school activities, and the childrenwere neither required nor allowed to participate in thedaily household chores. No lockers or shelf space wereprovided where children might keep their personalbelongings and clothes, so that they generally picked theirclothing from a communal pile.

Orphanage B had room for 200 children aged 516years. The child-care staff participated in all decisionsaffecting the children. Children of mixed ages livedtogether with one permanent house parent assigned toeach dormitory. Several staff members always ate withthe children; and there were organized after-school workassignments and sports activities in which the staff

members participated actively. Each child had a desig-nated shelf space for keeping personal belongings andclothing, and children were encouraged to decorate theirown dormitories (see Wolff & Gebremeskel, 1998, for adetailed description).

Behavioral symptoms. Group differences in be-havioral symptoms on the modified BSQ were assessed byan ANOVA with group (Solomuna, Orphanage A,Orphanage B), sex, and age as classifying variables, andrank order of behavioral symptoms as dependent meas-ures. As Table 2 indicates, the Solomuna orphans stillshowed significantly more behavioral symptoms thanchildren in Orphanage B, but they showed significantly

fewer symptoms than the children in Orphanage A (seeTable 2). Mood disturbances of depression and anxietywere now the most common symptoms in all three

groups; they accounted for most of the group differences.There were no main or interaction effects by sex or age,and no groupisex or groupiage interactions.

Direct observations. Free field observations indicatedthat the social interactions of the Solomuna orphans withpeers and adult strangers had normalized considerably.When an adult stranger entered the playground and saton the sidelines, the orphans now continued their co-operative group games for at least 10 minutes beforeapproaching him in small groups. Once they had madecontact, they still competed for possession of his hands orarms, but they no longer fought and bickered amongthemselves. Instead, they chatted cheerfully and returnedto their games as soon as they got bored with the

encounter.The patterns of social interaction had evidently

changed between 1991 and 1996, but an Eritrean socialworker, who had observed the interchange from adistance, commented that their efforts to make physicalcontact were still highly inappropriate by Eritrean cul-tural standards. Free field observations of home-rearedchildren under similar conditions supported the con-clusion, indicating that these children never approachedthe stranger but simply pointed at him and giggled.Similarly, the unaccompanied children in Orphanage Bpaid no attention to the adult stranger and continuedtheir group activities until a staff member introducedthem. Then, they briefly made polite conversation but

quickly returned to their previous activities. By contrast,the children in Group A approached the stranger and,like the Solomuna orphans, made tentative attempts tohold on to his arms and to touch his face.

Cognitive performance. Group differences in cogni-tive performance were tested by similar ANOVAs, withranks on cognitive measures as dependent variables.Table 3 indicates that the Solomuna orphans and childrenfrom Orphanage B performed the hand movement,Gestalt closure and triangle subtests of the K-ABCat a more advanced level than children from OrphanageA. The Solomuna orphans also performed the cognitivetests at a more advanced level than the two comparison

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Table 3Group Comparisons9- to 12-year-old Children: Cognitive Performance (by Ranks)

Solomuna(S)

OrphanageA

OrphanageB

Source Mean (SD) Mean (SD) Mean (SD) F(2)

K-ABC 63.8 (13.3) 57.6 (10.8) 63.7 (8.6) 4.8**aHand 14.0 (3.2) 12.5 (2.5) 14.7 (2.8) 5.6**a

Gestalt 15.1 (3.3) 12.2 (3.1) 14.3 (2.6) 12.9****aTriangle 11.6 (4.6) 9.6 (3.3) 11.8 (2.4) 7.7**aNumber 9.3 (3.1) 10.4 (2.6) 10.2 (2.3) 1.3Word 13.6 (3.3) 13.8 (3.2) 12.7 (3.5) 3.0

Raven 20.6 (9.9) 20.6 (8.0) 20.9 (9.0) 0.1Token 13.4 (2.8) 12.8 (2.6) 12.1 (3.5) 2.0Naming 26.2 (1.9) 23.7 (2.9) 23.2 (2.5) 20.4****b

**p .01; ****p .0001.a : SlBA; b: SAlB.

groups. There were no group differences in performanceon the Standard Raven Matrices or Token test.

