This document summarizes presentations given at an experts roundtable on ending the institutionalization of children. It discusses the impact of institutionalization on child development, noting that children raised in institutions have compromised development across cognitive, physical, emotional, social, and behavioral domains. Placement in family environments can help mitigate some of these negative effects, with earlier placement leading to better outcomes. It also discusses the economic case against institutionalization, citing both the direct costs of residential care and various indirect costs to society from the poor outcomes of children in institutions. Finally, it discusses practical implications and the need to invest in family support services, foster care, adoption and other alternatives to replace institutional care.

1. A Europe of Rights?
The role of MEPs in ending the institutionalisation of children
Experts Roundtable, European Parliament, 6 June 2012
Co- Chaired by Mairead McGuinness MEP and Arki Busson, Founding Chair of ARK

2. Table of Contents for Background PowerPoint Presentations
3-9 Fundamental rights and their application to children in institutions
• Dr. Maria Herczog Ph.D.
• Member of UN Committee on the Rights of the Child, President of EUROCHILD
10-25 Institutionalization in Early Childhood Impact on Child Development
• Charles H. Zeanah, M.D.
26-31 The Economic Case for Policy Change
• Dr Andy Bilson
• Professor of Social Work, University of Central Lancashire
32-45 Investing in Our Future: The Practical Implications of Childcare Reform
• Dr. Delia Pop
• Director of Programmes, Hope & Homes for Children

3. Fundamental rights and their
application to children in institutions
Dr. Maria Herczog Ph.D.
Member of UN Committee on the
Rights of the Child
President of EUROCHILD
European Parliament
6 June 2012

4. Child rights based approach
• UN CRC is a comprehensive, - universally agreed set of non-negotiable
standards and obligations, covering all children
• Core principles:
- non-discrimination;
- devotion to the best interests of the child;
- the right to life, survival and development;
- respect for the views of the child
• Children living in (alternative) residential care need special provisions
within this framework as they are a very vulnerable group often with
complex and challenging needs, diverse groups of children
• Articles of the UN CRC specifically relevant in this context: Art 7, 8, 9,
12,18,19, 20, 24, 25, 26, 28,31

5. UN Guidelines for the Alternative Care
of children
• UN CRC based guidelines adopted by GA in
2009
• Child rights in alternative (residential care) has
to be granted based on standards, quality care
and services, listening to children and taking
into consideration their views, family contact,
reunification if possible, preparation for
leaving, after-care if needed,

6. EU on child rights
• Children’s rights form part of the human rights that
the EU and EU countries must respect (Commission
communication)
• An EU Agenda for the rights of the child (2011):
reinforce the full commitment to promote, protect and
fulfill the rights of the child in all relevant EU policies
and actions
• EU Action to protect children from violence and when
they are vulnerable
• Fundamental Rights Agency: indicators to measure
well-being of children based on the implementation of
their rights

7. Council of Europe
• Rights of Children in residential institutions (2008)
outcomes on the implementation of Rec(2005)5
- Few countries established national standards
- Monitoring system in place in most countries in
principle, responsibilities and accountability a severe
problem, children are often not heard
- Support to families, preparation for leaving and after-
care crucial
Children without parental care: urgent need for
action(2010)- violation of rights – old and new risks

8. Child Rights Strategy of CoE
The programme will focus on four strategic
objectives:
1. promoting child-friendly services and
systems;
2. eliminating all forms of violence against
children;
3. guaranteeing the rights of children in
vulnerable situations; 4. promoting child
participation

9. Implementing child rights in
institutions
• Referral, assessment, placement decision,
involvement of all actors
• Placement, quality of care, rehabilitation,
family contact and support,
• Review, preparation for leaving, reunification,
after-care
• Documentation, evaluation, accountability,
research, data

10. Institutionalization in Early Childhood Impact
on Child Development
European Parliament
June 6, 2012
Charles H. Zeanah, M.D.

11. Brain Development in
Early Childhood
Video will play on next page

12. What builds healthy brains?
Nurturing and responsive relationships

13. Why institutional rearing
might be bad for the developing brain
Limited opportunities to form selective
attachments
lack of psychological investment by caregivers
rotating shifts
high child/caregiver ratio
Insensitive care
regimented daily schedule
non-individualized care
Isolation
limited response to distress
unchecked aggression

14. Institutional rearing
Children raised in institutions are
at dramatically increased risk for
a variety of social and behavioral
problems:
disturbances of attachment
indiscriminate behavior
emotional and behavior problems
inattention/hyperactivity
deficits in IQ and executive functions
syndrome that mimics autism
Developmental problems
believed to result from
deprivation inherent in
institutional care

15. Foster Care vs. Institutional Care
Author Foster Care Institution Country
Goldfarb (1943) 20 20 US
Goldfarb (1944) 40 40 US
Goldfarb (1945a) 15 15 US
Goldfarb (1945b) 70 70 US
Levy (1947) 129 101 US
Dennis & Najarian (1957) 41 49 Lebanon
Provence & Lipton(1962) 75 75 US
Roy et al. (2000) 19 19 UK
Harden et al. (2002) 30 35 US
Ahmed et al. (2005) 48 94 Iraqi Kurdistan
Nelson et al. (2009)* 68 68 Romania
*Randomized Controlled Trial

