CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction and Chapter Overview

The second chapter of this research provides a comprehensive and critical synthesis of
existing academic literature, policy documents, and empirical studies that frame the
investigation into the mental health of adolescents in institutional care in Egor Local
Government Area (LGA), Edo State, and the potential of foster care as a strategic alternative.
This review is structured into seven primary sections designed to systematically build the case
for the study:
1.​ Conceptual and Definitional Framework: Distinguishing institutional care, foster care,
and adolescent vulnerability.
2.​ Theoretical Frameworks: Detailing Attachment Theory, Trauma-Informed Care (TIC),
and the Social Ecological Model.
3.​ Global Empirical Review: Synthesizing international evidence on the mental health
sequelae of institutionalization.
4.​ Empirical Evidence from the Nigerian Context: Localizing the evidence to
socio-cultural and economic factors.
5.​ Institutional and Relational Correlates: Examining the direct mechanisms (LoS,
caregiver turnover) that impact well-being.
6.​ Policy and Legal Framework: Analyzing the disconnect between the Edo State Child
Rights Law and implementation reality.
7.​ Summary and Research Gaps: Final synthesis and delineation of the study's unique
contributions.
The depth of this review ensures that the findings of the current study are not only empirically
grounded but also directly relevant to advancing policy and practice in Nigerian child welfare.

2.2 Conceptual and Definitional Framework

A precise definition of the alternative care models under investigation is necessary to ensure
the conceptual rigor of this study. The terms 'orphanage' and 'institutional care' are often
used interchangeably, yet they represent a specific structure of care that fundamentally
contrasts with family-based models like foster care.

2.2.1 The Nature, Structure, and Risks of Institutional Care

(Orphanages)
Institutional care is defined here as a large-scale, congregate residential setting, typically
accommodating more than ten children, managed by non-familial, shift-working staff. While
intended to provide safety, the structural characteristics of these environments inherently
create conditions that impede healthy adolescent development:
[Link] Impersonal and Routinized Environment
The necessity of managing a large group of children leads to rigid, standardized routines (e.g.,
fixed wake-up/bedtimes, collective meals, scheduled playtime). As noted by Nelson et al.
(2007) in their extensive research, this lack of temporal and environmental predictability
prevents the development of the personalized context required for complex problem-solving
and executive functioning. The absence of contingent responsiveness—where a child's unique
emotional cues are met with an individualized, nurturing response—creates an emotionally
barren environment.
●​ Diffused Caregiving: The high staff turnover and shift-based rosters mean that children
rarely have one, or even a few, consistent adult figures. This fragmented caregiving
directly sabotages the core human need for a stable primary attachment figure, a
deficiency that becomes increasingly problematic during adolescence when identity
formation and separation from authority figures are key tasks ().
●​ Lack of Privacy and Ownership: Adolescents in institutions often lack private space,
personal belongings, and the right to make meaningful personal decisions. This
deprivation undermines the psychological task of achieving autonomy and
self-determination, which are crucial for successful adult functioning.
[Link] Stigmatization, Labeling, and Social Isolation
In the Nigerian context, the term 'orphanage' often carries a social stigma that labels the
residents as 'less than' or 'dependent.' This external prejudice often internalizes, contributing
significantly to the low self-esteem identified as a key mental health outcome (Objective 1).
Furthermore, while children are in a collective setting, they often experience social isolation
from the broader community and often engage in complex peer dynamics, including peer
violence and bullying, in the absence of consistent, effective adult mediation. This isolation
limits exposure to diverse social roles and non-institutionalized adult models, hindering social
development.

2.2.2 Foster Care: The Paradigm of Family-Based Alternatives

Foster care represents the intentional provision of a temporary or long-term substitute family
environment within a state-monitored framework. It is globally endorsed as the standard of
care for children unable to remain with their biological families, based on the principle of the
"best interest of the child."

