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The Risk of Harm to Young Children
in Institutional Care
The Risk of Harm to
Young Children in
Institutional Care
Kevin Browne
Professor of Forensic Psychology and Child Health, Institute of
Work, Health & Organisations, University of Nottingham, UK
This paper provides an international summary of the extent and scale of
young children living without parents in residential care ‘children’s homes’,and
of the reasons they are there. It also gives an overview of the risk of harm to
young children’s care and development after being placed in institutional care.
The author concludes with core recommendations for policy and practice to
prevent harm to children and to promote the rights of children to grow up in
a family environment.
UK
savethechildren.org.uk
UK
The Risk of Harm to
Young Children in
Institutional Care
Kevin Browne
Professor of Forensic Psychology and Child Health, Institute of
Work, Health & Organisations, University of Nottingham, UK
The Risk of Harm 5th pages 18/11/09 4:52 pm Page i
Published by
Save the Children
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First published 2009
© The Save the Children Fund 2009
The Save the Children Fund is a charity registered in England and Wales
(213890) and Scotland (SC039570). Registered Company No. 178159
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Printed by Stephen Austin & Sons Ltd
We’re the world’s independent children’s rights organisation. We’re outraged
that millions of children are still denied proper healthcare, food, education and
protection and we’re determined to change this.
Save the Children UK is a member of the International Save the Children
Alliance, transforming children’s lives in more than 100 countries.
The Better Care Network (BCN) brings together organisations and individuals
concerned about children without adequate parental care. Its mission is to facilitate active
information exchange and collaboration on these issues and advocate for technically sound
policy and programmatic action on global, regional, and national levels in order to:
• reduce instances of separation and abandonment of children
• reunite children outside family care with their families wherever possible and appropriate
• increase, strengthen and support family and community-based care options for children
• establish international and national standards for all forms of care for children
without adequate family care, and set up mechanisms for ensuring compliance
• ensure that residential institutions are used in a very limited manner and only
when appropriate.
The Better Care Network website can be found at http://www.crin.org/bcn/
The Better Care Network can be contacted for information or requests at
contact@bettercarenetwork.org
The Risk of Harm 5th pages 18/11/09 4:52 pm Page ii
Contents
Author’s biographical note iv
About this paper v
Introduction 1
1 The extent of institutional care for young children (0 to 3 years) 3
2 The extent of institutional care for all children (0 to 17 years) 5
3 Relative costs 6
4 Reasons for institutional care 7
5 Effects of institutional care on physical development and motor skills 9
6 The psychological harm caused to children by institutional care 11
7 Long-term effects of institutional care 16
8 The way forward: moving young children out of institutions and
preventing new admissions 18
9 Implications for policy and practice: a summary 21
References 22
The Risk of Harm 5th pages 18/11/09 4:52 pm Page iii
Kevin Browne is currently Professor of Forensic
Psychology and Child Health at the Institute of
Work, Health & Organisations, University of
Nottingham, and was previously holder of the
Chair of Forensic and Child Psychology at the
Universities of Liverpool and Birmingham. He has
worked and presented in more than 50 countries
worldwide, including leading multi-sector training
projects, on the prevention of child maltreatment
and maternal and child health in Russia and
Slovakia, supported by the British Government.
For 12 years he was an Executive Councillor of the
International Society for the Prevention of Child
Abuse and Neglect – where he also chaired their
research committee – and has been a consultant
to the European Commission, World Bank,
and UNICEF.He is Head of the World Health
Organization’s Collaborating Centre for Child
Care and Protection. He was also a consultant and
contributing author to the UN Secretary-General’s
World Report on Violence against Children (2006).
He recently led a two-year EU/WHO investigation
into 33 European countries on the extent,
characteristics and effects of early institutional care
on child development and behaviour (See: Browne,
K.D., Hamilton-Giachritis, C.E., Johnson, R. and
Ostergren, M. (2006). Overuse of institutional care
for children in Europe. British Medical Journal; 332:
485–487 [25/02/06]). This was followed by an
18-month project concerned with training policy-
makers and practitioners, and capacity building
community programmes and surrogate family care,
to deinstitutionalise and transform children’s
services across Europe.
iv
Author’s biographical note
The Risk of Harm 5th pages 18/11/09 4:52 pm Page iv
v
Save the Children and the Better Care Network
commissioned Professor Browne to undertake
this review of the evidence base on the risks of
harm to young children in institutional care. Both
organisations are concerned to improve the
situation of children without adequate care and to
do so on the basis of the best possible evidence
about both child development and professional
good practice.
This paper is being published to share the findings
of Professor Browne’s review and to stimulate
debate and further research on this topic. The views
expressed in this paper are those of the author and
not necessarily those of Save the Children or the
Better Care Network.
About this paper
The Risk of Harm 5th pages 18/11/09 4:52 pm Page v
1
Young children are frequently placed in institutional
care throughout the world. This occurs despite
wide recognition that institutional care is
associated with negative consequences for children’s
development (Carter, 2005; Johnson, Browne and
Hamilton-Giachritsis, 2006). For example, young
children in institutional care are more likely to suffer
from poor health, physical underdevelopment and
deterioration in brain growth, developmental delay
and emotional attachment disorders. Consequently,
these children have reduced intellectual, social
and behavioural abilities compared with those
growing up in a family home.
This paper provides an international summary
of the extent and scale of young children living
without parents in residential care ‘children’s
homes’, and of the reasons they are there. This is
followed by an overview of the risk of harm to
young children’s care and development after being
placed in institutional care, and considers core
recommendations for policy and practice to
prevent harm and promote the rights of a child to
grow up in a family environment (UNCRC, 1989).
To begin, a definition of what is meant by ‘institution
or residential care home for children’ is presented
to clarify the use of the term in this paper.
An institution or residential care home for children
is defined as a group living arrangement for more
than ten children, without parents or surrogate
parents, in which care is provided by a much smaller
number of paid adult carers. Typically in Europe this
would be one carer to six children of a similar age
during the day and fewer staff at night. Often the
staff are inadequately trained and poorly supervised,
making basic mistakes such as feeding a child (who
Introduction
Plate 1: A young child being fed inappropriately in his cot.
KEVIN BROWNE
should be able feed himself) on his back in a
sleeping position (see plate 1).
