Article summary with Institutionalisation and deinstitutionalisation of children 1: a systematic and integrative review of evidence regarding effects on development by Van IJzendoorn e.a. - 2020

What are institutions?

Institution refers to a publicly or privately managed and staffed collective living arrangement for children that is not family based. These include orphanages, children´s institutions, group homes, children´s villages, infant homes, and similar residential settings for children. The quality of these facilities varies greatly, depending among other factors on the extent of the training that staff receive, the rate of staff turnover, the quality of food, the child-to-caregiver ratio, and the standard of hygiene and health care.

Why are institutions often not capable of proving the necessary family environment for healthy child development?

Families are essential units which can usually provide children with the care, nurture, socialization, and protection required for healthy development. In institutions, care is often provided by teams of poorly paid staff, who often have little training and not enough time to provide a basic standard of care to the children. There is also a higher occurrence of peer and staff maltreatment of children. The social and cognitive aspects of institutional care are often of low quality and inconsistently delivered.

What is the Bucharest Early Intervention Project?

The Bucharest Early Intervention Project is the only study that used a randomized controlled design to study the benefits of deinstitutionalization. Some institutionalized children were randomly assigned to a high-quality foster care programme developed by the researchers. The other children were assigned to institutional care as usual. The study provides a test of the recuperative power of family life compared with continuing institutional care.

How did child care institutions arise?

The earliest reference to the institutionalization of children was in the year 787 in response to the problem of child abandonment. Over subsequent centuries, similar institutions were established in most major European cities and the colonies of Europe. Mortality in these settings was often high because of unsanitary conditions and poor nutrition. This instigated the transition from an institution-based to a family-based social welfare system. The number of children in institutions decreased and the number of children in foster care and adopted homes increased.

Which events caused a rise in the number of children in institutions?

Over time there have been several events that have caused the number of children in institutions to rise. For example, after the Russian Revolution in 1917 and World War 2 there were many displaced and abandoned children and not enough families that could offer fostering or adoption. Also, the HIV epidemic in the eighties in Africa caused a rise in the number of institutions. Finally, the one child policy in China, introduced in 1979, led to a substantial expansion of child institutionalization.

Why is it difficult to accurately estimate the number of institutionalized children?

Reliable data on the number of institutionalized children are difficult to collect because these numbers are not captured in household surveys or administrative data. Additionally, a high proportion of institutions in the world are not officially registered. The most recent estimate is around 6 million children, but this number is likely to have increased because of the HIV crisis, humanitarian emergencies, and the increased interest of private financial donors in funding the creation and operation of institutions.

Which factors may cause children to be institutionalized?

There are many different factors that can result in the entry of children into institutions, such as poverty, disability, parental mental health problems, or parental death. Cultural factors also play a role, for example in the case when children are born outside of marriage to young mothers in some societies. Child abuse within families may also play a role, though it is not often cited as the reason for institutionalization.

What is the difference between globally depriving institutions and psychosocially depriving institutions?

Globally depriving institutions refer to institutions where there are ten to thirty children per caregiver. Psychosocially depriving institutions refer to institutions where there are three to six children per caregiver. Most institutions are psychosocially depriving. These institutions often also have high staff turnover, employ staff with little training, have poor child-caregiver interactions, and often segregate children with health problems or disabilities. Especially in the early years of development, deficits in nutrition and hormonal growth suppression contribute to psychosocial growth problems in institutions.

How many children leave institutions and for what reasons?

Children can go to different caregiving environments after deinstitutionalization, including return to birth family or family networks, foster care, adoption, and ageing out into adult society. It is difficult to accurately estimate the number of deinstitutionalized children, because some countries reduce the number of institutions or reorganize them, no longer qualifying them as institutions. One major problem with promoting deinstitutionalization and closing institutions is that institutions often have a large number of local people who are dependent on the existence of the institution for employment. These people support the continuation of the facility.

What are the effects of institutionalization on child development?

Institutionalization is associated with substantial developmental delays and deviations, though there is a large variation in delays among the developmental domains.

• Institutionalization is strongly associated with delays in physical growth, cognitive development, brain development, and attention.
• The largest delays for physical growth and cognitive development emerge in infancy and early childhood.
• Attention problems tend to increase with age, possibly because executive attention develops later and deficits are difficult to detect in early childhood.
• Boys appear to have more delays than girls after institutionalization, but girls have more delays in physical health.
• Only a few children developed a secure attachment relationship with the closest caregiver in the institution. The proportion of dysregulated attachments is much higher in institutionalized children.

What are the effects of deinstitutionalization on child development?

Children show initial signs of rapid improvement following deinstitutionalization, though this accelerated development may represent a short-term catch-up at the expense of delayed development at a later developmental stage.

• Deinstitutionalization was followed by a catch-up in physical growth and cognitive development.
• There did not appear to be a recovery in children´s socioemotional problems after deinstitutionalization, but only few studies were analyzed.
• Children who have had extended deprivation can develop secure attachments with their new parents from adoption or foster placements, even after they have been exposed to severe deprivation.

Which contextual characteristics are associated with variations in the sequelae of institutional care?

A child´s response to institutionalization and deinstitutionalization will differ between individuals. Various contextual characteristics influence these responses:

• Pre-institutional context (the prenatal and postnatal risks that the child has been exposed to before entering institutionalization).
• The duration and timing of institutional care. Longer stays in the institution is related to larger developmental delays and deviations. Also, six to twenty-four months of age appears to be an especially sensitive period for the effects of institutional care.
• Quality of care.
• Post-institutional influences, including parent and family resources, quality of post-institutional care, and individual differences in parenting.

What is the difference between sensitive period and critical period?

Sensitive period refers to a time in development when individuals are especially sensitive to adverse exposures in a way that increased the risk of negative outcomes. These adverse exposures may be necessary to an adverse outcome to occur, but not everyone exposed is necessarily affected. Critical period refers to a time in development when exposure to specific experiences leads to inevitable and permanent negative outcomes. In these periods, the adverse exposures may not be necessary for adverse outcomes, but all children exposed to these adverse exposures will be affected.

Which child characteristics are associated with variations in the sequelae of institutional care?

Characteristics specific to the child may partially explain variations in the effects of institutionalization and deinstitutionalization. For example, genetic variations may affect the susceptibility of a child to both negative effects of institutionalized care and positive responses to placement in a supportive family. Also, the developmental status of a child at the time of their placement in a family after deinstitutionalization may influence the recovery trajectory of that child. The expectation is that the more ingrained the effects of deprivation are, the less amenable to recovery and the more persistent the problems may be.