June 2020
Focus on The Lancet Commission on Institutionalisation and Deinstitutionalisation of Children
'Policy and practice should be based on evidence, and this is why the  Lancet Commission’s  meta-analysis is so important. We have had few and fragmented studies to draw from when making the case for policy change. The meta-analysis now provides a coherent framework from a significant research base on the effects of institutionalization across different contexts. It can be used in policy dialogue and advocacy strategies in diverse situations to demonstrate the importance of safe and nurturing family-based care for children.'

- Philip Goldman, from 'The Lancet Commission: Policy and Practice Recommendations for Global, National and Local Actors'


This special issue of the BCN newsletter is published today to coincide with the launch of a series of papers by The Lancet Group Commission on Institutionalisation and Deinstitutionalisation , providing an evidence-based policy-focused review addressing the issue of institutional care across the globe. The Commission features a set of papers that present both a systematic review of the evidence on the negative effects of institutional care and the benefits of deinstitutionalisation, as well as a comprehensive framework of recommendations for policy and care reform.

The newsletter also highlights a critical new global enumeration study of the number of children in institutional care, also published in The Lancet , as well as other recent resources that add to the growing body of literature on the need for deinstitutionalisation and how it can be carried out globally.

The issue is introduced by brief commentaries from several of those involved in the Lancet Group Commission, including the Editors-in-Chief of The Lancet Psychiatry and The Lancet Child and Adolescent Health , Niall Boyce and Jane Godsland, who explain why the Lancet chose to focus on the topic of deinstitutionalisation, Chair of the Lancet Commission, Edmund J S Sonuga-Barke, who provides an overview of the history of the Commission and its significance, and two of the Commissions’ authors and members, Chris Cuthbert of Lumos and Philip Goldman of Maestral , who discuss the scale and harms of institutionalization of children and the policy and practice recommendations for global, national, and local actors, respectively.
From the Authors and Editors
Visible Harms; Invisible Children

by Chris Cuthbert, Global Director of Research, Lumos Foundation
The series of ground-breaking papers published by The Lancet Group and featured in this special edition of the Better Care Network newsletter is an essential read for all who care about the wellbeing of children in care. It is essential reading not only as the most authoritative and comprehensive picture to date of the very real and long-term harms of institutionalisation; but also because it comes in the wake of another important study exposing substantial gaps in official data on the children affected. 

Visible harms
In their meta-analysis of data on over 100,000 children from over 60 countries, Professor van Ijzendoorn and colleagues meticulously describe the adverse effects of institutionalisation across multiple domains of child development. The data show harms are most pronounced in the areas of physical growth, cognition and attention. Children who have lived in institutions are also at greater risk of attachment problems. Length of stay in institutions is associated with greater problems; and exposure between 6–24 months of age has been found to be especially damaging. Major longitudinal studies show that experience living in institutions can cast a long shadow on children’s development, increasing the risks of adversities right into adulthood.  
Yet despite the clear and compelling evidence on the harms experienced by children in institutions, this group of children remains largely hidden away from the world; invisible to many of the governments responsible for their welfare; and largely off the radar of the international development agenda. 

Invisible children
Another recent study, also published in Lancet Child & Adolescent Health , by Dr Chris Desmond of the Centre for Liberation Studies in South Africa and Dr Chunling Lu at Harvard University provides a systematic picture of what we do - and don’t – know about the scale of child institutionalisation around the world.
The research team conducted a comprehensive review of peer-reviewed publications, care transformation databases, surveys and grey literature, allowing them to compile a dataset of 344 data points from 136 countries. Even after this extensive search, the researchers still found substantial numbers of missing data points from countries with no – or no recently – available figures. The researchers developed multiple statistical models to account for missing data. They report a median estimate of 5.4million children world-wide living in institutions.  The true scale of the problem could be even higher due to poor or no data in many parts of the world.

