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 Birmingham

Ecological model of child development (Bronfenbrenner, 1979) Birmingham University Child Care and Protection Unit, 2007 Public Awareness PARENT CHILD FAMILY COMMUNITY SOCIETY Relatives Home Siblings Health and Social Services School and Neighbourhood Legislation

Birmingham University Child Care and Protection Unit, 2007

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

Proportion of children under 3 years in institutions * refers to estimates, Country 2003Proportion per 10,000 No u3 in institutions Country 2003Proportion per 10,000 No u3 in institutions Czech Rep Poland9*1 344 Belgium56*2 164Croatia8144 Latvia55395Albania8*133 Bulgaria Sweden8(*213) Lithuania46458 (505)Denmark7133 Hungary44773Germany Romania Ireland6*95 Slovak Rep.31502Cyprus4*15 Finland28(*466)Austria3*37 Malta2744Greece3114 Estonia26100Turkey2850 Spain23*2 471Italy2*310 Netherlands Norway<1(17) Portugal16714UK<1(*65) France13*2 980Slovenia00 Iceland00

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 CHD

Reasons for institutionalisation in 2003

Disability Overall, 33% of known sample had a disability (n=161) Significant difference between countries ( χ 2 =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 Denmark3820 France4430 Greece1816 Hungary1711 Poland2814 Romania3631 Slovakia4526

Entry to institutional care Group I - family, foster care, family residential unit (46%) Group II - maternity unit, hospital, street (54%) Significant difference between countries ( χ 2 =41.6, p<.001) *For Romania, figures exclude Timisoara and Maramures samples – information not available

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

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)

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

Evidence from Brain Scans

Placement Decisions Birmingham University Child Care and Protection Unit, 2007 Keep balance between child protection and family preservation

Protection/Out of Home Placements Birmingham University Child Care and Protection Unit, 2007  Institution ?? No child under 5 should be in institutional care  International Adoption Last resort Only in the best interests of the child Institutional Care Care in Community  Family 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

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) Latvia55 (1)77 (1) Bulgaria50 (2)47 (3) Lithuania46 (3)56 (2) Hungary44 (4)13 (6) Romania33 (5)31 (4) Slovakia31 (6)5 (7) Estonia26 (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 International adoption (% of total adoptions) Countries <10 children per 10,000 in institutional care International adoption (% of total adoptions) Luxembourg Netherlands Norway Denmark Finland92Iceland Ireland Belgium87Cyprus Italy Spain77Germany UK 28 5 France75Austria Sweden 3232 Malta56Greece Slovenia 1010 Average83.14Average43.75 t=3.0, df=15, p=0.0 1

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 Birmingham University Child Care and Protection Unit, 2007

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. CHD

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 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.