Residential care implies an organised, routine and
impersonal structure to the living arrangements for
children (eg, all children sleep, eat and toilet at the
same time) and a professional relationship, rather
than parental relationship, between the adults and
children. It is recognised that this definition would
include children admitted to hospital, children in
emergency care and those who attend boarding
schools and summer camps. Therefore, children
The Risk of Harm 5th pages 18/11/09 4:52 pm Page 1
who live in an institution without a parent for more
than three months are ‘institutionalised children’
and the focus of our concern.
Institutions or residential care homes for children
are sometimes incorrectly referred to as ‘infant
homes’ or ‘orphanages’. The so-called ‘infant homes’
often provide a non-stimulating, clinical environment
for toddlers and young children up to four years of
age, and the vast majority (94 to 98%) of children in
‘orphanages’ have at least one living parent, often
known to the authorities (Browne et al., 2005, 2006;
Carter, 2005; Tobis, 2000). It is acknowledged that
these figures do not refer to children in conflict
or disaster zones, but even in these areas only a
minority of children in institutions are orphans,
with many of them being displaced and separated
from a living parent or relative whose whereabouts
may be unknown. Perhaps the increasing numbers
of HIV orphans in sub-Saharan Africa are the only
exception to this misnomer, although it has been
reported that 59% of children from Zimbabwe living
in institutions have at least one parent alive, and
there is much anecdotal evidence that the majority
of ‘HIV orphans’ in sub-Saharan Africa, whether in
institutional care or otherwise, have at least one
living parent.
2
THE RISK OF HARM TO YOUNG CHILDREN IN INSTITUTIONAL CARE
The Risk of Harm 5th pages 18/11/09 4:52 pm Page 2
The damaging practice of placing young children
in residential care without a parent or surrogate
parent is a worldwide phenomenon. However, most
information on the numbers and characteristics
of young children in institutional care has been
published for Europe where, ironically, this practice
is regarded as the traditional response to ‘protecting’
children from harm and ‘rescuing’ them from poor
and inadequate parenting. Indeed, Europeans in
all parts of the world have been placing young
children in need of help and support into social
care institutions for over 200 years. However,
the information from Europe, like elsewhere, has
problems of reliability and validity. For example,
there is no standardisation of types of institutions,
of the government department(s) responsible,
of the data collected or of the methods used,
and some countries only report data from state
institutions and do not include children in ‘children’s
homes’ run by privately owned, faith-based or
non-governmental organisations (NGOs). This
makes international comparisons problematic and
complex but still very informative, as the following
surveys demonstrate.
In 2003, a survey of 33 European (excluding
Russian-speaking) countries was carried out under
the auspices of the World Health Organization
(WHO) Regional Office for Europe, as a part of
the EU Daphne programme to combat violence to
women and children. The study mapped the official
recorded number and characteristics of children
under age three years in residential care (Browne
et al., 2005a) and found that 23,099 young children
(out of an overall population of 20.6 million under
three) had spent more than three months in
institutions, of more than ten children, without
a parent. This represents 11 children in every
10,000 under three years in residential care homes
throughout the European Economic Community
(EEC). The figures varied greatly between the
different countries. Four countries had none or
less than one per 10,000 children under three
in institutions, 12 countries had institutionalised
between one and ten young children per 10,000,
seven countries had between 11 and 30 children per
10,000 and, alarmingly, eight countries had between
31 and 60 children per 10,000 under three years in
institutional care. Only Iceland, Norway, Slovenia and
the UK had a policy to provide foster care rather
than institutional homes for all needy young children
under the age of five. Of most concern were the
15 countries with more than one in every thousand
(10 per 10,000) infants or toddlers living the first
part of their lives in a residential ‘children’s home’
without a parent. In 2003, these countries were
Belgium, Bulgaria, Czech Republic, Latvia, with more
than 50 per 10,000; Hungary, Lithuania, Romania,
Slovak Republic with more than 30 per 10,000;
Finland, Malta, Estonia, Spain, with more than 20 per
10,000; and Netherlands, Portugal and France, with
more than 10 per 10,000.
Another 2003 survey using official statistics from
27 countries in Central and Eastern Europe (CEE)
and the Former Soviet Union (FSU) showed that
most Russian-speaking European countries and
Newly Independent States (NIS countries) in
3
1 The extent of institutional
care for young children
(0 to 3 years)
The Risk of Harm 5th pages 18/11/09 4:52 pm Page 3
Central Asia have at least 20 children in every
10,000 under three years in ‘children’s homes’
(UNICEF Innocenti 2004). There was an overlap in
the two surveys carried out in 2003, and a strong
correlation was found for the number of young
children resident in children’s homes between the
11 countries that appeared in both surveys (Browne
et al., 2006). This suggests that, although difficulties
exist when collecting such information, reasonable
estimates can be made and the data is reliable
enough to inform policy and practice.
Browne et al. (2006) averaged the official data
from both surveys and estimated the total number
of children under three years in institutional care
for 47 out of the 52 countries (90.4%) in the
WHO European (and Central Asian) region. The
five countries with no data for 2003 were Israel,
Luxembourg (later estimated to be 12 per 10,000
under three), Monaco, San Marino and Switzerland.
It was calculated that 43,842 young children
from a population of 30.5 million 0 to 3 years
(14.4 per 10,000) were in residential care homes
without parents. The greatest numbers of under-
threes in institutional care were found in Russia
(10,411), Romania (4,564), Ukraine (3,210),
France (2,980) and Spain (2,471).
4
THE RISK OF HARM TO YOUNG CHILDREN IN INSTITUTIONAL CARE
The Risk of Harm 5th pages 18/11/09 4:52 pm Page 4
Carter (2005) claims that the overuse of institutional
care for children is far more widespread than official
statistics suggest. He reports 2002 figures from the
non-governmental organisation (NGO) EveryChild
for 20 countries in Eastern Europe and the Former
Soviet Union. The figures show the total number of
children (0 to 17 years) in social care facilities within
these 20 countries to be approximately 1.3 million,
and nearly double the 714,910 children officially
reported to UNICEF for the same time period.
Over the past 15 years, Carter (2005) observes
a small decline (13%) in the absolute number of
children in institutional care in this specific region.
However, if the decline in birth rate is taken into
account, the proportion of the child population in
social care facilities has actually increased by 3%
since the collapse of the communist systems.
