Introduction The negative effects of institutional rearing are well documented. Poor caregiving, lack of stimulation and the absence of a consistent caregiver have been implicated in the negative outcomes among institutionalised children (Rutter, Kreppner and O'Connor, 2001). As fostering and adoption are not as yet available or even accepted in some countries, orphanages are still being used as child placements following disasters, war situations and other causes of parent loss or absence (Aboud et al, 1991; Johnson et al, 1992). Although such settings can provide a secure and positive alternative to abusive and unsafe family or community environments, they cannot provide individualised and family nurturing (McKenzie, 1998). Instead, evidence, predominantly from studies with infants and young children, indicates the risk of attachment disorders and developmental delays (in the physical, behavioural, social and cognitive domains) (Suman, 1986; Vorria et al, 2003; Johnson, Browne and Hamilton-Giachritsis, 2006). These are largely accounted for by the absence of individual nurturing relationships with primary caregivers (Daunhauer, Bolton and Cermak, 2005). Findings are similar to those from research with children in public care who have been raised in a range of institutions (Browne et al, 2006). Additional risk factors operate for children orphaned by HIV/AIDS (Freeman, 2004; Masmas et al, 2004).