[Link] Relational and Developmental Advantages

The primary advantage of foster care lies in its ability to provide stable, consistent, and
individualized care (Schofield & Beek, 2014). This environment offers:
●​ Correctional Relationship Experience: For adolescents with histories of trauma, the
consistent responsiveness of foster parents offers a corrective experience to repair
broken trust and disordered attachment patterns. This stable presence counteracts the
effects of relational instability inherent in institutional settings.
 ●​ Normalization of Life Skills and Social Context: Living in a family allows adolescents to
observe and participate in normal domestic routines, learn crucial independent living
skills (e.g., budgeting, grocery shopping, complex social navigation), and receive
age-appropriate privacy and autonomy—all skills crucial for a successful transition to
adulthood. The integration into community schools and social networks minimizes the
stigma associated with institutional placement.
[Link] Therapeutic Foster Care (TFC) and Enhanced Models
Given the high prevalence of complex trauma and co-morbid mental health needs among
OVC, standard foster care may be insufficient. Therapeutic Foster Care (TFC) models
specifically train foster parents to manage severe behavioral challenges, mental health crises,
and complex trauma histories. These programs are often mandated to provide weekly in-home
therapy, intensive case management, and crisis stabilization, thus integrating professional
psycho-social support directly into the family setting. The theoretical benefits evaluated in
this study (Objective 4) align most closely with this therapeutic approach, suggesting that for
high-need adolescents in Egor LGA, TFC represents the gold standard.

2.2.3 Adolescent Vulnerability in Alternative Care: A Period of

Intensified Risk
The developmental period of 13 to 19 years is marked by rapid neurological maturation,
particularly in the prefrontal cortex (PFC), which governs executive functions, impulse control,
and emotional regulation. In alternative care, this critical window is often complicated:
●​ Grief and Loss Re-processed: The trauma of parental loss, separation, or neglect is
re-processed during adolescence as the individual begins to form an independent
identity. Unresolved grief often contributes directly to depressive symptomology and
social withdrawal (Internalizing Disorders).
●​ Identity Conflict and Stigma: Institutional settings can make identity formation
challenging. The collective identity of 'orphanage resident' conflicts with the adolescent's
need for personal uniqueness and individuality. The lack of adult role models who
successfully navigate the external world exacerbates this identity confusion.
●​ Neurobiological Implication: Allostatic Load: Chronic stress associated with
institutional instability and trauma leads to the dysregulation of the
Hypothalamic-Pituitary-Adrenal (HPA) axis, resulting in chronically elevated cortisol
levels. This neurobiological stress response, termed Allostatic Load, is strongly
implicated in the onset and severity of anxiety disorders and mood instability observed
in this population (Objective 1).

2.3 Theoretical Frameworks Guiding the Study: Deep

Dive
The theoretical foundation of this study provides the mechanisms for the observed
relationship between the care environment and mental health outcomes. This research is
anchored by three interrelated models: Attachment Theory, the Trauma-Informed Care (TIC)
framework, and the Social Ecological Model.

2.3.1 Attachment Theory: Disorganized Attachment and DSED

John Bowlby’s Attachment Theory is the primary framework for explaining the relational
deficits arising from institutional care. When care is inconsistent, abusive, or fragmented (as in
institutional shift-work), children are highly likely to develop Disorganized Attachment.

[Link] Disinhibited Social Engagement Disorder (DSED)

A specific and highly visible consequence of early relational deprivation in institutions is
Disinhibited Social Engagement Disorder (DSED). DSED is characterized by a child actively
approaching and interacting with unfamiliar adults in a manner that is overly familiar,
disinhibited, and not culturally normative. This behavior is often mistakenly interpreted as
friendliness, but it is a maladaptive strategy for seeking care without a secure foundation. For
adolescents in Egor LGA, DSED can manifest as:
●​ Indiscriminate Affection: Seeking attention and physical contact from any adult without
discernment.
●​ Poor Boundary Setting: Difficulty understanding and respecting social and personal
boundaries.
The presence of DSED in institutionalized adolescents strongly supports Hypothesis
(Caregiver transitions and anxiety/attachment issues), demonstrating a failure to form secure,
specific attachments due to high turnover.