Comparable data for North America is difficult to
identify as they refer to all children in public care
as ‘fostered’, rather than restricting this term for
children placed into professional surrogate families.
Nonetheless, Johnson et al. (2006) report that on
30 September 2001, 542,000 children (0–18 years)
were in public (‘foster’) care in the USA, and
approximately one quarter of these (130,857) were
under five years. Across the 50 states, an average
of 9% of children under 12 years in public (‘foster’)
care were placed in residential children’s homes
(ranging from 1.3% in Hawaii to 27.2% in Arizona).
Therefore, it can be estimated for the USA that
approximately 11,777 young children under five
years resided in residential care institutions. Outside
the developed world of Europe and North America,
the problem of institutionalised young children is
commonplace, but accurate statistics are unavailable.
Overall, UNICEF estimates that the total number of
children in institutional care globally is 2.2 million,
but they point out that under-reporting and a lack
of regulation in some countries indicates that this
figure is an underestimate. Information available
from UNICEF and other international organisations
suggests that the use of residential care for children
is increasing, especially for countries in economic
transition, conflict or disaster zones. In sub-Saharan
Africa, for example, recent reports indicate that the
number of privately funded institutions has risen
rapidly. A contributing factor is the concern about
where to place the growing numbers of children
orphaned by HIV/AIDS. It was estimated in 2001
that Ethiopia alone has 989,000 children orphaned
by AIDS. Therefore, governments are looking for
simple solutions, without considering what is in the
best interests of children in adversity.
5
2 The extent of institutional
care for all children
(0 to 17 years)
The Risk of Harm 5th pages 18/11/09 4:52 pm Page 5
Funding institutional care rather than the
alternatives is misguided when the relative costs
are considered. Analyses of children of all ages in
Romania, Ukraine, Moldova and Russia show that
institutional care is six times more expensive than
providing social services to vulnerable families
or voluntary kinship carers; three times more
expensive than professional foster care; and twice
as expensive as community residential/small group
homes (Carter, 2005). Furthermore, analyses of data
from 13 countries in western and central Europe
demonstrated that institutional care was twice
as expensive as foster care for young children
with disabilities, and three times more expensive
than foster care for young children without any
disabilities. This finding was independent of the
level of spending on quality of care in each country
(Browne et al., 2005a). Institutions are more
expensive than family-based alternatives, partly
because 33% to 50% of paid staff employees
in residential care have no direct contact with
children, according to reports from Montenegro,
Serbia and Slovakia (Browne, 2007; Browne,
Vettor and Dejanovic, 2006; Tinova, Browne and
Pritchard, 2007).
6
3 Relative costs
The Risk of Harm 5th pages 18/11/09 4:52 pm Page 6
It has been observed that institutional care
is increasing in countries where there is
economic transition, because for many families
and communities the changes have increased
unemployment, migration for work, family
breakdown and single parenthood (Carter, 2005;
Tinova et al., 2007). In these countries, poverty
seems to be the main underlying factor for placing
a child in institutional care, with single parents and
parents with large unplanned families equally
challenged by poverty and unable to cope (Sigal
et al., 2003). This situation is compounded further
by impoverished child welfare services. Hence, in
Europe an association has been reported between
low community health and social services spending
and high numbers of abandoned and institutionalised
children. Furthermore, inadequate health and
social services for parents (eg, mental health and
alcohol/drug addiction services) also means that
children are likely to remain in institutional care for
longer periods of time (Browne et al., 2005b; 2006).
However, the relationship between child poverty
and institutional care is not straightforward because
there are also significant numbers of children who
live in residential care facilities in economically
developed countries.
In the USA and western Europe child protection
systems have developed faster than family-based
alternative care. Therefore, when parents are judged
by professionals as abusive, neglectful or incapable of
meeting the physical and/or psychological needs of
the child, professionals are given powers to remove
the child to a place of safety. All too often this
is a residential care facility rather than surrogate
foster or kinship family care. This inappropriate
intervention can compound the effects of abuse
and neglect, and contribute to the suffering of
children and the harm done to them.
The child’s characteristics may also increase the
chances of institutional care because of discrimination
and negative social attitudes towards children with
physical and/or mental disabilities, children from
ethnic minorities, illegitimate children and children
from single mothers or broken families, all of whom
are over-represented in residential care. In some
countries even gender may have an influence,
with female children more often abandoned to
institutional care and international adoption.
Browne et al. (2005b) found different reasons for
young children being taken into institutional care
in economically developed countries within the
original 15 EU member states in 2003, compared
with EU accession countries that were in economic
transition in 2003. Figure 1 (see page 8) gives the
official cited reasons for children under three
years being in social care facilities for six of the
15 EU member states in 2003. The vast majority
of children (69%) were placed in residential
care because of abuse and neglect, 4% due to
abandonment, 4% because of disability and 23% for
social reasons, such as family ill-health or parents
in prison. No biological orphans
(ie, without living
parents) were placed in institutions.
By contrast, Figure 2 gives the official cited reasons
for children under three years being placed in
residential care for 11 of the 14 EU accession
countries in 2003. Only 14% were placed in
institutions due to abuse or neglect, 32% were
7
4 Reasons for institutional care
The Risk of Harm 5th pages 18/11/09 4:52 pm Page 7
abandoned, 23% had a disability, 25% were ‘social
orphans’ (placed because of family ill-health and
incapacity) and 6% were true biological orphans.
In 2003, children were most often placed in
residential care in European economically developed
countries for abuse and neglect, whereas in parts
of Europe undergoing economic transition it was
mainly because of abandonment and disability.
Overall, 27% of young children had a disability on
admission to residential care, but approximately a
third of children leaving care had some form of
disability that required follow-up in the community
where possible, possibly due to the effects of
growing up in an institution (Browne et al., 2004).