Good data matters
Good data matters for ensuring adequate support to meet children’s needs. Governments can’t create policies and services for children they don’t know exist. When children are counted, they are more likely to be included in government programs, ensuring they grow up healthy, safe, and better-prepared to contribute to society. Good data matters for accountability. Until we shine a light on the issue, violations of children’s rights will persist, hidden away from official and public scrutiny. 
We should take these new studies as a wake-up call. They provide compelling evidence of the harms of institutionalisation - harms that are largely out-of-sight and out-of-mind.  There are many things that can be done right now to ensure children in institutions are no longer left behind. Here are three key actions that would be a good start:

  1. DEFINITIONS: Agree a standard global definition of institutional care so that consistent high-quality data can be routinely gathered and reported and disaggregated in all countries
  2. CAPACITY BUILDING: Invest in capacity building to ensure national statistical agencies have the capability to regularly count children in institutions in all countries (especially low and middle income countries and countries where institutions are frequently unregistered). 
  3. MONITORING: Vigorously promote adoption of the Tracking Progress Tool on the UN Guidelines for the Alternative Care of Children

Let us act now to make sure these children are counted. To make sure they count.
For every child, a home

by Niall Boyce and Jane Godsland, Editors-in-Chief of The Lancet Psychiatry and The Lancet Child and Adolescent Health
What is not being talked about in the global conversation about the health and wellbeing of children and young people? As the Editors-in-Chief of The Lancet Psychiatry and The Lancet Child and Adolescent Health , we ask this question a lot. We became aware of the relatively neglected issue of institutionalised children through occasional research and newspaper reports. And when we looked into the problem further, we came to realise how large and complex it is. Despite increasing concern for the welfare of children in institutions, we realised that there was a gap in the literature that, if addressed, had the potential to accelerate progress towards deinstitutionalisation and family care. The scale of the issue needed to be thoroughly investigated and summarised, and a roadmap written to guide policymakers worldwide on how to move children into family-based care.
It had to be concise but comprehensive, and detailed but accessible. Too much even for one Lancet journal to manage! We decided to team up, pooling our resources to facilitate this landmark piece of work.

Working with Edmund Sonuga-Barke, Philip Goldman, and the rest of the team has been a real pleasure. They have brought facts, figures, thoughtfulness, and an incredible degree of passion and commitment to this Commission . Although publication marks the end of a three-year project, it is just the beginning of a journey towards the sustainable deinstitutionalisation of children. As we start to rebuild the post-COVID-19 world, we have the opportunity to ensure that every child, wherever they are, grows up with the warmth and support of a family environment. And as the Commission shows, everyone can do something towards this goal. Please join us.
Shining a light on the injustice of institutionalisation and the damage it causes to children in order to promote care reform across the globe

by Edmund J S Sonuga-Barke, FBA, FMedSci, King’s College London, UK
Chair of the Lancet Commission on Institutionalisation and Deinstitutionalisation of Children
Across the world between 5-6 million children and young people live in institutional facilities – many in extremely impoverished conditions lacking many resources, experiences and opportunities that we assume are necessary for healthy human development. Such a situation is recognised as a major threat to normal child development and mental health, a drain on human capital within communities and wider societies and an infringement of the rights of the child to grow up in a family. Great progress has been made in some countries at addressing this scandal by reducing the reliance of institutional options and replacing them with safe family-based alternatives. However, the problem is still very serious in other countries.

Motivated to shine a light on this often overlooked problem, and the need to highlight the global scale and significance of its impacts on the mental health and wellbeing of children across the world, the editors of The Lancet Psychiatry and The Lancet Child & Adolescent Health , Niall Boyce and Jane Godsland, approached me to set up a Lancet Group Commission . They knew me from my work demonstrating the long-term adverse effects of institutional care in the English and Romanian Adoptees (ERA) study published in The Lancet in 2017. My initial brief back in the autumn of 2017 was to put together a team of world authorities on child-care research, practice and policy to write an evidence-based policy-focused review addressing the issue of institutional care across the globe. Of course, I agreed - excited by the opportunity that this would have to reshape the international discussion about institutional care and to promote real change in real people’s lives across the globe. There was also a certain sense of trepidation – given the daunting scale of the task at hand. The launch today of the two linked papers of the Lancet Commission represents the fruits of the labour of a wonderfully talented and hard-working set of colleagues (too many to list individually here) – who, through their efforts, have clearly demonstrated their commitment to the world’s most vulnerable children and their families.

At the core of our work was the conviction that policy and practice reform in this, as any other area, must be based on a rigorous evaluation of evidence: The first step was therefore to carefully
examine the claims of the negative effects of institutional care and the benefits of deinstitutionalisation. We saw very quickly how fragmented and scattered that evidence was. It came in very different forms of study using myriad different designs. So, we quickly realised that a full systematic review was going to be required. This meant some seriously heavy lifting. In Marinus Van Ijzendoorn and Marian Bakermans-Kranenburg and their team, we were blessed with the world’s leading experts in this area of work.