[Link] Internal Working Models (IWMs)

The core component of the theory relevant to adolescent mental health is the Internal
Working Model (IWM). The Disorganized IWM established in the institution manifests
profoundly in adolescent self-view and social behavior:
●​ Self-View: The adolescent views themselves as unworthy of consistent care, leading to
deep-seated low self-esteem and hopelessness. This cognitive template makes them
highly vulnerable to depressive symptoms ().
●​ Other-View: They view others, particularly authority figures and potential intimate
partners, as unpredictable and untrustworthy, leading to poor compliance, externalizing
behaviors, and difficulties forming meaningful peer or romantic relationships. Foster care
aims to provide a reliable, consistent IWM to replace this maladaptive template.

2.3.2 The Neurobiological Foundation of Trauma-Informed Care (TIC)

The Trauma-Informed Care (TIC) framework, as defined by SAMHSA, insists that care
systems must recognize and respond to the pervasive impact of trauma.

[Link] The Adverse Childhood Experiences (ACEs) and Polyvictimization

Most OVC have experienced multiple traumas (e.g., parental death, poverty, neglect, abuse,
and the subsequent trauma of institutional removal). This experience of Polyvictimization
results in chronic activation of the stress response system. The core principle of TIC is to
provide environments that ensure:
1.​ Safety and Stabilization: Physical and emotional predictability (lacking in institutional
care).
2.​ Trustworthiness and Transparency: Clear, consistent staff behavior (undermined by
turnover).
3.​ Peer Support and Collaboration: Empowering the adolescent voice.
4.​ Empowerment, Choice, and Control: Allowing adolescents to make meaningful
decisions about their lives (stifled by institutional routines).
The TIC approach suggests that moving the adolescent to the stable, predictable, and
empowering environment of foster care is essential to reduce the allostatic load and promote
neurobiological healing, thereby improving mental health outcomes.

2.3.3 The Social Ecological Model and Structural Failure

Bronfenbrenner’s Social Ecological Model allows for the structured analysis of the
environment's influence on the child's development across various levels.
●​ Microsystem Failure: The institutional setting itself (the child's immediate microsystem)
fails due to overcrowding and staff-to-child ratios (Objective 2). The structure is
inherently flawed because it attempts to substitute the individualized emotional input of a
family with a bureaucratic, collective system.
●​ Mesosystem Disruption: In institutions, the connection between the primary care
environment and external systems (school, community, healthcare) is often weak or
managed impersonally. This disruption (a breakdown in the mesosystem) often results in
poor academic performance and peer integration.
●​ Macrosystem and Policy Failure: The continued reliance on institutional care in Edo
State, despite international and national legislative mandates for family-based
alternatives, represents a Macrosystem failure. The lack of funding and political will to
develop the foster care infrastructure (Exosystem) directly perpetuates the harmful
conditions within the Microsystem, thus justifying the policy focus of this study
(Objective 5).

2.4 Global Empirical Review: The Enduring Sequelae

of Institutionalization
International, longitudinal studies provide compelling evidence that institutional care is a
severe developmental risk factor, with effects that persist long into adulthood.

2.4.1 Specific Mental Health Outcomes in Institutional Settings

(Global)
The long-term study of children raised in institutions, most notably the Bucharest Early
Intervention Project (BEIP), provides the definitive evidence base:

[Link] Depression and Anxiety

Meta-analyses consistently show that institutionalized youth have up to four times the rate
of clinical depression and anxiety disorders compared to community controls (Van IJzendoorn
et al., 2011). These internalizing problems are linked to the environment's failure to provide a
sense of control or emotional validation. The hyper-vigilance necessary for survival in an
unpredictable institutional environment transitions into chronic anxiety when the adolescent is
faced with the complexity of the external world.