8
THE RISK OF HARM TO YOUNG CHILDREN IN INSTITUTIONAL CARE
Figure 1. Reasons for institutionalisation of young children under three years in
economically developed EU member states, 2003 (data from Belgium, Denmark, France,
Greece, Portugal and Sweden)
Figure 2. Reasons for institutionalisation of children under three years in EU accession
countries undergoing economic transition, 2003 (data from Croatia, Cyprus, Czech
Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Romania, Slovakia and Turkey)
Orphan 0% Abandoned 4%
Disabled 4%
Abused/neglected 69%
Other 23%
Orphan 6%
Abandoned 32%
Disabled 23%
Abused/neglected 14%
Other 25%
The Risk of Harm 5th pages 18/11/09 4:52 pm Page 8
Typically, institutions for young children under four
years are overcrowded, clinical environments with
highly regimented routines, unfavourable care-giver
to child ratios, and unresponsive staff who see their
roles more related to nursing and physical care than
to psychological care (Nelson et al., 2007). Often,
young children will spend a significant proportion
of each day in a cot with a ‘vacant stare’ or tapping
on the bars of their cot/crib ‘cage’ (Maclean, 2003),
having already become habituated to the novelty of
the non-interactive soft toys left with them and any
pictures on otherwise blank walls (see plate 2).
Much emphasis is placed on infection control, and
the children experience the outside world only
on rare occasions under strict supervision and
limited play. The everyday contact with dirt, which
challenges and helps develop a child’s immune
9
KEVIN BROWNE
Plate 2: A young child in
residential care at a ‘children’s
home’ in Montenegro
5 Effects of institutional care
on physical development
and motor skills
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 9
system, is mostly restricted. This over-control of the
children’s environmental experiences has a number
of detrimental effects (Carter, 2005; Mulheir and
Browne, 2007; Smyke et al., 2007):
• Physical under-development, with weight, height
and head circumference below the norm.Severe
conditions may result in failure to thrive;
• Hearing and vision problems that may result
from poor diet and/or under-stimulation.
Often the problems are not diagnosed and
are left untreated;
• Motor skill delays and missed developmental
milestones are common for children in
institutional care, and in severe conditions
stereotypical behaviours, such as body
rocking and head banging, are often seen.
• Poor health and sickness result from
overcrowded conditions, with cots back to
back and limited environmental experiences
inhibiting the development of the immune
system. Children may be isolated from staff
and other children when they are sick and at
a time when they most need comforting and
sensitive care;
• Physical and learning disabilities may arise
as a consequence of institutional care from
a combination of motor skill delays and
retarded developmental stages, especially
under conditions of poor health and sickness.
Many of the problems described above are hidden
by incomplete records of the development of
children in residential care (Mulheir and Browne,
2007). Sometimes records are falsified or
exaggerated – for example, the implementation
of immunisation programmes within the
institutions (Carter, 2005).
10
THE RISK OF HARM TO YOUNG CHILDREN IN INSTITUTIONAL CARE
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 10
The damaging psychological consequences of
institutional care have been written about for over
50 years. The publications of Goldfarb (1944; 1945)
and Bowlby (1951) were particularly influential and
highlighted a number of emotional, behavioural and
intellectual impairments that characterised children
who had been raised in residential care. Children
living in institutions without parents are reported
to perform poorly on intelligence tests and to be
slow learners with specific difficulties in language
and social development, in comparison to children
with foster parents. In addition, they had problems
concentrating and forming emotional relationships,
and were often described as attention-seeking. The
lack of an emotional attachment to a mother figure
during early childhood was attributed as the cause
of these problems, which were considered to be
long-lasting.
‘Attachment theory’ (Bowlby, 1969) emphasised
the negative consequences of institutional care
compared with family-based care and the
importance of a primary care-giver for normal
child development. This led to a decline in the use
of institutional care or large children’s homes in
some parts of the English-speaking world. In other
parts of world, child care policy has been less
concerned with the psychosocial needs of children.
Instead, an emphasis has been placed on the physical
needs of children and controlling their environment.
In these countries, this has led to a reliance on
institutions, rather than on the development of
substitute parenting, such as kinship care, foster
care and adoption (Browne, 2002).
Johnson et al. (2006) carried out a systematic
search of the literature and found that since these
early studies there have been 2,624 articles on
early privation/deprivation of parenting or children
in institutional/residential care published in English
from 1944 to 2003. They reviewed in detail
27 research studies that used a control or
comparison group and met the following criteria:
• Population – children 0–17 years
• Intervention – children exposed to residential
care in an institution under the age of five years,
without a primary caregiver, for varying lengths
of time
• Comparator – children exposed to family-based
care with a primary caregiver for varying lengths
of time
• Outcome – child to primary caregiver
attachment patterns, social and behavioural
development, cognitive development.
Effects of institutional care on social
behaviour and interaction with others
Of the 27 studies scientifically investigated by
Johnson et al. (2006) concerning the development
of children who have been raised in institutions,
17 studies measured social and behavioural
problems that were more prevalent in residential
care children compared with other children.
Evidence of negative social or behavioural
consequences for children raised in institutional
care was reported by 16 (94%) of the studies,
highlighting problems with anti-social conduct,
11
6 The psychological harm
caused to children by
institutional care
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 11
social competence, play and peer/sibling
interactions. In addition, one in ten children who
spent their early lives in poor conditions, often
deprived of interaction with others, were found
to show ‘quasi-autistic’ behaviours such as face
guarding and/or stereotypical ‘self-stimulation/
comfort’ behaviours, such as body rocking or head
banging (Beckett et al., 2002; Rutter et al., 1999,
2007b; Sweeny and Bascom 1995). However, the
severity and duration of difficulties varied greatly
across the studies, reflecting the different situations
and experiences of the children studied in various
countries. Observations carried out in European
residential care homes have since confirmed more
stereotypical behaviour in children who are under-
stimulated in institutions of poorer quality – after
six months the young children were observed to
have become socially withdrawn. As a consequence
of failed interactive initiatives, young children learn
not to be sociable, and visible efforts of a child
to interact with others become rare due to
unresponsive care-giving practices (Nelson et al.,
2007). This observation is particularly pertinent
to children under three years of age where a
six-month institutional placement represents a
significant proportion of their early life experience.
EU/WHO research in seven European countries
(Denmark, France, Greece, Poland, Hungary,
Romania, and Slovakia) has demonstrated that the
average length of stay for infants was 15 months,
with a mean age of 11 months on admission and
26 months on departure (Browne et al., 2004).
Poor care-giver to child ratios not only inhibit
social interaction, but also influence the way staff
respond to the needs of the children in residential
care, which can significantly influence the children’s
attention-seeking behaviour. A Serbian children’s
home (regarded as a national centre of excellence),
with two staff and 16 children per room,provides
two examples of how things go wrong.
