Institutionalisation of millions of children worldwide should be gradually phased out in favour of family-based care

The number of children entering institutions should be gradually reduced to zero, according to a new report published in The Lancet Child & Adolescent Health and The Lancet Psychiatry journals. The authors call for every effort to be made to minimise children's exposure to institutional care.

To help achieve this, they recommend strengthening and supporting families to reduce the need for separation. They also propose ways to ensure child safety, to protect children without parental care by providing high-quality family-based alternatives, and to strengthen systems for the care and protection of children.

Led by 22 of the world's leading experts on reforming care for children, the Commission includes a review and meta-analysis of the effects of institutionalisation and deinstitutionalisation on children's development, and makes 14 policy recommendations addressed to policymakers at all levels. The Commission was chaired by Professor Edmund Sonuga-Barke, Professor of Developmental Psychiatry, Psychology and Neuroscience at King's College London who leads the English and Romanian Adoptee (ERA) Project. The report is published in two parts, alongside an Executive Summary, and four Commentaries from leading experts in the field.

Writing in the Executive Summary of the report, Niall Boyce, Editor-in-Chief of The Lancet Psychiatry, Jane Godsland, editor-in-chief of The Lancet Child & Adolescent Health, and Commission Chair Professor Edmund Sonuga-Barke, King's College London, UK, say: "The global intent to provide optimal care for separated children has never been greater. Momentum to move children from institutions and into families is building, led by welcomed evidence and practical leadership from many sectors within child health, child protection, and social welfare. It is essential that governments, voluntary organisations, and health and social care professionals work together so that action is not taken precipitately, with potentially unintended adverse consequences, but is instead timely, sustainable, and child-centred."

In 2015, between five and six million children were estimated to be living in institutions (eg, orphanages, residential homes) in 137 countries worldwide [1]. According to the authors of the new report, while the number appears to have decreased in recent years in some countries, it appears to have increased in other countries over the last 30 years largely due to the HIV crisis.

The effects of institutionalisation and recovery

In the first part of the commission, published in The Lancet Psychiatry journal, the authors reviewed evidence of the effects of institutionalisation, addressing two main questions: whether growing up in an institution is detrimental to development compared with growing up in a family or family-like environment, and whether deinstitutionalisation leads to recovery. They reviewed 308 studies from the past 65 years, which were conducted across 68 countries and involved over 100,000 children.

The study found strong negative associations between institutional care and children's development, especially in relation to physical growth, cognition and attention. The authors also found significant, but smaller, negative associations between institutionalisation and socioemotional development and mental health.

The authors warn that these effects may be especially harmful to babies aged six to 24 months, and that longer stays in institutions are associated with larger developmental delays. These effects can be rapidly reversed in the years immediately after deinstitutionalisation (particularly in physical and brain growth), although substantial impairment can persist for the most seriously affected children over the longer term.

The authors note other risks of institutionalisation, including the effects of children not being able to participate in social, cultural, economic and religious life in their communities, the vulnerability of institutionalized children to violence and neglect, and the role some institutions play in child trafficking.

Phasing out the institutionalisation of children

Continuing the use of institutionalisation means that these health and social costs will continue to accrue. It also runs counter to the benefits of deinstitutionalisation of child welfare systems, as well as the UN-recognised right of children to be raised in a family environment. In the second part of the Commission, published in The Lancet Child & Adolescent Health journal, the authors identified evidence-based policy recommendations to promote family-based alternatives to institutionalisation:

A global push for reform

1. International agencies (such as UNICEF, the World Bank, International Monetary Fund, the EU, the Organization of American States, the Association of Southeast Asian Nations, government aid agencies, non-governmental organisations, philanthropists, and faith-based organisations) should launch a new global initiative to support the ability of families to care for children and the progressive elimination of
2. International agencies should improve data collection on children living outside of family care to ensure their welfare is properly monitored and that accurate figures for the number of children in institutions are known.
3. International organisations should help address the causes of institutionalisation and, at the same time, progressively redirect funding from institutions to family-based care. They should support the strengthening of government child protection systems, while also helping to prevent the trafficking of children into and from institutions.
4. Children's views should be included in initiatives to adapt care, especially those of over-looked groups such as children with disabilities. International agencies should highlight the case for reform by uncovering human and child rights abuses.
5. Faith-based organisations and leaders should work with other stakeholders and use their voices to change knowledge, attitudes, and practices in their communities to promote the protection of children in family-based care, and to strengthen families.
6. Donors and volunteers should redirect their funding and efforts from institutional care to community-based and family-based programmes. Recent years have seen a rise in private funding for orphanages and other residential institutions and a rise in the profitable 'voluntourism' industry. This might have inadvertently led to an increase in privately-managed institutions, and might encourage child trafficking to recruit children to institutions from families.

Building momentum for change at the national level

1. To guide care reform, each country should begin to measure the number of children in different kinds of alternative care, children in need of support, and children who are at risk of family separation.
2. Ministries and organisations responsible for child welfare should develop and implement a plan for care reform that includes family strengthening, family-based alternative care, and the progressive elimination of institutions.
3. Governments should include sufficient resources in their budgets to support reform.
4. National monitoring and evaluation should not only focus on the quality of care provided by different services, but also on assessing developmental outcomes for children.

Taking action locally

1. Local agencies, including local authorities and community-based organisations, should ensure that families with children who are at risk of separation are identified early, so they can be strengthened in their ability to provide care.
2. Local agencies should create teams of well-trained social workers and psychologists who can help children reintegrate from institutions into families.
3. As a first step towards the transition from institutional to family care, institutions should increase the availability of stable caregivers.
4. Institutions should involve staff in the process of transitioning to a family-based care system and give them the opportunity to be trained in the new skills required, creating a new workforce that supports deinstitutionalised children and their families.

"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," says co-author Beth Bradford, Changing the Way We Care, U.S..

Commission Chair Professor Edmund Sonuga-Barke, King's College London, UK, concludes: "Together, the two parts of this Commission constitute both a call to action to end the scourge of institutionalisation, and a carefully considered and practical plan of action for agencies working at all levels across the international community—global, regional, and local. Building on the very welcome growing momentum for a shift from institutional to family-based care, this Commission calls for a step change in the rate of deinstitutionalisation and the promotion and delivery of high-quality family-based care alternatives. In doing so, it makes practical recommendations for ways to strengthen and support birth families and reduce the need for separation while ensuring child safety, to protect children without parental care by providing high-quality family-based alternatives, and to strengthen systems for the care and protection of children."