As the review started to take shape our policy experts got to work. Again, the enormity of the challenge became apparent very quickly. In particular, we needed to create a comprehensive framework if we were going have an impact on the lives of institutionalised children - we needed to motivate change at every level of the political and social care system - addressing powerful global organisations, national governments as well as local policy-makers and practitioners. This recognition shaped our work and eventually structured our commission’s recommendations. What was very striking to me as Chair of the Commission and non-expert on policy reform, was how readily consensus about the key recommendations was achieved.

The hard work is done, now the hard work begins! It’s vital that this Commission is not simply lauded and then forgotten, or its impact only felt in academic papers or within high level policy documents – its recommendations need to be enacted at the grass roots in order to transform the lives of children, their families and communities. The long road of dissemination-to-implementation starts now.
The Lancet Commission: Policy and Practice Recommendations for Global, National and Local Actors

by Philip S. Goldman, President, Maestral International
Member of the Lancet Commission on Institutionalisation and Deinstitutionalisation of Children
Through 2019, the Lancet Group Commission was busy putting its final touches on a meta-analysis of over 300 studies on the effects of institutions and deinstitutionalization in children. In parallel, a global dialogue was occurring on a draft U.N. General Assembly Resolution on the Promotion and Protection of the Rights of Children focused on children without parental care, and ultimately more than 250 non-governmental organizations and UNICEF endorsed ‘Key Recommendations’ for that Resolution (which was adopted by the UNGA in December).

The Key Recommendations were based on decades of evidence and experience from every region of the world and represented a consensus framework by those organizations that endorsed them. They therefore became the natural foundation for our article on policy and practice recommendations for global, national and local actors for the Lancet Commission . In that sense, the work of the 22 authors of the Commission was richly informed by the experience of the entire care reform sector, which we did our best to capture in this article.

Policy and practice should be based on evidence, and this is why the Lancet Commission’s meta-analysis is so important. We have had few and fragmented studies to draw from when making the case for policy change. The meta-analysis now provides a coherent framework from a significant research base on the effects of institutionalization across different contexts. It can be used in policy dialogue and advocacy strategies in diverse situations to demonstrate the importance of safe and nurturing family-based care for children.

The policy and practice recommendations in this article are presented at three levels: global, national and local. Each section presents the context, the policy aims, strategies for change, implementation of change, monitoring and evaluation of change, and key recommendations. The ultimate focus is to change the lives of children on the ground, and it is important that efforts be coordinated across all three levels to achieve that objective.

The article makes the case for significantly strengthening global coordination by multilaterals, bilaterals,
NGOs, donors, and faith-based and volunteer organizations to promote “a substantial, well planned, and safe progressive elimination of institutions in children’s care systems.” Child protection and welfare systems should instead be based on a continuum of programs and services that strengthens the ability of families to care for children, that prevents separation, and that ensures effective, supported and monitored placement in a family after a child has been separated. Issues related to the importance of faith-based engagement and addressing voluntourism are addressed.

Stronger families also contribute to stronger communities. They are supportive of better health, education and social outcomes, and thus promote intergenerational poverty reduction and social cohesion. This is squarely in line with the objectives of many global organizations.

The national section focuses on the importance of developing strong child welfare and protection systems that support family-based care for children and family strengthening, while progressively eliminating the role of institutions in the system. This means building constituencies for change for a shared national vision around that objective. Six elements of the system are addressed: (i) policies, legislation and regulations; (ii) community, civil society and social norms; (iii) continuum of care from prevention to response; (iv) structures, functions and capacities; (v) fiscal management and resource allocation; and (vi) evidence and data for decision-making. A model is also presented for scaling up national care reform, and the importance of adequate resourcing and capacity building are stressed.

The local section is in many ways the most important, for that is where children and families are reached. Children end up in institutions due to a variety of drivers which need to be understood before an effective strategy and approach can be formulated and implemented. Families and communities need the resources to address those drivers and to build strength, cohesion and resilience. The ultimate goal is to bring the number of children in institutions to zero, while ensuring that children and families are better off. The section presents examples of evidence-based interventions that have been shown to strengthen families in many different contexts, as well as ways of successfully managing the transition or closure of children’s institutions.