In addition to the expected main effects by age, therewere main effects by sex. Males outperformed females onthe composite score for K-ABC subtests [males 64.4;females 58.7 ; F(1,53)l7.2,p0.01], the Gestalt closuresubtest [males 14.9 ; females 12.7; F(1,53)l17.9, p.0001], and the number recall subtest [males 10.6; females9.6; F(1,53)l5.4, p .05]. There were no ageisex,ageigroup, or groupisex interactions.

Parental Status

All children in the three comparison groups wereofficially classified as orphans. However, a quarter of the

children in Orphanage A and in Orphanage B had one ortwo living parents who, as a result of the war, could nolonger care for them, whereas nearly all Solomunaorphans had lost both parents during the war. The effectsof parental loss on psychological function were thereforetested by similar ANOVAs, with number of survivingparents (0, 1, 2) and institution as between-subjectsvariable, and the rank order of symptom frequency andcognitive performance as outcome measures. The analy-ses indicated that parental loss had no measurable effecton any of the outcome measures, and that there were nointeractions of parental loss by institution. However, theBSQ was a screening instrument that was not well suitedfor uncovering potentially important feelings of emotion-al distress that might later surface as serious psychiatricillnesses (Harris, Brown, & Bifulco, 1990; Ragan &McGlashen, 1986; Rutter & Maughan, 1997).

Discussion

Developmental Outcome of the Solomuna Orphans

One major issue raised by these studies, which mayhave more general clinical implications, concerns thedevelopmental outcome of war orphans who lose bothparents to the violence of war at a vulnerable age and

spend their growth years in an institutional setting. Thepersistence of deviant social interactions as well as the

persistence of behavioral symptoms among the mostseriously affected Solomuna orphans suggests that eventhe best efforts of the Social Affairs Department possibleunder war-time conditions had not been sufficient to meetthe great emotional needs of the war orphans (Cliff &Noormahomed, 1993; Gabarino, Kostelny, & Dubrow,1991; Jensen & Shaw, 1993; Terr, 1991).

Nevertheless, residential settings that distribute re-sponsibilities for the children broadly, and encouragecooperative peer interactions and close ties between staffand children, can go a long way toward mitigating thetraumatic effects of multiple adverse experiences. Thus,they may also reduce the risk for serious psychiatricillness in later life (Freud & Burlingham, 1943).

Deviant Social Interactions

Superficial overfriendliness is said to be a commonsymptom among children in Western cultures who areplaced in residential care at a young age and then returnedto their families. Such symptoms are interpreted asindicators of insecure attachment and of a diminishedcapacity for close social relationships in later life(Chisholm, Carter, Ames, & Morison, 1995; Colton,1988; Goldfarb, 1945; Hodges & Tizard, 1989a; Rutter,1985; Rutter & Maughan, 1997). From the clinicaldescriptions in these reports it is, however, not clearwhether the grossly aberrant social interactions of the

Solomuna orphans were simply an exaggerated ex-pression of overfriendliness, or whether they indicated aqualitatively different, and perhaps more ominous, re-sponse to early trauma.

For example, the deviant social behavior of the orphanswas clearly more driven and aggressive than the termoverfriendliness implies. In Western social settings,such behavior is only observed in children who are placedin residential care before the age of 2 years (Wolkind &Rushton, 1994). By contrast, the Solomuna orphans hadall come to the Solomuna orphanage after the age of 3 or4 years. The group comparisons also indicated thatgrowing up in a residential setting per se was not sufficient

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to induce the deviant social interactions. Unaccompaniedchildren who had been protected from the constantthreats of physical harm and who had grown up in asupportive and child-centered residential environmentbehaved essentially like home-reared or refugee children.By contrast, unaccompanied children who had beenspared the threats of aerial bombardment but hadgrown up in an impersonal institutional setting showed

the same deviant patterns of social interaction as theSolomuna orphans who had grown up in a sociallysupportive environment. In other words, the same ab-errant social interactions may have been the result ofdifferent adverse events singly or in combination. Finally,the phenomenon of overfriendliness may have quali-tatively different long-term consequences for socialintegration in a culture that is based on principles ofcommunal cooperation and mutual interdependence,than in cultures that value the privacy and autonomy ofthe nuclear family.

