Overuse of institutional care for children in Europe

From:  BMJ, 25 February, 2006

Children in institutional care are at risk of attachment disorder and developmental delay, but Europe still relies heavily on this form of care for children in adversity

A minority of children live without their parents, either because their biological parents have died or abandoned them or because their parents do not have the means to care for them appropriately. Under the United Nations' Convention on the Rights of the Child all 52 countries in the World Health Organization's European region agreed to provide children in need with temporary or permanent substitute care. Substitute care varies from institutional care to forms of family based care, such as guardianship by relatives or friends, fostering, or adoption. The services that have been offered have changed over time and have been influenced by political, economic, and social changes.

Institutional care is commonplace

The recent special issue of the BMJ on Europe in transition identified the problems associated with the reform of healthcare systems from centralised state bureaucracies to health insurance and market led services. The editorial on mental health in post-communist countries highlighted the overuse of institutions for people with mental health problems and intellectual disability and the lack of a public health approach involving primary care and community services.1 A recent survey by the University of Birmingham and the WHO regional office for Europe reported overuse of institutional care for young children in need—with and without disabilities.2 However, institutional care of young children was not restricted to countries in transition and was common throughout the European region (table 1). Institutions were defined as residential health or social care facilities with 11 or more children, where children stay for more than three months without a primary care giver. Small institutions had the capacity for 11-24 children and large institutions 25 or more children, regardless of age.2

View this table:
[in this window]
[in a new window]
Table 1 Rates per 10 000 (rounded to the nearest whole number) of children under 3 in institutional care without a parent across the WHO European region in 2002



The recent WHO initiative on the prevention of child abuse3 expressed concern about the lack of community services to uphold the child's right to grow up in a family environment. National child protection policies and legal procedures to rescue children from abuse, neglect, and abandonment have sometimes developed piecemeal and not in parallel with primary care strategies for prevention of abuse and alternative family based care. Thus, in some countries, not enough surrogate family placements are available, so that children may be placed in institutions for long periods.

Is the evidence of harm being ignored?

More than 50 years of research provides convincing evidence that institutional care is detrimental to the cognitive, behavioural, emotional, and social development of young children.4-6 Improvements are seen in cognitive ability when children are removed from institutional care at an early age and placed in a family.6 7 However, institutional care has a lasting impact on behavioural and social development, even when a child is later placed in a supportive family.8-10

Children in institutional care rarely have the opportunity to form an attachment to a parent figure/carer,11 and they spend less time on play, social interaction, and individual care than children in a family.12 13 Thus, the institutional care of children less than 3 years old may have negative effects on neural functioning at this crucial period of brain development.14 15

The hidden extent of institutional care

Despite the importance of this issue, few data are available on the numbers and characteristics of young children in institutional care, although reports to the World Perspectives on Child Abuse between 1998 and 2004 show that 38 of the 52 countries in the European region have child protection services.16 A search of EMBASE, Medline, ISI Web of Science, SOSIG, and Science Direct up to 2003 yields little information. However, EU/WHO and Unicef have surveyed official statistics from governments relating to children under 3 raised in institutional care (table 1).2 17

These results have several limitations including incomplete data, the use of data from before 2002 in four countries, and the need to estimate population figures for children under 3 from figures for children under 5 in 15 countries. Pearson product moment correlations were performed on 11 countries that appeared in both surveys. The correlation between the two data sources (r = 0.633, P < 0.04), suggests that reasonable estimates can be made.

The data from both surveys were averaged and the overall numbers and rates per 10 000 children under 3 in institutional care were calculated for countries in the WHO European region where data were available (not FYR Macedonia, Israel, Luxembourg, Monaco, San Marino and Switzerland). It was estimated that 43 842 children under 3 resided in institutional care within 46 countries. With an estimated total population of children under 3 of 30 521 197 in these countries, the overall rate of institutionalisation was 14.4/10 000.

The five countries with the highest numbers of children under 3 in institutional care were Russia (10 411), Romania (4564), Ukraine (3210), France (2980), and Spain (2471). However, when considered as a proportion of the population under 3 in each country, the five countries with the highest rates of institutionalisation of young children were Bulgaria (69/10 000), Latvia (58/10 000), Belgium (56/10 000), Romania (52/10 000), and Serbia and Montenegro (50/10 000). Although institutional care for children in need is generally seen as most prevalent in eastern Europe, other European countries have a high number of young children in this form of care.

Countries that spend less on community health and social services are more likely to have higher proportions of institutionalised children.2 When parent support services (such as mental health and alcohol or drug addiction services) are absent young children are likely to remain in institutional care for long periods. This is particularly important for children under 3, for whom a six month institutional placement represents a large proportion of their early life experience.5 6 EU/WHO sponsored research in Denmark, France, Greece, Poland, Hungary, Romania, and Slovakia showed 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.18

Alternatives to institutional care

Countries in transition have used international adoption as an alternative to the long term institutional care of children.2 However, adoption is not always in the best interests of the child and article 21 of the UN convention states that it should be considered only as a last resort. Services should be offered to parents and surrogate parents before adoption is considered, but this rarely happens with international adoption.19 Furthermore, adoption agencies and the parents they represent often assume that many children in residential care are orphans,19 a myth propagated by the term "orphanages." In fact, only 4% of young children in residential care have no biological parent living.2 Ironically, some economically developed countries that "import" children have high numbers of children in their own residential care institutions (France and Spain, for example). This indicates that parental rights are better respected and defended in these countries than in others, sometimes at the expense of children's rights.