Case 1
An 18-month-old boy quickly learnt that when he
hit other children he would receive attention from
the staff, albeit negative. As any attention is better
than no attention at all, his aggressive behaviour
was being unknowingly rewarded by the staff’s
behaviour, to the extent that his hitting became such
a problem that he was socially isolated from others
(staff and children) at 18 months of age.
Case 2
A two-year-old girl with suspected learning
difficulties nevertheless learnt that scratching
herself and pulling her hair quickly received
attention from the staff. Again, this attention
reinforced the behaviour, and the little girl scratched
herself and pulled her hair out all the more. This
pain was preferable to the feeling of neglect and lack
of attention for this child. Given that the staff had,
on average, seven other children to care for, they
managed the situation by tying the child up in her
own bed clothes to prevent her self-harming.
Although this was effective in limiting the child’s
self-harm, it constituted physical abuse and
neglect of the child in full visibility of the senior
management, who condoned this practice (see
plate 3).
Effects of institutional care on the
formation of emotional attachments
Johnson et al. (2006) reviewed 12 studies that
specifically considered the formation of emotional
attachments for children in institutions compared
with other children. Only one study found no
supporting evidence for greater attachment
difficulties for children growing up in residential
care. Nine studies report significantly more
indiscriminate friendliness, over-friendliness and/or
disinhibited behaviour for children in institutions,
suggesting ‘disorganised attachment disorder’ has
greater prevalence among these children compared
with children in families or children who were
admitted to institutional care after the age of two
years (Wolkind, 1974; Rutter et al., 2007a).
Smyke, Dumitrescu and Zeanah (2002) proposed
a ‘continuum of attachment disorder’, based on the
quality and the sensitivity of care-giving children
received, after they compared emotional attachment
problems in three groups of Romanian children:
12
THE RISK OF HARM TO YOUNG CHILDREN IN INSTITUTIONAL CARE
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1. Children raised by their biological parents,
where few showed attachment problems
2. Children placed in small family-like homes
with four consistent care-givers, where some
exhibited attachment problems
3. Children in a residential care institution,with
20 staff acting as care-givers at different times,
where the majority demonstrated significant
attachment difficulties.
In terms of emotional attachments, even apparently
‘good quality’ institutional care can have a detrimental
effect on children’s ability to form relationships
throughout life. The lack of a warm and continuous
relationship with a sensitive caregiver can produce
children who are desperate for adult attention
and affection. Superficially, the behaviour of these
children can appear ‘normal’ (or pseudo-secure),
but their lack of discrimination in seeking affection
is indicative of disorganised/disorientated or
disinhibited attachment disorder (Zeanah, 2000;
Rutter et al., 2007a). The presence of attachment
disorder is more common in children who have
spent more of their infancy in institutional care
(O’Connor et al., 1999, 2000a). However, this
pattern is not an inevitable consequence of early
deprivation and there are mediating factors that
can ameliorate the negative effects, such as the
child being a particular favourite of a residential
care worker and receiving sensitive care giving.
Nevertheless, this is rare and children in institutional
care clearly have limited opportunities to form
selective attachments, compared with children in
family-based care, especially where there are large
numbers of children, small numbers of staff and a
lack of consistent care through shift work and
staff rotation.
Effects of institutional care on
intellect and language
Johnson et al. (2006) found that 12 of the 13 studies
that considered intellectual development reported
that poor cognitive performance and lower
IQ scores were associated with children in
institutional care, illustrating the negative effects
of this environment in comparison to family-based
care on the development of the mind. However,
some of these studies also suggest that early
removal to family-based care can result in recovery
and catch up.
Since the completion of the Johnson et al. (2006)
systematic review, a randomised controlled trial,
comparing abandoned children reared in Romanian
institutions with abandoned children first placed
in institutions and then moved to foster care in
13
6 THE PSYCHOLOGICAL HARM CAUSED TO CHILDREN BY INSTITUTIONAL CARE
KEVIN BROWNE
Plate 3: A two-year-old girl
tied up in bed clothes to
prevent her scratching and
pulling hair in a Serbian
children’s home
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 13
Romanian communities, has been carried out
(Nelson et al., 2007). All institutionalised children
initially showed the effects of institutionalisation
(mean IQ 77 indicating “greatly diminished
intellectual performance [borderline mental
retardation])”, compared with children growing
up in their biological families who had never been
institutionalised (mean IQ 103); this supported
previous findings (Smyke et al., 2007).
However, the children randomly assigned to
foster care showed significant gains in intellect at
42 months (mean IQ 86), with those fostered
before the age of 18 months showing a higher
intellectual performance (mean IQ 94) compared
with those who were fostered after 24 months
(mean IQ 80).This supports the idea of a critical
period of development in early childhood.
At 54 months of age, no improvement in intellectual
performance was observed in those children
who remained in institutional care (mean IQ 73),
whereas those children in foster care maintained
their higher level of cognitive functioning (mean
IQ 81). As yet, fostered children had not caught
up with children growing up in biological families
(mean IQ 109).
The disruption to the development of mind
associated with under-stimulated children in
institutional care is most obviously expressed by
the delay in language acquisition. Goldfarb (1944,
1945) investigated speech and language organisation
in infancy, at six to eight years, and at adolescence.
He observed a clear deficiency in language
development in all three age groups compared with
same age groups of fostered children. Other studies
have since reported deficits in the language skills
and early reading performance of children raised
in institutions (Roy and Rutter, 2006). These deficits
include poorer vocabulary and less spontaneous
language (Tizard and Joseph,1970). Nevertheless,
Croft et al. (2007) found that children recover well
from these deficiencies in language development
once placed in a family, although socio-economic
status and background of the child’s new family have
an effect on this language development (Geoffroy
et al., 2007).
