***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: In a r and omized controlled trial , we compared  ab and oned children reared in institutions to ab and oned children placed in institutions but then moved to foster care . Young children living in institutions were r and omly assigned to continued institutional care or to placement in foster care , and their cognitive development was tracked through 54 months of age . The cognitive outcome of children who remained in the institution was markedly below that of never-institutionalized children and children taken out of the institution and placed into foster care . The improved cognitive outcomes we observed at 42 and 54 months were most marked for the youngest children placed in foster care . These results point to the negative sequelae of early institutionalization , suggest a possible sensitive period in cognitive development , and underscore the advantages of family placements for young ab and oned children BACKGROUND We examined the effects of a foster care intervention on attention and emotion expression in socially deprived children in Romanian institutions . METHODS Institutionalized children were r and omized to enter  foster care or to remain under institutional care . Subsequently , the institutionalized and foster care groups , along with a community-based comparison group , were evaluated on emotion tasks at 30 and 42 months of age . Behaviors reflecting positive and negative affect and attention were coded from videotapes . RESULTS Data indicated that at both age points , children who received the foster care intervention showed higher levels of attention and positive affect compared to children who remained institutionalized . Compared to the community sample , children in the foster care intervention showed higher levels of attention to the emotion-eliciting tasks at 42 months of age . CONCLUSIONS The results of this r and omized trial demonstrate the impact of a family-based intervention on the development of attention and positive affect This study examined classifications of attachment in 42-month-old Romanian children ( N = 169 ) . Institutionalized since birth , children were assessed comprehensively , r and omly assigned to care as usual ( CAU ) or to foster care , and compared to family-reared children .  Attachment classifications for children in foster care were markedly different from those in the CAU . Importantly , children placed in foster care before 24 months were more likely to have secure attachments and if placed earlier were less likely to have disorganized or insecure-other attachments . Cognitive status predicted greater likelihood of organized attachment in the CAU and greater likelihood of secure attachment in the foster care and never-institutionalized groups . Foster care is an important intervention to reduce the adverse effects following early deprivation BACKGROUND Children reared in institutions experience elevated rates of psychiatric disorders . Inability to form a secure attachment relationship to a primary caregiver is posited to be a central mechanism in this association . We determined whether the ameliorative effect of a foster care ( FC ) intervention on  internalizing disorders in previously institutionalized children was explained by the development of secure attachment among children placed in FC . Second we evaluated the role of lack of attachment in an institutionalized sample on the etiology of internalizing disorders within the context of a r and omized trial . METHODS A sample of 136 children ( aged 6 - 30 months ) residing in institutions was recruited in Bucharest , Romania . Children were r and omized to FC ( n = 68 ) or to care as usual ( CAU ; n = 68 ) . Foster parents were recruited , trained , and overseen by the investigative team .  Attachment security at 42 months was assessed using the  Strange Situation Procedure  , and internalizing disorders at 54 months were assessed using the Preschool Age Psychiatric Assessment . RESULTS Girls in FC had fewer internalizing disorders than girls in CAU ( OR = 0.17 , p = .006 ) . The intervention had no effect on internalizing disorders in boys ( OR = 0.47 , p = .150 ) . At 42 months , girls in FC were more likely to have secure attachment than girls in CAU ( OR = 12.5 , p < .001 ) , but no difference was observed in boys ( OR = 2.0 , p = .205 ) . Greater attachment security predicted lower rates of internalizing disorders in both sexes . Development of attachment security fully mediated intervention effects on internalizing disorders in girls . CONCLUSION Placement into FC facilitated the development of secure attachment and prevented the onset of  internalizing disorders in institutionalized girls . The differential effects of FC on attachment security in boys and girls explained gender differences in the intervention effects on psychopathology . Findings provide evidence for the critical role of disrupted attachment in the etiology of internalizing disorders in children exposed to institutionalization This study investigated the effects of early institutional care on memory and executive functioning .  