Practices of alternative care for young children and their consequences Birmingham University Child Care and Protection Unit, 2007 EU Daphne/WHO Training

Practices of alternative care for young children and their

consequences

Birmingham University

Child Care and Protection Unit, 2007

EU Daphne/WHO Training Programme, April 19, 2007 Danish Seminar/Presentation 1

Professor Kevin Browne WHO Collaborating Centre on Child Care and Protection

University of BirminghamEmail: [email protected]

Ecological model of child development(Bronfenbrenner, 1979)



Public Awareness

PARENT CHILD

FAMILY

COMMUNITY

SOCIETY

Relatives

Home Siblings

Health and Social Services

School and Neighbourhood

Legislation



Proportion of all children under 3 years who are in institutional care, 2003 (blue lines are estimates).

0 10 20 30 40 50 60 70

Slovenia

UK

Norway

Turkey

Austria

Greece

Cyprus

Ireland

Denmark

Albania

Croatia

Poland

Netherlands

Portugal

Spain

Hungary

Estonia

Malta

France

Slovak Republic

Romania

Latvia

Lithuania

Belgium

Czech Republic

Proportion of children under 3 years in institutions *refers to estimates,

Country 2003 Proportionper 10,000

No u3 in institutions

Country 2003 Proportionper 10,000

No u3 in institutions

Czech Rep. 60 1 630 Poland 9 *1 344

Belgium 56 *2 164 Croatia 8 144

Latvia 55 395 Albania 8 *133

Bulgaria 50 1 238 Sweden 8 (*213)

Lithuania 46 458 (505) Denmark 7 133

Hungary 44 773 Germany 7 1 495

Romania 33 2 915 Ireland 6 *95

Slovak Rep. 31 502 Cyprus 4 *15

Finland 28 (*466) Austria 3 *37

Malta 27 44 Greece 3 114

Estonia 26 100 Turkey 2 850

Spain 23 *2 471 Italy 2 *310

Netherlands 16 1 284 Norway <1 (17)

Portugal 16 714 UK <1 (*65)

France 13 *2 980 Slovenia 0 0

Iceland 0 0

The danger of institutions for young children has been known for 50 years

Both Bowlby (UK) and Vygotsky (Russia) have emphasised the following:

• (a) infants need one to one interaction with sensitive and caring parent figure to which they develop a secure attachment.

• (b) the negative consequences of children growing up in an institution with attachment disorders and later antisocial acts

CHDCHD

Reasons for institutionalisation in 2003

Reasons For Institutionalisation Of Children Under The Age Of Three - EU Member States

0% 4% 4%

69%

23%orphan

abandoned

disabled

abused/neglected

other

Reasons For Insitutionalisation Of Children Under The Age Of Three - other surveyed Countries*

6%

32%

23%

14%

25%orphan

abandoned

disabled

abused/neglected

other

Disability• Overall, 33% of known sample had a disability (n=161)

• Significant difference between countries (χ2 =16.3, p<.02)

• Of total sample:– Developmental delay 24% (n=115)– Heart malformations 4% (n=20)– Foetal alcohol syndrome 3% (n=14)– Physical disabilities 4% (n=18)

% Disability % Developmental delay

Denmark 38 20

France 44 30

Greece 18 16

Hungary 17 11

Poland 28 14

Romania 36 31

Slovakia 45 26

Entry to institutional care

• Group I - family, foster care, family residential unit (46%)• Group II - maternity unit, hospital, street (54%)

• Significant difference between countries (χ2 =41.6, p<.001)

*For Romania, figures exclude Timisoara and Maramures samples – information not available

0

20

40

60

80

100

Denmark France Greece Hungary Poland Romania Slovakia

%Group I

Group II

Contact with siblings

• 70% of children had siblings– 38% of siblings were placed together– Of those not placed together, sibling contact was

maintained/re-established for 34%

*For Romania, Hunedora sample only; excluding data from Timis and Maramures

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Denmark France Greece Hungary Poland Romania Slovakia

No contact

Contact

Placed together

Length of stay in Institutional care

• The average age that children entered their current institution was 11 months and departed at 26 months.

• The average length of stay in the current institution was 15 months with a range from 10 months (Poland) to 20 months (Greece).

• The overall length of time spent in any institutional setting was 16 months. Many children (54%) entered from maternity/paediatric units (average age entered care was 10 months).

EEG Recordings from a Young Child

EEG Activity Across Regions of the Child’s Brain (Bucharest Early Intervention Project - Nelson and Koga,

2004)

0

0.5

1

1.5

2

2.5

3

3.5

Front Cent Pariet Occip Temp

Institution

Community

Evidence from Brain Scans

Impact on brain development

• Normal brain temporal lobes – high activity and cell growth

• Neglected brain temporal lobes – low activity and cell death

L L RR

Neurobiological – brain scans show impact of severe neglect on brain and development of empathy & social behaviour

Evidence from Brain Scans

Placement Decisions


Child Care and Protection Unit, 2007 Keep balance

betweenchild protection andfamily preservation

Protection/Out of Home Placements



Institution ??

No child under 5 should be in institutional care

International Adoption

Last resort

Only in the best interests of the child

Institutional CareCare in CommunityFamily Support with Day care/therapeutic interventions

Care by Non-offending parent (in the absence of the offender)

Kinship Care (grandparent/other relative)

Foster / therapeutic foster home

National Adoption - Only 4% are true orphans!

Ratio of national to international adoptions 2003

0% 20% 40% 60% 80% 100%

Slovenia

Austria

Slovak Rep.