Effects of institutional care on the
developing brain
Further to the findings of the systematic review
by Johnson et al.(2006), recent advances in the
field of neurobiology have added greatly to our
understanding of why institutional care, particularly
in very young children, has a negative effect on
child development. The human infant is born with
some 100 billion neurons, and each neuron forms
about 15,000 synapses during the first two years
of life (Balbernie, 2001). The overabundance of
synapses and neurons in the infant’s brain allows
the adaptation of the brain in response to the
environment (neuroplasticity).Synapses that are
frequently used are reinforced, whereas redundant
synapses are ‘pruned’. Thus, early experience
determines which neural pathways will become
permanent and which will be eliminated (Balbernie,
2001). The human infant is genetically predisposed
to interact with others, but for this process to
result in optimal brain development the infant needs
to interact with a caregiver who will handle, talk and
respond to them in a sensitive and consistent way,
repeatedly introducing new stimuli appropriate
to their stage of development (Schaffer, 1990;
Trevarthen and Aitken, 2001; Perry and Pollard,
1998). Hence, a strong case has been proposed for
the maturation of the infant brain being embedded
in the relationship between the infant and the
primary caregiver (Perry and Pollard, 1998; Schore,
2001a), usually the mother.
While a socially rich family environment promotes
infant brain growth, an impoverished environment
through parental neglect or institutional care has
the opposite effect and will suppress brain
development (Glaser, 2000). Without a supportive
and predictable parent providing a one-to-one
relationship to ‘scaffold’ infant learning, there is
no process to guide synaptic connections and the
development of neural pathways. This leads to the
pruning of synapses in those areas of the brain that
are under-stimulated. All areas of the cortex can
be affected by early institutional care, but there is
significantly reduced metabolic activity in the frontal
and temporal lobes of the developing brain (Chugani
et al., 2001) and fewer connections between these
14
THE RISK OF HARM TO YOUNG CHILDREN IN INSTITUTIONAL CARE
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 14
regions (Eluvathingal et al., 2006). This results in
neural and behavioural deficits, especially for social
interactions and emotions (right temporal cortex),
and language (left temporal cortex) (Schore, 2001a,
2001b, 2003).
The child’s lack of opportunity to form a specific
attachment to a parent figure is a typical feature of
residential care. The culture of institutional practice
is primarily concerned with the physical care of
children and the establishment of routines, with less
emphasis on play, social interaction and individual
care (Giese and Dawes, 1999). Thus, the residential
care of young children under three years old
may have the potential to negatively affect brain
functioning at the most critical and unparalleled
period for brain development, and have long-lasting
effects on social and emotional behaviour
(Balbernie, 2001; Schore, 2001a, 2001b, 2003).
15
6 THE PSYCHOLOGICAL HARM CAUSED TO CHILDREN BY INSTITUTIONAL CARE
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 15
Overall, the evidence suggests that early institutional
care is typically detrimental to all developmental
domains of children. Features of institutional care
that contribute to developmental delays include
low staff to child ratios/interaction, low levels of
staff experience and autonomy, strict routines, poor
provision of books and play equipment, children’s
lack of personal possessions and individuality
(eg, birthday celebration), and children’s lack of
‘everyday’ experiences and trips outside the
institution (Mulheir and Browne, 2007; Smyke et al.,
2002). Much of the recent UK and North American
research investigating the long-term effects of these
residential care experiences has compared young
children adopted nationally (without institutional
care experiences) with similar-aged children
‘imported’ from Romania through international
adoption after experiencing early institutional care.
These studies have demonstrated that many young
children with institutional care backgrounds can
make a rapid recovery from their poor health, sleep
and eating problems (Beckett et al., 2002; Fisher
et al., 1997), and ‘catch up’ on their physical and
cognitive development when they are placed
in a caring family environment at an early age
(Rutter and The English and Romanian Adoptees
Study Team, 1998; Marcovitch et al., 1997). This
is despite the initial obvious problems shown in
their preschool years (Beckett et al., 2006; Vorria
et al., 2006). Indeed, a substantial proportion of
children who had experienced early deprivation
in institutional care were shown to have normal
intellectual functioning at age 11 (Kreppner et al.,
2007), as long as the new family setting had been
responsive to their needs.
However, the poor conditions and deprivation
encountered by children in Romanian ‘children’s
homes’ have a profound effect on development,
and complete recovery has only been observed, so
far, in children who were placed in family-based care
before the age of six months. Children who were
placed later made significant improvements in their
development after leaving institutional care, but
were still at an intellectual and social disadvantage
six years later (Beckett et al., 2007; O’Connor
et al., 2000b).
The effects of early institutional care on social
and emotional behaviour also seem to be as
persistent as delays in intellectual development.
The insecure/anxious attachments shown by
Romanian adoptees were qualitatively different
from national adoptees. Romanian adoptees from
institutional care backgrounds had disinhibited
emotional attachments, and there were few
differences in the children’s social responses to
their adopting parents or strangers (O’Connor
et al., 2003). This attachment disorder was still
evident at age 11 years (Rutter et al., 2007a).
Furthermore, one in ten Romanian adoptees
also exhibited quasi-autistic behaviours, and
three-quarters of this group had autistic features
to their behaviour at age 11 (Rutter et al., 2007b).
The child’s first emotional attachment to their
primary caregiver (usually a mother figure) is
considered to be a ‘blueprint or inner working model’
for all later emotional attachments, as the young
child learns how to love and to be loved, which
forms the basis of self worth and empathy for
others (Bowlby, 1969; Egeland, Bosquet and Chung,
16
7 Long-term effects of
institutional care
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 16
2002; Grossman and Waters, 2006). The absence
of this experience puts the child at a considerable
disadvantage, with a greater probability of low self
esteem, anxiety and depression, possibly leading
to social withdrawal, antisocial behaviour and
delinquency (Andersson, 2005; Browne and
Herbert, 1997; Fisher et al., 1997). However, studies
have not confirmed higher levels of aggression in
Romanian adoptees, despite their observed inability
to share intimacies and poor peer relations
(Gunnar et al., 2007; Tarullo, et al. 2007).