[Link] Disordered Stress Response (Cortisol)

Biological studies have revealed permanent changes in the stress physiology of
institutionalized children. Studies on institutionalized adolescents show blunted or flattened
diurnal cortisol rhythms (the natural cycle of cortisol release), indicating a disordered HPA
axis. This biological disruption underlies mood dysregulation, sleep problems, and
compromised immune function, reinforcing the neurobiological mechanisms outlined by the
TIC framework.

2.4.2 Long-Term Adult Outcomes of Institutional Care

The true cost of institutionalization is measured by the outcomes achieved by adolescents
transitioning into adulthood:
●​ Increased Risk of Homelessness and Unemployment: Adults who spent their
adolescence in institutional care face significantly higher rates of homelessness, reliance
on state aid, and chronic unemployment compared to those exiting foster care (Dozier et
al., 2017). This is attributed to the lack of independent living skills and the absence of a
transitional family support network.
●​ Criminal Justice Involvement: Institutionalized youth are more likely to have poor
impulse control (PFC hypoactivity) and poor self-regulation, leading to higher rates of
substance abuse and involvement in the criminal justice system in early adulthood.
●​ Intergenerational Transmission of Trauma: Former institutionalized individuals often
struggle to form secure attachments with their own children, perpetuating a cycle of
relational trauma and compromised developmental outcomes.

2.4.3 The Efficacy of Family-Based Care: Comparative Evidence

The evidence base strongly favors family-based alternatives as a mechanism for mitigation
and recovery:
●​ Catch-Up Growth: BEIP data showed that children moved from institutions to foster
care before the age of two demonstrated significant cognitive catch-up and reductions
 in DSED symptoms. While cognitive gains are less pronounced in adolescence, emotional
regulation and adaptive functioning still show improvement in stable foster placements
(Rutter, 2010).
●​ Cost-Effectiveness and Societal Savings: A compelling argument for
deinstitutionalization lies in economics. While the initial investment in recruiting and
supporting foster care may seem high, the long-term societal cost of maintaining
institutionalized populations (via healthcare, social services, and correctional services)
far outweighs the cost of supporting a high-quality family-based care system. Studies in
the US and Europe demonstrate a clear fiscal advantage to foster care over residential
care in the long run.

2.5 Empirical Evidence from the Nigerian Context:

Localizing the Risk
To ensure the study's relevance, local Nigerian research must be integrated, reflecting the
unique socio-cultural and economic factors that influence care provision in regions like Edo
State.

2.5.1 Socio-Cultural Determinants of Institutional Reliance

[Link] The Role of Religious and Philanthropic Institutions
In Nigeria, a significant number of orphanages are run by faith-based organizations or receive
heavy funding from international and local philanthropic bodies. This institutional support,
while driven by noble intentions, paradoxically entrenches the institutional model. Donors
often prefer to support tangible structures (buildings, centralized facilities) rather than the
less visible, decentralized, and complex social work systems required for foster care. This
funding dynamic creates a powerful economic incentive to maintain the orphanage structure,
contributing to the policy gap identified in the study.

[Link] The Erosion of Kinship Care

Historically, the primary alternative care system in Nigeria was the extended family (kinship
care). However, rapid urbanization, economic hardship, and the HIV/AIDS epidemic have
eroded the capacity of extended families to absorb OVC. This breakdown is the primary driver
compelling children into non-kin, institutional care. The stigma of poverty often outweighs the
cultural mandate for kinship care, meaning many children in Nigerian orphanages are not 'true
orphans' but children whose living relatives are simply too poor to support them.