Subjects were participants in the Bucharest Early Intervention Project ( BEIP ) and included institutionalized children , children with a history of institutionalization who were assigned to a foster care intervention , and community children in Bucharest , Romania .  Memory and executive functioning were assessed at the age of 8 years using the  Cambridge Neuropsychological Test and Automated Battery ( CANTAB ) . As expected , children with a history of early institutional care performed worse on measures of both visual memory and executive functioning compared to their peers without a history of institutional care . In comparing children r and omly assigned to the foster care intervention with their peers who had continued care in the institution , initial comparisons did not show significant differences on any of the memory or executive functioning outcomes . However , for one of the measures of executive functioning , after controlling for birth weight , head circumference , and duration of time spent in early institutional care , the foster care intervention was a significant predictor of scores . These results support and extend previous findings of deficits in memory and executive functioning among school-age children with a history of early deprivation due to institutional care . This study has implication s for the millions of children who continue to experience the psychosocial deprivation associated with early institutional care OBJECTIVE Our purpose was to measure the agreement , reliability , construct validity , and feasibility of a measurement tool to assess  systematic review s ( AMSTAR ) . STUDY DESIGN AND SETTING We r and omly selected 30 systematic review s from a data base . Each was assessed by two review ers using : ( 1 ) the enhanced quality assessment question naire ( Overview of Quality Assessment Question naire [ OQAQ ] ) ; ( 2 ) Sacks ' instrument ; and ( 3 ) our newly developed measurement tool ( AMSTAR ) . We report on reliability ( interobserver kappas of the 11 AMSTAR items ) , intraclass correlation coefficients ( ICCs ) of the sum scores , construct validity ( ICCs of the sum scores of AMSTAR compared with those of other instruments ) , and completion times . RESULTS The interrater agreement of the individual items of AMSTAR was substantial with a mean kappa of 0.70 ( 95 % confidence interval [ CI ] : 0.57 , 0.83 ) ( range : 0.38 - 1.0 ) . Kappas recorded for the other instruments were 0.63 ( 95 % CI : 0.38 , 0.78 ) for enhanced OQAQ and 0.40 ( 95 % CI : 0.29 , 0.50 ) for the Sacks ' instrument . The ICC of the total score for AMSTAR was 0.84 ( 95 % CI : 0.65 , 0.92 ) compared with 0.91 ( 95 % CI : 0.82 , 0.96 ) for OQAQ and 0.86 ( 95 % CI : 0.71 , 0.94 ) for the Sacks ' instrument . AMSTAR proved easy to apply , each review taking about 15 minutes to complete . CONCLUSIONS AMSTAR has good agreement , reliability , construct validity , and feasibility . These findings need confirmation by a broader range of assessors and a more diverse range of review Contrary to some conventional wisdom , in this large study that r and omly sample d orphans and separated children from 5 countries , prevalence of reported traumatic events was no worse among those institutionalized than among those in family-based care . Reported incidence of physical or sexual abuse was actually higher for those in family-based care . Underst and ing the specific context , and elements contributing to potential harm and benefits in both family-based and institutional care , are essential to promoting the best interest of the child . Contrary to some conventional wisdom , in this large study that r and omly sample d orphans and separated children from 5 countries , prevalence of reported traumatic events was no worse among those institutionalized than among those in family-based care . Reported incidence of physical or sexual abuse was actually higher for those in family-based care . Underst and ing the specific context , and elements contributing to potential harm and benefits in both family-based and institutional care , are essential to promoting the best interest of the child . Background : Policy makers struggling to protect the 153 million orphaned and separated children ( OSC ) worldwide need evidence -based research on the burden of potentially traumatic events ( PTEs ) and the relative risk of PTEs across different types of care setting s. Methods : The Positive Outcomes for Orphans study used a 2-stage , cluster-r and omized sampling design to identify 1,357 institution-dwelling and 1,480 family-dwelling orphaned and separated children in 5 low- and middle-income countries ( LMICs ) in sub-Saharan Africa and Asia . We used the  Life Events Checklist developed