Therefore, research over the last decade has
confirmed earlier findings that institutional care
in early life predisposes children to intellectual,
behavioural and social problems later in life. Many
of the problems observed in samples of severely
deprived children, such as stereotyped behaviours
and eating problems, show rapid improvement once
the child is removed from institutional care and
placed in a supportive family environment. However,
placement with a family is not enough by itself
to overcome difficulties, as poor outcomes have
been observed for some children restored to their
natural family (Hodges and Tizard, 1989a). The age
of placement into a kinship, foster or adopting family
and the quality of the subsequent family care are
important factors in the outcome of children who
have experienced institutional care (Brand and
Brinich, 1999; Gunnar et al., 2007). While
subsequent placement in a supportive family can
result in the formation of close attachments within
that family, many institutionally raised children will
still have problems interacting with peers and adults
outside the family (Hodges and Tizard, 1989a;
Gunnar et al., 2007). Other studies, have shown
how, even after early placement with a family,
children who have spent their infancy in institutions
are more likely to manifest social and emotional
problems in adolescence compared with children
who have been adopted but who were not
institutionalised (Hodges and Tizard, 1989a, 1989b;
Gunnar, et al., 2007; Rutter et al; 2007ab; Tarullo et
al., 2007). Disinhibited attachments and emotional
vulnerability shown by these children place them at
risk of physical and sexual abuse, as their craving for
attention may result in a readiness to trust teenage
and adult strangers and make them obvious targets
for substance misuse and sexual exploitation
(Carter, 2005; Elliott, Browne and Kilcoyne, 1995).
Yang et al. (2007) found that childhood institutional
care was a risk factor for the development of adult
personality disorder. This may be related to the
potential for abuse and neglect in residential
care. This has been observed in institutions all
over Europe (see plate 3), but again the most
comprehensive evidence comes from Romania.
With the permission of the Government of
Romania, a national survey on “Child abuse in
residential care institutions” was carried out by
UNICEF in 2000. An anonymous questionnaire was
given to 3,164 children aged 7 to 18 years (7.8% of
the overall population in residential care). The study
(UNICEF, 2002) found that 37.5% of children in
residential care institutions report that they have
been victims of severe physical punishment or
“beatings” (approximately two-thirds were boys
and one-third girls). The perpetrators of this
physical abuse were residential care staff in the vast
majority of the reports (77%). Nearly one fifth
(19.6%) of the respondents (approximately half boys
and half girls) claimed to have been blackmailed for
sexual activities and a further 4.3% claimed that
they were “constrained” to have sex. The reported
perpetrators of these acts of sexual abuse were
older residents of the same sex (50%), older
residents of the opposite sex (12%) and institutional
staff (1.3%) offending inside the institution, as well
as relatives (3.9%), other young people (2.6%) and
adults (1.3%) offending outside the institution.
However, a significant minority of the respondents
would not identify their perpetrator (29%). When
the number of children resident in institutional care
in Romania and elsewhere is considered, these
findings could suggest a considerable number of
children suffering maltreatment while in residential
care. It is this group that is most at risk of offending
against others in later life (Haapasalo and Moilanen,
2004; Hamilton, Falshaw and Browne, 2002).
17
7 LONG-TERM EFFECTS OF INSTITUTIONAL CARE
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Regardless of the quality of institutional care,
‘normal’ child development requires the
opportunity for frequent and consistent one-to-one
interaction with a parent or foster parent. This is
especially important for the under-threes because
the early years are critical for brain development.
Therefore, it is recommended that no child under
three years should be placed in a residential care
institution without a parent/primary caregiver.
High-quality institutional care should only be used
as an emergency measure to protect or treat
children. Even then, it is recommended that the
length of stay should be as short as possible, and
non-violent parents should be encouraged to visit
or stay with the child. Hence, the vast majority of
childcare experts argue that all 24-hour residential
care institutions for children under five (including
children with disabilities) should be transformed
into other services, such as mother-baby units and
day care facilities (see plate 4),and the children in
them returned to family-based care (Mulheir and
Browne, 2007). However, the under-fives currently
living in institutional care should be moved to
family-based care only when kinship, foster or
adopting families have been carefully assessed,
recruited and trained, and associated community
services are in place. Deinstitutionalisation without
comprehensive assessments on the suitability
of kin, foster or adopting family carers, prior to
the move, will place the child at risk of entering
a placement that cannot meet their needs.
A European study (Browne et al.,2004) identified
ways in which young children under five in
institutional care were being de-institutionalised
and returned to family-based care in seven
European countries (see page 12). Nearly one in
five children (19%) returned to their parents or
relatives, 63% entered a new family (38% into
foster care and 25% adopted), and 18% were
inappropriately moved to another institution of
11 children or more (11%), or a specialist institution
for children with disabilities (7%). The study found
that countries with better community support
services were more likely to base their decisions
on the child’s needs, and to provide the most
appropriate placement and better preparation
for the move. Most countries assessed children’s
physical, health and developmental needs, together
with the physical environment and carer suitability.
However, only half of the disabled children had their
disability assessed as part of the decision-making
process and only 38% of children with siblings were
placed together with one of their siblings.
Countries in transition have been observed to
seek simple solutions to the long-term institutional
care of children and have considered international
adoption as serving the interests of these children.
However, recent research has shown that the
child’s best interests are rarely considered or their
rehabilitation with their biological family prioritised
over international adoption procedures. Hence,
18
8 The way forward: moving
young children out of
institutions and preventing
new admissions
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 18
international adoption is rarely the last resort that
it is proposed to be (UNCRC, 1989 Article 21). In
fact, research has shown that international adoption
is associated with an increase in the numbers of
children in residential care rather than a decrease
in both sending and receiving countries (Chou and
Browne, 2008).
It is important to emphasise that poor practices
in the deinstitutionalisation process may further
damage children – for example, if the transition is
too rapid with little preparation for the child, as
observed in Romania (Mulheir et al., 2004), or if
the needs of the children are not considered or
treated as a priority. Up to a third of children who
leave institutions show disability or developmental
delay and require follow-up home visits by health
and/or social service professionals or volunteers.
Investment in day care, community health and social
services is also essential as a prevention strategy
to stop children entering residential care in the
first place (see plate 4). Parents of children with
disabilities often welcome the idea to collect their
child from day care, after work each day. They
return their child the following morning for
physiotherapy and other interventions necessary
to meet the child’s needs, and are their full-time
carers at weekends. Twenty-four hour residential
care for children with disabilities cannot be justified
on the basis of required interventions, as these
interventions usually take place between 9am and
5pm. Day care provides the opportunity for these
interventions to take place, while allowing parents
to continue working and bringing in income for
their families. This breaks the cycle of parents giving
up their children to institutional care because
they cannot afford to be full-time carers (Browne,
Vettor and Dejanovic, 2006; Browne 2007).