We hope that the Commission’s articles make a difference in your work. We also hope that we can deepen our collaboration at all levels and use these findings to help make the world a better place for children –especially the most vulnerable

This Executive Summary provides an overview of the Lancet Group Commission , which advocates global reform of the care of separated children through the progressive replacement of institutional provision with safe and nurturing family-based care. It provides essential information on both the global scale of institutionalisation and its physical, social, and mental health consequences. It presents a pragmatic roadmap for carefully managed change.  

This paper from the Lancet Group Commission reviews the literature on child institutionalisation and deinstitutionalisation from a global perspective. This review included a survey of historical and cultural trends and estimates of current numbers of children in institutional care, a systematic review and meta­-analysis of developmental sequelae, and a largely qualitative review of factors found to predict individual variations in such outcomes. The study found compelling evidence that institutional care is associated with negative developmental outcomes. Policy recom­mendations to support the implementation of these care reform goals at the global, regional, and local levels are set out in a linked policy paper published in The Lancet Child & Adolescent Health

In this part of the Commission , international experts in reforming care for children identified evidence-based policy recommendations to promote family-based alternatives to institutionalisation. 14 key recommendations are addressed to multinational agencies, national governments, local authorities, and institutions. These recommendations prioritise the role of families in the lives of children to prevent child separation and to strengthen families, to protect children without parental care by providing high-quality family-based alternatives, and to strengthen systems for the protection and care of separated children. 

In this commentary piece for The Lancet Psychiatry, Joan Kaufman Center for Child and Family Traumatic Stress highlights some key findings and recommendations from the  Lancet Group Commission . The author builds on the Commission's "call for the progressive elimination of all forms of institutional care for children," by suggesting a timeframe of "10 years should be sufficient to achieve the goal of eliminating institutional care for children worldwide."

In this commentary piece, Anne Longfield, Children’s Commissioner for England, explores the use of children's care homes in England and the need for improved supports to prevent placement in children's home and to provide for the needs of children and young people who are placed in these homes. Longfield applauds "the ambition of the [ Lancet Group Commission ] by Philip Goldman and colleagues to drive a reduction of the number of children living in institutions around the world," noting that "in England, the number of children living ininstitutions has substantially decreased over the past50 years, but there is still much further to go."

In this commentary piece, Aisha K Yousafzai notes that "the evidence presented [in the  Lancet Group Commission ] and their call to action to ensure abandoned children can thrive in family-based care environments rather than in institutions matters now more than ever as the global community addresses unprecedented challenges to ensure a generation of children are not left behind with respect to their survival, health, development, learning, and safety."

Also in the Lancet
The aim of this study by Chris Desmond, Kathryn Watt, Anamika Saha, Jialin Huang, and Chunling Lu was to estimate global-level, regional-level, and country-level numbers and percentages of children living in institutional care. The study includes a systematic review generating a dataset of 344 data points across 136 countries, including official and survey data, as well as peer reviewed and grey literature. The study found that global estimates from 2015 range between 3.18 million to 9.42 million children, with a median estimate of 5.37 million. The authors also noted that there is considerable uncertainty regarding the number of children living in institutions and that, to improve estimates of the size of this population, we need to standardise the definition of institutional care and improve data collection, particularly in countries with large child populations.

This comment piece by Charles H Zeanah and Kathryn L Humphreys accompanies the study on the number of children in institutional care around the globe. The comment provides a general overview of the harmful effects of institutionalisation, applauds the efforts of the researchers to "obtain an account of the prevalence of institutionalised children," and highlights the challenges ahead.

Additional Resources on Deinstitutionalisation

The purpose of this checklist from the European Expert Group on the transition from institutional to community-based care, with Hope and Homes for Children, is to ensure EU funds in the 2021-2027 programming period contribute to independent living and inclusion in the community, including by supporting desk officers to check the consistency of the measures to transition from institutional to family-based and community-based services for children and the prevention of institutionalisation and separation of children, including with disabilities, from their families.

The aim of this report from the European Expert Group on Transition from Institutional to Community-based Care was to collate information about policies and plans, changes over time, strengths and areas of concerns relevant to advancement in deinstitutionalisation in 27 EU countries and for six target groups: adults with disabilities, adults with mental health problems, children (including children with disabilities), unaccompanied or separated migrant children, homeless persons and older adults.

This article from Global Social Policy describes a policy adoption case study about deinstitutionalization of childcare in Georgia since independence. It highlights the evolving and non-homogeneous nature of transnational agency in the area of childcare deinstitutionalization, and offers insights into the complex relationship between transnational agency and national policymaking.