by the National Center for Posttraumatic Stress Disorder to examine self-reported PTEs among 2,235 OSC ages 10–13 at baseline . We estimated prevalence and incidence during 36-months of follow-up and compared the risk of PTEs across care setting s. Data collection began between May 2006 and February 2008 , depending on the site . Results : Lifetime prevalence by age 13 of any PTE , excluding loss of a parent , was 91.0 % ( 95 % confidence interval ( CI ) = 85.6 , 94.5 ) in institution-dwelling OSC and 92.4 % ( 95 % CI = 90.3 , 94.0 ) in family-dwelling OSC ; annual incidence of any PTE was lower in institution-dwelling ( 23.6 % [ 95 % CI = 19.4 , 28.7 ] ) than family-dwelling OSC ( 30.0 % [ 95 % CI = 28.1 , 32.2 ] ) . More than half of children in institutions ( 50.3 % [ 95 % CI = 42.5 , 58.0 ] ) and in family-based care ( 54.0 % [ 95 % CI = 50.2 , 57.7 ] ) had experienced physical or sexual abuse by age 13 . Annual incidence of physical or sexual abuse was lower in institution-dwelling ( 12.9 % [ 95 % CI = 9.6 , 17.3 ] ) than family-dwelling OSC ( 19.4 % [ 95 % CI = 17.7 , 21.3 ] ) , indicating statistically lower risk in institution-dwelling OSC ( risk difference = 6.5 % [ 95 % CI = 1.4 , 11.7 ] ) . Conclusion : Prevalence and incidence of PTEs were high among OSC , but contrary to common assumptions , OSC living in institutions did not report more PTEs or more abuse than OSC living with families . Current efforts to reduce the number of institution-dwelling OSC may not reduce incidence of PTEs in this vulnerable population . Protection of children from PTEs should be a primary consideration , regardless of the care setting OBJECTIVES To investigate the prevalence of stereotypies in children with a history of early institutional care , evaluate the efficacy of a foster care intervention compared with institutional care on the course of stereotypies , and describe correlates in language , cognition , and anxiety for children who exhibit stereotypies . DESIGN R and omized controlled trial . SETTING Institutions in Bucharest , Romania . PARTICIPANTS One hundred thirty-six children with a history of early institutional care . Intervention Comparison of a foster care intervention with continued care as usual in an institution . MAIN OUTCOME MEASURES The presence of stereotypies as well as outcomes in language , cognition , and anxiety . RESULTS At the baseline assessment prior to placement in foster care ( average age of 22 months ) , more than 60 % of children in institutional care exhibited stereotypies . Follow-up assessment s at 30 months , 42 months , and 54 months indicated that being placed in families significantly reduced stereotypies , and with earlier and longer placements , reductions became larger . For children in the foster care group , but not in the care as usual group , stereotypies were significantly associated with lower outcomes on measures of language and cognition . CONCLUSIONS Stereotypies are prevalent in children with a history of institutional care . A foster care intervention appears to have a beneficial/moderating role on reducing stereotypies , underscoring the need for early placement in home-based care for ab and oned children . Children who continue to exhibit stereotypies after foster care placement are significantly more impaired on outcomes of language and cognition than children without stereotypies and thus may be a target for further assessment s or interventions Look After the Child Investing in children has been demonstrated to improve their lives , both during the school-age years and afterward , as assessed by outcomes such as employment and income ; furthermore , these investments often help those in the most need . Campbell et al. ( p. 1478 ) report that these investments can also lead to improved adult health . Results from a r and omized and intensive intervention that involved 122 children in four cohorts recruited in the 1970s suggest that full-day child care for the first 5 years of life has produced adults in their 30s with better metabolic and cardiovascular health measures . Large investments in preschool children ’s education , health care , and nutrition provide long- 
    Output:
    
The major intervention pathway for ameliorating cognitive challenge seems to be placement out of the institutions which shows benefits and redresses some cognitive outcomes - yet not a total panacea .
The single study providing training and monitoring of harsh punishment and maltreatment showed immediate and decided reductions .
This data suggest , despite the paucity of studies , violence and abuse , by commission or omission is prevalent in institutions , has an effect on child well-being and is amenable to intervention .
Simple training or more complex structures to place children within conducive alternative environments ( or to avoid institutionalised placements in the first place ) seem to be the main pathway of intervention