Child abandonment can also be prevented through
community, health and social services, by engaging
mothers during pregnancy, identifying those children
who are at high risk for abandonment (out of
poverty, lack of social support or cultural stigma),
and offering intervention at birth, such as shelter
and accommodation (ie, mother and baby unit) or
foster care of the mother and baby (for young
mothers under 18 years). The identity of the
mother and the identity of the newborn child
is best established and legally registered prior to
them leaving the maternity unit (Browne, Poupard
and Pop, 2006).
19
8 THE WAY FORWARD: MOVING YOUNG CHILDREN OUT OF INSTITUTIONS AND PREVENTING NEW ADMISSIONS
KEVIN BROWNE
Plate 4: A pilot day care
scheme to prevent children
entering into institutional
care within Montenegro
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 19
Mulheir and Browne (2007) have formulated a best
practice model to deinstitutionalise and transform
children’s services so that the majority of children
and families in need receive community-based
interventions, with the child remaining in their
family home. Where this is impossible for a small
minority of children (eg, due to risk of harm by an
abusive and/or neglectful parent), alternative family
placements (kinship or foster care) are sought or
shelter provided for the child, together with their
non-abusive parent. Only a very small number of
exclusive 24-hour institutional settings are proposed
to remain for adolescent and teenage children
who are at risk to themselves or to others. The
residential care of all children under five years
(whether disabled or not) is prevented through the
implementation of a ten-step model (See Table 1).
20
THE RISK OF HARM TO YOUNG CHILDREN IN INSTITUTIONAL CARE
Table 1 : The ten-step model to deinstitutionalising and transforming children’s services
(Mulheir and Browne, 2007)
STEP 1 Raising awareness of the harmful effects of institutional care on young children
Raising awareness and their development.
STEP 2 The establishment of an effective multi-sector project management team (at national and
Managing the process regional levels) to pilot projects in one or more areas or institutions.
STEP 3 To audit the nature and extent of institutions for residential care of children nationally
Country level audit and to measure the number and characteristics of children who live in them.
STEP 4 Data collection and analysis within an institution of admissions, discharges and length of
Analysis at institution level stay of children,and an assessment of individual needs of the children in residence.
STEP 5 Design of alternative services based on individual needs of children and an assessment
Design of alternative of family based services currently available (eg, mother–baby unit for parents at risk of
services abandonment) and those new services that need to be developed (eg, day care and foster
care services for children with disabilities).
STEP 6 Management plan and practical mechanism for the transfer of resources – financial,human
Plan transfer of resources and capital. Finances should always follow the child.
STEP 7 Preparing and moving children and their possessions on the basis of their individual needs
Preparing and moving and treatment plans. Matching these needs and plans to the new placement and the capacity
children of the new carers. Transfer procedures need to respect the rights of the child and always be
in their best interest.
STEP 8 Preparing and moving staff by assessing staff skills, staff training needs and staff expectations
Preparing and moving staff in relation to the new demands of transformed services for children.
STEP 9 Carefully considering logistics to scale-up a successful pilot project involving one institution
Logistics or one region, to a national strategic plan.
STEP 10 Setting up a national database of children in public care to monitor and support the transfer
Monitoring and evaluation of children from institutional care to family based care. This involves health and social service
staff making home visits to families with deinstitutionalised or newly placed children to
assess, monitor and evaluate the treatment plans and optimal development of the children.
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 20
1. Institutional care of young children is harmful
to children’s development and negatively
affects neural functioning at the most critical
and unparalleled period of brain development,
causing physical, intellectual, behavioural, social
and emotional skill deficits and delays.
2. An estimated 43,842 (14.4 per 10,000) children
under three years are officially recorded as living
in institutional care for more than three months
without a parent, within 47 countries of the
WHO European region, but this is likely to be
an underestimate. Every effort should be made
to prioritise the deinstitutionalisation of these
children into family-based care as soon as
possible, following a best practice model that
considers and respects the needs and rights of
the child.
3. Institutional care is not restricted to countries
in transition, but is common throughout the
entire world. At least nine out of ten children
in residential care have one living parent, and
are mostly placed in institutions for social and
economic reasons in transition countries, and for
reasons of abuse and neglect in economically
developed countries.
4. Young children placed in a caring family
environment by the age of six months will
probably recover and catch up on their physical
and intellectual development. Those children
placed in a family after six months of age
are likely not to recover completely from
their intellectual deficits. All young children
with institutional care experiences may be
permanently affected in their neural functioning
related to social interactions and emotional
attachments, leading to a greater probability of
poor intimate relationships, antisocial behaviour
and mental health problems.
5. Children under three years old should not be
placed in residential care without a parent.When
institutions are used as an emergency measure,
the child should be moved into foster family
care as soon as possible. For all countries, child
protection legislation and interventions to deal
with abusive and neglectful parents should be
developed in parallel with community services
and alternative family-based care for children.
6. Education and training for policy-makers and
practitioners is urgently needed on the
appropriate care and placement of young
children facing adversity. Any form of alternative,
family-based care must provide high-quality care
that enhances the development and protection
of the child. Children returning to their biological
families or being adopted/placed in surrogate
families require their carers to be carefully
assessed, supported and monitored to prevent
the child continuing to experience poor
parenting, maltreatment and additional moves.
7. Countries in transition have used international
adoption as an alternative to long-term
institutional care of children, which may not be
in the best interest of the child. Services should
be offered to parents and surrogate parents
before international adoption is considered, but
this rarely happens with international adoption.
21
9 Implications for policy and
practice: a summary
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THE RISK OF HARM TO YOUNG CHILDREN IN INSTITUTIONAL CARE
The Risk of Harm 5th pages 18/11/09 4:53 pm Page 24
The Risk of Harm to Young Children
in Institutional Care
The Risk of Harm to
Young Children in
Institutional Care
Kevin Browne
Professor of Forensic Psychology and Child Health, Institute of
Work, Health & Organisations, University of Nottingham, UK
This paper provides an international summary of the extent and scale of
young children living without parents in residential care ‘children’s homes’,and
of the reasons they are there. It also gives an overview of the risk of harm to
young children’s care and development after being placed in institutional care.
The author concludes with core recommendations for policy and practice to
prevent harm to children and to promote the rights of children to grow up in
a family environment.
UK
savethechildren.org.uk
UK