2.5.2 Local Studies on Specific Adolescent Mental Health Outcomes

Nigerian studies focusing on adolescents in care consistently highlight the prevalence of
behavioral and emotional problems, validating the need for the current study in Egor LGA.
●​ Emotional and Behavioral Problems: A study by Olowu and Alaka (2014) in Ondo State,
 using the Strengths and Difficulties Questionnaire (SDQ), found elevated scores for
Conduct Problems (stealing, lying, aggression) and Emotional Symptoms (anxiety,
depression) in institutionalized youth compared to matched controls. These externalizing
behaviors are often interpreted as a failure of the institution to provide adequate
emotional containment and personalized disciplinary models.
●​ Gender Differences in Mental Health: Emerging Nigerian research indicates that
female adolescents in institutional care may exhibit higher rates of Internalizing
Disorders (depression, anxiety, self-harm) linked to perceived vulnerability and
gender-specific trauma, while male adolescents show higher rates of Externalizing
Disorders (aggression, conduct problems). The current study must be sensitive to
potential gender differences in its analysis of mental health prevalence.
●​ Self-Concept and Future Orientation: Local research has also confirmed that
institutionalized adolescents demonstrate a poorer sense of self-concept and a lack of
clear future orientation (Adeleke et al., 2020). The institutional model, which provides all
needs without requiring active planning or agency, fails to equip adolescents for the
competitive transition to independence.

2.5.3 The Capacity Crisis in Deinstitutionalization in Nigeria

The slowness of deinstitutionalization (moving children out of institutions) in Nigeria is not due
to a lack of legal framework, but a profound capacity crisis within the social welfare system:
1.​ Recruitment and Vetting: Difficulty in recruiting sufficient foster parents due to a lack of
financial incentive and a deep-seated cultural preference for biological or kinship ties.
2.​ Training and Monitoring: Inadequate government funding to provide the necessary
professional, trauma-informed training for foster parents and a severe lack of robust,
independent monitoring systems to ensure placement stability and prevent abuse.
3.​ Infrastructure: The absence of dedicated, well-staffed social work units within the
Ministry of Women Affairs and Social Development capable of managing the complexity
of foster care case work and the required post-placement follow-up.

2.6 Institutional and Relational Correlates of Mental

Health in Care
This section explores the specific mechanisms within the institutional environment that are
hypothesized (in and ) to correlate with adverse mental health outcomes.

2.6.1 Length of Stay (LoS) and Developmental Lag ( Mechanism)

The duration of residency in an institutional setting (LoS) is widely considered the single
most critical institutional risk factor.
●​ Cumulative Deficit Model: Psychological theory suggests that the longer the exposure
to a sub-optimal environment, the greater the cumulative developmental deficit. An
adolescent who has spent five years in institutional care has missed five years of
 consistent attachment, personalized decision-making opportunities, and varied
community exposure.
●​ Compounding Trauma: LoS acts as a proxy for compounding trauma, as the original
trauma of loss is continuously reinforced by the chronic relational deficits of the
institution. This prolonged exposure during adolescence interferes with the
establishment of stable, non-institutionalized identity and is thus hypothesized to
correlate positively with the severity of internalizing disorders like depressive symptoms
().

2.6.2 Caregiver Turnover, Relational Instability, and Burnout (

Mechanism)
Caregiver turnover refers to the frequency with which a child experiences a change in their
primary non-familial adult care provider, a phenomenon endemic to institutional care.
●​ Re-enactment of Trauma: Each new caregiver transition forces the adolescent to
re-enact the trauma of initial loss and abandonment. For children with pre-existing
trauma, this instability prevents the brain from entering a state of safety, perpetuating the
high-alert state associated with anxiety.
●​ Caregiver Burnout: High turnover is often caused by low wages, poor support, and
emotional exhaustion (burnout) among staff. Burned-out caregivers are less emotionally
available, more prone to punitive discipline, and less able to provide the individualized
therapeutic responses adolescents require. This mechanism directly reinforces the
hypothesized impact on anxiety and attachment issues ().

2.6.3 Educational and Vocational Preparedness

A key correlate often overlooked is the institution's capacity to prepare adolescents for the
transition to independence. Institutional structures often focus only on basic academic
qualifications, neglecting vital elements:
●​ Vocational Skill Deficits: Adolescents often lack access to diverse vocational training,
career counselling, or mentorship opportunities that are readily available in family
settings.
●​ Financial Literacy: The centralized nature of institutional provision means teenagers
rarely handle money, budget, or participate in the economic decision-making of the
household, leading to poor financial literacy—a significant risk factor for homelessness
post-discharge.