16. Bucharest Early Sf Maria
Intervention Project Sf Vasile
Sf Andrei Controceni
Sf Ecaterina Giulesti
Study Design
136 Institutionalized
Children (6-30 months)
Community Care As Usual Foster Care
n=72 n=68 n=68
Assessments at 30, 42, 54 months
Follow-ups at 8 and 12 years

17. Main effects of intervention
Cognitive development
Higher IQs
Enhanced expressive and
receptive language
Physical development
Greater height and weight
Reduced stereotypies
Emotional development
More positive emotion expressed
Less anxiety and depression
Social development
Enhanced competence
More secure attachments
Fewer attachment disorders
Fewer psychiatric symptoms and less
impairment
Larger, more mature and better
functioning brains

18. IQs of Children in Foster Care and Care
as Usual groups by age at placement
100
90
80
70
30 mo 42 mo 54 mo

19. Age at placement and
language at 42 months
1
0
IG FC>29m FC>24m FC>16m FC<15m
Reynell z score
-1
-2
Expressive
Receptive
-3
-4
Age of foster placement

20. Distribution of electrical activity
C
across the scalp by timing and group
FCG > 24
CAUG
3.80μV2
FCG < 24
NIG
2.44μV2

21. Worldwide investigations of family
placement following institutional rearing
Consensus statement (2012) from European and
American investigators studying children in
institutions:
“…research findings applied to clinical and
policy recommendations suggest ‘the earlier
the better’ rule for enhanced caregiving is a
reasonable conclusion.”

22. Aren’t the outcomes different in better
quality institutions?
In better quality institutions:
Growth and intellectual retardation are reduced (but
not eliminated)
Social and emotional development remain severely
compromised.
Greece (Vorria et al., 2003), U.K. (Tizard et al., 1975)

23. Institutional Care vs. Foster Care in
Washington, D.C.
Measures Results
Intelligence Family > Institution
Language/Communication Family > Institution
Skills of daily living Family > Institution
Socialization Family > Institution
Adaptive Behavior Family > Institution
More institution resembled a family, better outcome
Jones Harden (2002)

24. Attachment mediates intervention
effects of psychopathology
42 mo.
Security of
Attachment
FCG vs. CAUG ✕ 54 mo.
Total Psychiatric
Symptoms
Psychiatric Impairment

25. Conclusions about institutional
rearing and child development
Children raised in institutions have compromised
development across most but not all domains.
Placement in families leads to developmental gains
Sooner children are placed in families the better, but
complete recovery is rare after 6 months of age
Evidence for sensitive periods in some domains

26. The Economic Case for
Policy Change
Dr Andy Bilson
Professor of Social Work
University of Central Lancashire

27. The direct cost of institutional care
 Comparison of direct costs including social work support
e.g. annual costs in UK (2005-6):
Foster care £55,608
Kinship care £20,220
Own parents £8,064
Residential
£141,768
unit
Independence £30,096
e.g. In Montenegro “The average annual costs in 2003 for a
child without disabilities and aged under three years were 41,051
euros for residential care and 13,124 euros for foster care. For a
child with disabilities of the same age, the average annual costs
were 43,017 euros for residential care and 30,998 euros for
foster care.”

28. Increasing Cost & Expenditure: England
 House of Commons Children, Schools and Families Committee. Looked-after Children: Third Report of Session 2008–
09

29. Indirect costs
 Lower IQ  Unemployment
 75 studies covering 3,888 children  Evidence in
19 countries - IQ 20 points lower in Austria, England, Hungary, Ireland,
institutions Netherlands, Sweden
 Higher mortality & suicide  Homelessness
 Finland 3 fold risk of dying before  England 1 in 5 end up homeless
25, Russia 1 in 10 care leavers commit
suicide, Sweden 4 to 5 times more  Mental Illness
likely to be hospitalised for suicide  Sweden between 5 and 8 times
attempts more likely to be hospitalised in
 Poor education teens and 4 to 6 times in young
adulthood
 Evidence in
Austria, England, Hungary, Ireland,  Early pregnancy and own
Netherlands children in care
 Crime  Evidence in Sweden, England
 England 27% of the adult prison Drugs, prostitution, autism

population has spent time in care
…
“Outcomes are poor even when compared to other children with roughly
comparable backgrounds and problems.” [Source: UK Parliament 2009 ]

30. Alternatives
 Invest in support for families and communities
 e.g. in a number of countries (Bulgaria, Romania, Georgia, Ukraine, Russia)
projects have found that up to 80% of children at risk of entry to institutional care
require only short term support to prevent entry such as help to claim entitlements,
to get legal papers etc.
 e.g. in Moldova reasons for children entering institutions were assessed and in one
area the reason was the lack of transport to take children to school. A bus was
provided for local villages and reduced entry to institutions
 e.g. where children are left with grandparents or other relatives whilst parents work
in other countries provide support for these carers
 Develop alternative family based placements
 Develop supported kinship care, foster care, and national adoption.
 e.g. in Ukraine even children with disabilities can be fostered because the financial
incentives make this attractive