Therapeutic foster care and rehabilitation services have been introduced in Iceland, Norway, Slovenia, and the United Kingdom (table 1) to prevent institutional care of young children. This approach is urgently needed in those European countries with high proportions of young children in institutional care, such as Bulgaria, Latvia, Belgium, and Romania. Only a few countries use foster care therapeutically to provide treatment for the child or a role model for parents in difficulty as a part of family rehabilitation. Those countries in transition that are developing foster care (for example, Latvia and Romania) provide care only until the child is adopted, with little attempt at rehabilitating parents in difficulty. Parents may object to foster care when its purpose is unclear, often preferring the anonymity of institutional care and not understanding the potential damage to their developing child.

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. Surrogate families require careful selection, support, and monitoring to prevent the child continuing to experience poor parenting, maltreatment, and additional moves.

Conclusions and recommendations

Young children who are institutionalised experience developmental delay, although those who are placed in a caring family environment by the age of 6 months will probably recover and catch up on their physical and cognitive development.5-7 However, difficulties with social behaviour and attachments may persist,20 leading to a greater chance of antisocial behaviour and mental health problems.5

Children less than 3 years old, with or without disability, should not be placed in residential care without a parent. When institutions are used as an emergency measure, the child should be moved into a foster family as soon as possible. In all countries in Europe, 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.

Summary points

Institutional care for young children is not restricted to countries in transition but is common throughout the WHO European region of 52 countries

An estimated 43 842 (14.4/10 000) children under 3 are in institutional care within 46 countries of the WHO European region

Education and training for policy makers and practitioners is urgently needed on the appropriate care and placement of young children facing adversity

Children who move from institutional into family care before the age of 6 months will probably recover their physical and cognitive development

In life threatening circumstances emergency institutional care may be essential, but the child should be moved into foster care as soon as possible


Contributors and sources: The authors are experts in child care and protection and child development in general. They have worked on several child health projects in Russia, Romania, Slovakia, and the UK and carried out international surveys. The first draft was written by KB and RJ and the second draft by KB and CH-G with comments by MO. The survey was devised and carried out by all authors. KB is the guarantor. The views expressed are those of the authors and not necessarily those of the organisations they represent.

Funding: The authors' research was funded 80% by the EU Daphne programme and 20% by the WHO Regional Office for Europe.

Kevin Browne, centre director1, Catherine Hamilton-Giachritsis, senior lecturer1, Rebecca Johnson, research fellow1, Mikael Ostergren, regional adviser for child and adolescent health and development2

1 Centre for Forensic and Family Psychology, University of Birmingham, Birmingham B15 2TT, 2 WHO Regional Office for Europe, Copenhagen, Denmark

Correspondence to: K Browne K.D.Browne@bham.ac.uk


Overuse of SOMETHING

I had to laugh when I read the European interpretation of "institution", as it cites specific numbers:

Institutions were defined as residential health or social care facilities with 11 or more children, where children stay for more than three months without a primary care giver. Small institutions had the capacity for 11-24 children and large institutions 25 or more children, regardless of age.2 

In America, foster-care and adoption are home-based shelters... with some foster/adoptive parents taking in as many as 30 children.  In fact, this has become a trend that's being encouraged by websites like Foundation for Large Families . 

Today, while agencies are screaming, “We need more foster/adoptive families," they are over-looking their most valuable resource: the already large family.

Families who have more experience because of their prior adoptions are less likely to disrupt an adoption. They know where to turn for help when needed. They also know what is just a phase in a child’s life opposed to when a child needs therapeutic help.

What may seem overwhelming to a small family is not for a large family. We are professional parents who have been accredited by the children we are raising. Many of us have joyfully adopted a child who has repeatedly been turned down for adoption by other families. We take great pride in our children and our families. We know how to love a child who appears not to want to be loved. We can love a child even knowing we may never be loved back. http://www.google.com/search?sourceid=navclient&ie=UTF-8&rls=HPID,HPID:2006-20,HPID:en&q=large+adoptive+families

Meanwhile, not all foster/adoptive parents are all that NICE to another's parent's child, and the term "shelter" for a foster/adopted child is not much more than a cot on a back porch, shared with 8 or 10 other children.

However, my own knowledge of these realities PALES in comparison to folks posting their videos and cries for help on YouTube:  http://www.youtube.com/watch?v=q2cIwTT0U4I

I strongly encourage readers to take the time to review the collected videos within that link, because THEY are the voice of reality behind Child Placement, and how appearances and statistics are rarely what they seem.... even in the USA.

home industries

In our thread about the Judith Leekin case, I listed a couple of large abusive families in this comment. and made the comparison between large families and small scale institutions. One commonality in many of  these large families is factor "home schooling", though I don't want to hijack this thread with that topic. I guess I should sit down and write a post about that.

Forgotten Children of Texas

Pound Pup Legacy