Dissociation of Emotional and CognitiveDevelopment

A second issue of general clinical interest was thepersistent dissociation between emotional distress andcognitive development. At the age of 47 years, theSolomuna orphans had exhibited significantly morebehavioral symptoms than the refugee children but theyoutperformed the latter on most of the cognitive tests. Atthe age of 912, they again exhibited significantly morebehavioral symptoms of emotional distress than thechildren in Orphanage B, but they performed the cog-nitive tests on a par with the latter and at a moreadvanced level than the children from Orphanage A.

A rapid recovery of cognitive functions despite per-sistent emotional symptoms has also been observed

among Western children who spend the early years in aresidential setting but are then adopted by middle-classfamilies. On the other hand, children who are restored totheir own families often show both persistent cognitivedelays and persistent emotional symptoms. In Westerncultures, the critical factor accounting for such effectsappears to be the socioeconomic status (and by inferencethe intellectual climate) of thefamily to which the childrenare restored (Hodges & Tizard, 1989b; Rutter &Maughan, 1997; Tizard & Hodges, 1978). For Eritreanchildren, socioeconomic factors were largely irrelevantbecause most of them were either still living in residentialsettings or had only recently been placed with extendedfamilies. On the other hand, the quality of child care in a

residential setting that encouraged peer teaching and afree exchange of ideas between children and adults mayhave served the same function for the Solomuna orphansas a middle-class environment did for Western children.

In sum, the social interactions of the Solomunaorphans with strangers had normalized substantially overthe 5-year interval, as had their capacity for cooperationand sharing with peers. Moreover, they exhibited signifi-cantly fewer behavioral symptoms than the children inOrphanage A. Their cognitive performance equaled orexceeded that of the two comparison groups; and theiracademic achievement was on a par with that of home-reared children. Thus, the patterns of child care and

the supportive social environment in the SolomunaOrphanage and Zero School may have mitigated manyof the more ominous psychiatric disorders that wouldhave emerged in a less supportive social environment. Thefindings also suggest that the principles of child care inthese institutions may have been designed specificallyto prepare the orphans for re-entry into the largerEritrean society. The prognosis for the long-term mental

health of the Solomuna orphans, although still guarded,may therefore be more hopeful than the persistenceof their behavioral symptoms might suggest. However,further longitudinal studies are required to test theseclaims.

Limitations of the Study

(1) One serious, but unavoidable, limitation was thatthe studies had to be carried out under difficultand constantly changing environmental conditions.

(2) Another was the almost total lack of informationabout the lives of the Solomuna orphans before theycame to the institution. Such information might have

helped to explain some of the individual differences inemotional state among the orphans, and it might haveprovided a basis for making informed guesses abouttheir long-term psychiatric prognosis.

(3) Until now, the orphans have been followed for only5 years. Any firm conclusions about the long-termeffects of growing up in an institutional setting willtherefore also require further follow-up studies.

(4) The behavioral symptom questionnaires were notwell suited for identifying latent emotional disordersthat might later surface as serious psychiatric illnesses(Harriset al., 1990 ; Rutter,1985; Rutter & Maughan,1997); and none of the cognitive measures had beenstandardized for East African populations.

(5) The proposed longer-term follow-up studies wouldalso benefit from (a) behavioral questionnaires thatassess feelings of depression, anxiety and aggression;(b) in-depth interviews with children and adolescents ;(c) quantitative observations of social interactionswith peers and significant adults; and (d)the inclusionof qualitative measures of intellectual developmentthat focus on operative rather than figurativeknowing (Piaget, 1968).

Conclusions

Despite these limitations, the findings may serve as apoint of departure for social service agencies in other war-

torn Third World countries that are confronted by thesame awesome task of providing humane care forhundreds of thousands of war orphans in countries whereadoption and foster care are not viable options. General-izations based on the Eritrean experience must take intoaccount potentially important cross-cultural differences,and particularly the social context into which the childrenwill be reintegrated. However, the finding that residentialsettings governed by principles of collective responsi-bility, which encourage close personal ties with stableadults, can mitigate and partially offset the more seriouspsychological consequences of having lost both parentsand chronic exposure to the violence of war, should be

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relevant for all war-torn Third World countries (see alsoMcKenzie, 1997).

AcknowledgementWe aregrateful forthe generous financialsupport of the William T. Grant Foundation that made thisstudy possible. The work summarized in this report is thecollective effort of many dedicated Eritreans. The two indi-viduals listed as authors take full responsibility for the prep-

aration of the report.

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