31. Issues and Challenges
Issues
 There is a clear economic and social case for reform
 Cost benefits are potentially very high
 Supporting continued use of institutions is untenable
and leads to social exclusion
Some Challenges
 Large scale grants need extensive support for the
implementing infrastructure and effective monitoring
 Brings a focus on wicked problems – e.g. social
inclusion of Roma minorities
 Requires multi-disciplinary and community work

32. Investing in Our Future
The Practical Implications of Childcare
Reform
Dr. Delia Pop
Director of Programmes

33. Who are the children in institutions?
Children in institutions
• 54.12% boys and 45.88% girls
• 20.98% have a range of medical conditions
• Come from urban and rural areas in equal
proportions Their families in most cases are disempowered and
struggle to cope with a range of risk factors:
Children at risk • Poverty, without adequate living conditions, lacking
• 52.67% boys and 47.33% girls housing, secure income/employment
• 39.69% have a range of medical and developmental • Single parent families (mostly mothers)
conditions • Poor parenting skills and family planning
• Come from rural and urban areas in equal • Lack support of extended families
proportions • Discrimination due to illness or ethnicity
Are placed in institutions from: In certain country contexts:
• 27.50% from maternity and hospitals • Substance abuse (alcohol/drugs)
• 20.41% from families • Family violence
• 19.39% temporary placed at the request of parents
• 18.09% are relinquished by parents
• 10.27% parents deprived of parental rights
• 2.46% parents missing, dead or imprisoned
• 1.88% are abandoned and found

34. Reliance on Institutionalisation
Family at Risk Inaction Family in Crisis Pcmn Isu n
a i ii
l e etnt t s
n o
•Unsustainable •Loss of •Children’s •Children are
source of income income, housing wellbeing at risk separated from
•Marginalisation •Discrimination •Capacity to their families
•Ill/health issues •Disability intervene and •Families remain
•Lack of access to •Lack of medical achieve positive vulnerable and at
basic services support, welfare changes in a risk
assistance, etc. short period of
•Poor family and
time is reduced
social •Family
relationships breakdown
•Poor parenting •Parents’ capacity
skills to provide
adequate care to
children at
critical level

35. Consequences
• Stunted • Attachment
growth disorders
• Ill/health
Physical Emotional
Development development
Cognitive Long term
Development institutionalisation
• Lower IQ • Up to 20% of
• Loss of children
potential average 14
years in care

36. Other Consequences
• Families remain vulnerable and the root
causes which led to children’s separation are
not resolved
• Economic costs – long term expenditure in
direct costs of institutionalisation with very
poor outcomes for children
• Social costs – marginalisation, isolation, lack
of opportunities, increased risk for the cycle
to be repeated

37. Separation
Institutiona
Complex
lisation
social &
“one
economic
solution fits
problems
all”
Up to20%
Use of scarce children spend
resources 14 years in
ineffectively residential
care

38. Are the consequences inevitable?
• Some are inevitable but many can be avoided
• Children can survive a great deal when appropriately cared
for
• We can avoid the consequences even when resources are
limited by carefully thinking how resources are allocated
• Children’s care is not cheap but resources can be allocated
efficiently
• Efficient interventions need to be identified and the
“production line needs to be replaced with baking the
cake”

39. De-institutionalisation – the
Engine for Childcare Reform
Closing and replacing residential care in large institutions with a range of
alternative services designed to match children’s needs and realise their
rights:
• Prevention services, supporting children and their carers at home
• Mother and Baby Units, Emergency Reception Centres
• Adoption
• Family based alternative care: kinship care, foster care, assisted living
and
• Short/medium and/or long-term residential care in small group
homes

40. De-institutionalisation
Reduced
number of
children
placed in care
Early
intervention Permanency
and family through
support adoption
Institution
closure
Family based
Efficient
care with
allocation of
better
resources
outcomes

41. ACTIVE Family Support
Inputs Outputs Outcomes Impact
• €441,560 • 255 • 250 • 224
families families families
and 499 and 489 and 441
children children children
supported remained with
together significant
outcomes

42. Return on Investment
€441,560
(€921/child)
441
children
with
improved €4,123,250
outcomes
saved in
institutional
care costs

43. De-institutionalisation
# of Monthly TOTAL TOTAL
%
Children Per Child Monthly Annual
National level 75% 45 €265 €11,925 €143,100
County level 25% 15 €292 €4,380 €52,560
€16,305 €195,660

44. De-institutionalisation

45. De-institutionalisation
Additional costs
Capital investment - purchase, renovation, furnishing and equipping of small
family home €120,000
Purchase of vehicle for mobile team €5,000
Transitional costs provided by local government
Covering income lost by the Institution due to decrease in number of children
€16,500 euros
Institution – supported on average of 75 children/year, at a total annual cost of
€195,660 (€2,609/child)
New system – supports on average 190 children/year, at a total annual cost of
€164,500 (€866/child). Most importantly it provides better outcomes for children
and serves more than twice as many beneficiaries