"Please, sir, I want some more," Oliver Twist famously asked in the food line at an orphanage.
Instead he got a blow to the head with a ladle.
In the real world, conditions at orphanages can be even bleaker. Back in the 1990s, media coverage of Romanian orphanages showed dozens of children sitting unclothed in crowded rooms. Most were neglected, and many were suffering from debilitating diseases like polio. Those with mental disabilities were confined to cribs or straitjackets.
So the call has always been to take the world's estimated 2 million to 8 million orphaned and abandoned children living in institutions, and place them with foster families.
A study out of Duke University offers a different perspective.
Some kids in institutions can do just as well as those in a foster home, says Kathryn Whetten, the study's lead author and a population health researcher at Duke who focuses on children.
As you might expect, it's an arguable conclusion.
The study, published this week in PLOS ONE, looked at kids ages 6 to 12 in five low- and middle-income countries: Cambodia, India, Ethiopia, Kenya and Tanzania. The goal was to work with a culturally diverse sample.
For three years, researchers tracked the well-being of more than 1,300 children in orphanages, where care is provided by shift workers, and 1,400 who were cared for by a foster family. Every six months, they compared the physical and mental health of the subjects, along with their learning ability and memory.
If the policymakers' assumptions were true, Whetten says, children in the institutions should have fared much worse than their counterparts in foster care.
That wasn't what she found.
Both groups improved on most measures. And while children in family-based care improved more over time, the difference was statistically insignificant. Children in institutions scored higher on physical health, which may mean the institutions were more likely to meet the children's basic needs.
Whetten is quick to point out that she is not arguing that institutions are better than foster care — a statement she calls "absurd." Rather, she says policies that call for the complete deinstitutionalization of orphanages around the globe is not a one-size-fits-all solution.
In both settings, "there are kids that are doing terribly, and there are kids that are doing pretty well," she says. "So if you were to magically take away all of the institutions today, we wouldn't see an improvement in the health of the kids."
If that were to happen, some kids might move from good institutions into families that aren't able to provide quality care because of poverty, violence and other struggles in lower-income countries.
Charles Nelson doesn't agree. He's a professor of pediatrics at Harvard Medical School and Boston Children's Hospital, and he studies how social interaction — or the lack thereof — affects children's brain development.
"Work that goes back 50 years show that kids in institution early in life don't do as well as those in a family, regardless of how good those institutions are," he says.
His own research shows that children deprived of parental bonding at an early age tended to have smaller brains with abnormal wiring in certain areas. When he looked at orphanages in Romania, he also found that the longer it took for a child to transfer to foster care, the lower they scored on cognitive tests.
Nelson cautions that Whetten's study may be misleading because it doesn't describe the environment that the kids in foster families grew up in, nor does it compare the two groups to children who were raised in stable homes. If the foster families in the sample were prone to violence, drugs or abuse, he says, the data don't reveal much.
"Without telling us how old the kids were when they went into the institution and what the families are like," he says, "I don't know if I can believe the findings."
Whetten says the study is part of an ongoing project, and it isn't arguing that one setting is better than the other. "It's the quality of care and the history of the individual children that makes the difference," she says. And policymakers need to recognize that, she says, rather than looking for an easy solution to a complex problem.
Critics like Nelson definitely want some more evidence before they're convinced.