UK

Turkey

Hungary

Estonia

Germany

Romania

Bulgaria

Malta

Lithuania

Italy

Cyprus

Ireland

France

Spain

Latvia

Belgium

Luxembourg

Sweden

Norway

Finland

national

international(incoming children)

international(outgoing children)

International adoption correlates with increased the institutional care of young children in donor countries (data from Browne et al., 2005)

Spearman’s rho correlation coefficient = 0.786, p<0.04

International adoption promotes institutional care of young children in donor countries (Browne et al., 2005)

Country

Ranks in ( )

Children under 3 in institutional care

(rate per 10,000)

International adoption (% of total adoptions)

Latvia 55 (1) 77 (1)

Bulgaria 50 (2) 47 (3)

Lithuania 46 (3) 56 (2)

Hungary 44 (4) 13 (6)

Romania 33 (5) 31 (4)

Slovakia 31 (6) 5 (7)

Estonia 26 (7) 25 (5)

International adoption promotes institutional care of young children in host countries (Browne et al., 2005)

Countries

>11 children

per 10,000 in institutional care


Countries

<10 children

per 10,000 in institutional care


Luxembourg

Netherlands

98

97

Norway

Denmark

98

96

Finland 92 Iceland

Ireland

93

69

Belgium 87 Cyprus

Italy

68

62

Spain 77 Germany

UK

28

5

France 75 Austria

Sweden

3

2

Malta 56 Greece

Slovenia

1

0

Average 83.14 Average 43.75

t=3.0, df=15, p=0.01

Legal framework for international adoption

UNCRC - United Nations Convention on Rights of Child (1989)

• Best interests of the child (Article 3)• International adoption only as a last resort (Article 21b)• Respect privacy of child (Article 16)• State’s responsibility to support parents in difficulty

(Article 18)

Hague Convention (1993)• No improper financial gain from intercountry adoption

(Article 32) (‘Reasonable’ professional fees?)• Child must be adoptable (Article 4)

(BUT only 4% of children in institutions are ‘true’ orphans, Browne et al. 2005)

Transforming of children’s services

COMMUNITY SERVICES

FOSTER CARE

RESIDENTIAL CARE

Pyramid of services to children and families: There are pitfalls in attempting to reduce residential care

What does an individual child need as an alternative to institutionalised care? (1)

• Local services: what health and social facilities are available to ensure a young child’s needs are being met free of charge (home visits by professionals?)

• Assessment of each family in relation to their child needs, parent’s capacity to meet the needs, social and economic factors inhibiting the parent’s capacity

• Support for families, financial, practical and emotional

What does an individual child need as an alternative to institutionalised care? (2)

• Rehabilitation of families assessed as being high risk of harming the child physically, sexually or emotionally through abuse or neglect

• Foster Care of a high standard to care for the child and act as a role model to parents being rehabilitated

• Adoption only after rehabilitation of parents and extended family interventions have failed

• Free Legal Representation for parents and child involved in public care proceedings

Causes of child abandonment by the family

Very serious economic problems Mother’s lack of formal education Few specialist services in local communities

(e.g. to visit pregnant mothers) Lack of sexual education and family planning Poor housing and homelessness Teenage parenting Poor preparation for birth and traditional

practices of peri-natal care



Prevention of Harm to Abandoned and Maltreated Children

• Mother and baby units offer support and shelter to mothers high risk of abandoning their children.

• Alternative family based care for abandoned young children and babies (foster care).

• Surrogate family apartments for abandoned children (consider national adoption).

• Integration of children with and without disabilities.

CHDCHD

UNCRC Recommendations for Children without Parental Care 1

• Increase awareness of short and long-term consequences for children living without a primary caregiver in institutional care

• Consider reasons WHY children are being placed in institutional care and for how long ? (‘Economic orphans’ or ‘social orphans’ or ‘biological orphans’)

• Further develop community support services for families as a preventative strategy

• Promotion of foster care and national adoption;

UNCRC Recommendations for Children without Parental Care 2

• International adoption to be used as a last resort and only when proven to be in the best interest of the child (UNCRC)

• All placement decisions to consider optimal developmental time-frames of the child and effects of relocation

• Monitor the format of institutions on offer for child protection (large & impersonal OR small & family based)

• More effective use of resources for children. Capacity build foster and adoptive care and rehabilitation of families at less cost than institutional care

Training and dissemination

• Training events planned for 2006 in those countries with the highest rates (30+ per 10,000) of young children in institutional care– Czech Republic, Belgium, Bulgaria, Latvia, Lithuania,

Hungary, Romania, Slovakia

• Supported by a training manual entitled ‘De-institutionalising and transforming services for children: A guide to good practice’

STEPS TO DE-INSTITUTIONALISATION

4

5

6

7

8

9

10

3

2

1 Raising awareness

Country/regional level analysis

Design services

Planning transfer of resources

Preparing & moving children

Preparing & moving staff

Logistics

Monitoring & evaluation

Managing the process

Analysis at institution level

Conclusions on the process of deinstitutionalisation of young children

Evidence suggests the deinstitutionalisation process may further damage young children:– If the transition is too rapid – If the child’s needs are not considered– If the child’s needs are not a priority

A third of children leave institutions with disability or developmental delay requiring community health and social service support and home visits, 42% of children are NOT followed up.

Documents

Practices of alternative care for young children and their consequences Birmingham University Child Care and Protection Unit, 2007 EU Daphne/WHO Training