This article from Global Social Policy compares how the global policy of deinstitutionalisation (DI) of child welfare travelled, was translated and institutionalised in two post-Soviet countries – Russia and Kazakhstan .

This special issue of the Institutionalised Children Explorations and Beyond journal, guest-edited by Delia Pop, Tessa Boudrie and Mark Riley of Hope and Homes for Children, focuses on deinstitutionalization in South Asia .

Based on the information gathered throughout the course of the Opening Doors for Europe ’s Children campaign, this final report first reflects on: (1) the rationale for the campaign and how it operated; (2) the progress towards child protection system reform across campaign countries as well as the developments at the EU level; and (3) the lessons learnt from the campaign and some final recommendations to the European Union.

This paper from the Proceeding International Conference on Social Sciences describes the challenges in changing policy and practice in the provision of formal alternative care in Indonesia .

This paper from the Journal of Social Work in Developing Societies is based on field work experience, review of relevant literature and studies on alternative child care system in Nigeria . Findings from the review suggest a range of family-based alternative child care that social workers in Nigeria and other developing societies may well consider in practice and programme intervention. Rethinking institutional care using suitable alternatives, say the authors, may help prevent unnecessary separation and reduce the number of vulnerable children going into institutional care.

This report from Lumos sets out the evidence about the harm that institutions can cause children and presents the case for prioritising family and community-based alternatives to institutional care in Europe . It outlines EU expenditure on transforming systems of care, highlighting positive examples, as well as instances where a stronger focus on the transition from institutional to family and community-based care could have resulted in better outcomes for the target group. It also explores the barriers that have been hindering progress towards greater care transformation globally and makes recommendations for change. 

This doctoral research explores how the European Union membership has changed the post-communist heritage of institutional care in Bulgaria , focusing on the transformation of orphanages through the deinstitutionalization reform.

This study analyzes longitudinal statistics from 18 years of Hope and Homes for Children programs in Romania to demonstrate the cost savings and ability to support a higher number of children at risk if the state were to invest money into programs that allow children to remain in a family environment, rather than be placed in institutional care.

This paper from the Scottish Journal of Residential Child Care outlines the Child Rescue Centre's process of transitioning from residential care to family-based care in Sierra Leone .

Latest Resources on Institutional Care
The aim of the present study from the Children and Youth Services Review was to provide understanding into the past and present experiences of individuals who had resided in a child-care institution in Greece during their childhood and/or adolescence and to contribute to the study of the long-term impact of institutional care on adult life.

The aim of this study from the journal of Child Indicators Research is to compare the subjective well-being (SWB) of children hosted in institutions and in foster families with the well-being of children living with their families in Portugal . Results indicate that children in residential care have a lower SWB in all variables compared to foster care and general populations groups.

This article from Dialogues in Clinical Neuroscience & Mental Health argues that Greece 's use of closed-type institutions for child protection is a violation of children’s rights and a practice of secondary victimization, stigmatization and exclusion of children living in these institutions.

Using 20-year follow-up data from a unique natural experiment – the large scale adoption of children exposed to extreme deprivation in Romanian institutions in the 1980s – the authors of this paper from Psychological Medicine examined, for the first time, whether such deficits are still present in adulthood and whether they are associated with deprivation-related symptoms of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD).

This study from the Archives of the International Association for Child and Adolescent Psychiatry and Allied Professions examines the mental health symptoms of children in institutional care in Ankara, Turkey and possible factors that may cause these symptoms.

This paper from Just for Kids Law (JfKL) explores an issue that the organization has come across through their work: cases of under 18s (mainly 16- and 17-year olds) in the UK who are facing homelessness and do not receive the support they are entitled to from local authority children’s services. 

The current literature review from Dialogues in Clinical Neuroscience & Mental Health provides a conceptual and empirical framework for understanding child institutional maltreatment.

This brief from the Australian Childhood Foundation Centre for Excellence in Therapeutic Care & Southern Cross University addresses issues in young people’s participation in decision-making in residential care in Australia .

In this webinar organized by the European Network on Independent Living, Validity Foundation, and Disability Rights International, a panel including persons with disabilities and experts in disaster management, human rights and service provision discuss the need for “emergency deinstitutionalisation” of persons with disabilities and how this could be achieved.

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