2.7 Policy and Legal Framework: From Intent to

Implementation in Edo State
The effectiveness of policy is measured not by its existence, but by its implementation,
particularly in ensuring the psychological well-being of OVC.
2.7.1 Deconstructing the Edo State Child Rights Law (2007) and the
Principle of Subsidiarity
The Edo State Child Rights Law (Edo CRL, 2007) provides the legal mandate for a shift in care
philosophy.
●​ Principle of Subsidiarity: International guidelines stress the Principle of Subsidiarity,
which holds that placement outside the birth family should occur only when necessary,
and, when needed, the alternative should be the least restrictive setting possible. This
principle legally and ethically places family-based care (foster care) above institutional
care.
●​ The Mandate for Oversight and Gatekeeping: The Law mandates rigorous oversight
and monitoring of all alternative care facilities by the Ministry of Women Affairs and Social
Development. Furthermore, effective gatekeeping mechanisms—a formal system to
determine why a child needs care and which type of care is best—are essential to
prevent unnecessary institutional placement. The perceived failure in Egor LGA is not a
legal void, but an implementation deficiency in this gatekeeping process.

2.7.2 International Standards and Monitoring Challenges

The UN Guidelines for the Alternative Care of Children (2009) demand that all states move
towards deinstitutionalization. However, in the Nigerian context, the monitoring and evaluation
(M&E) of alternative care faces significant challenges:
1.​ Data Deficits: A lack of standardized data collection on the outcomes and well-being of
OVC in both institutional and non-institutional care, making evidence-based policy
reform difficult.
2.​ Regulatory Capture: Reliance on charitable funding often compromises the regulatory
capacity of the government, as the Ministry may hesitate to enforce strict standards or
close non-compliant institutions for fear of cutting off crucial services.

2.7.3 Justifying Policy Recommendations

The analysis of the policy and legal framework reveals that Hypothesis (: There is no
significant difference in the expected mental health outcomes between the existing
institutional care model and a family-based foster care model, as perceived by the orphanage
management and staff) is essential. If staff and managers—the primary implementers of
policy at the ground level—do not perceive foster care as superior, then the policy shift will
never gain traction. The findings of this research are designed to provide the empirical
leverage required for the Ministry to enforce:
●​ Public Awareness Campaigns: To counter the cultural reliance on orphanages.
●​ Dedicated Social Work Capacity: Investment in professional social work teams
specializing in TFC models and rigorous post-placement monitoring.

2.8 Summary of Literature Review and Research

Gaps
This expansive review has established the critical relationship between the care environment
and the mental health outcomes of adolescents. Theoretically, Attachment Theory explains
the emotional withdrawal and low self-esteem observed in institutions, while the
Trauma-Informed Care approach interprets internalizing disorders (anxiety, depression) as
the neurobiological consequence of chronic stress and trauma. Empirically, both global and
local Nigerian studies confirm that institutionalized adolescents exhibit significantly higher
rates of anxiety, depression, conduct disorders, and lower self-esteem compared to
family-raised peers. Crucially, the length of stay and caregiver instability are identified as
specific exacerbating factors. Finally, while the Edo State Child Rights Law provides the
necessary legal blueprint for a shift to family-based care, the practical policy implementation
remains weak due to structural and cultural resistance.

The Present Study's Unique Contributions:

The current research is crucial for addressing the identified gaps:

1.​ It provides the first localized, quantitative data on specific mental health prevalence
(anxiety, depression, self-esteem) in the targeted Egor LGA orphanage population.
2.​ It empirically tests the relationship between specific institutional variables (duration of
residency and caregiver transitions) and mental health outcomes in the Nigerian context
( and ).
3.​ It contributes unique data on the perceptions and awareness of foster care among
institutional stakeholders (), which is vital for designing effective, localized
deinstitutionalization strategies in Edo State.