Evidence and best practice clearly demonstrate that the better models of residential care offer small, “family-style” environments with qualified and consistent caregiving. Such care is a recognized option within the continuum of alternative care for children when family care is not available or possible. However, even high-quality residential care cannot replace families, and it is recommended that it be used primarily for temporary or rehabilitative purposes, with every effort made to transition children back into family care. Large institutions with high child-to-caregiver ratios and a lack of individualized or developmentally appropriate care have the most negative and often life-long consequences for children. These are not recognized as viable or recommended options for children’s care.
Residential care is used too often as a “first resort” response without consideration for or investment in family care options. Too frequently, children are placed in care, without proper planning, and ultimately lose connection with parents, extended family, and community, without any hope of reintegration. When orphanages provide limited opportunities for interaction between children and their families, they hinder reunification.
Orphanages whose operation supports long-term over temporary care inhibits reintegration. At a minimum, every child in an orphanage should have an individualized care plan that minimizes the time spent in an orphanage and facilitates eventual integration into a family. In too many instances this is not the case. In Malawi, for example, only 9% of more than 6,000 children in care had a case plan and only one-third of these children reported being visited by a relative. In Ethiopia, only one-third of all orphanages reported having case plans.
Lack of Individualized Care Has Long-Term Consequences
Evidence demonstrates that compared to a nurturing family environment, most orphanage settings, particularly for infants and young children, do not support a child’s proper development. In many instances, placement in orphanages may produce long-term and sometimes permanent effects on children’s brains and their physical, intellectual, and social-emotional development. Children raised in large-scale orphanages often have pervasive growth problems, including stunting (severe growth delay), and impairments in fine and gross motor skills and coordination.
The larger the orphanage, the less likely it is that children receive care from a consistent caregiver focusing on the child’s individualized needs. Typically, children will be group-fed on a schedule rather than on-demand, diapers will be changed on a schedule rather than as needed, and less attention will be paid to a child’s individual growth, social, and emotional development. Poor quality care and a lack of individualized stimulation can lead not only to health and development problems but to isolation and lack of identity (the core sense of self that is developed through close relationships)
Research from Romania has shown that the chronic neglect associated with larger-scale orphanages can weaken and disrupt the developing brain structure and functioning, impeding language acquisition and creating problems in mental health and chronic physical disease. Here neglect is defined as “warehouse-like conditions with many children, few caregivers, and no individualized adult-child relationships that are reliably responsive and where only basic survival needs may be met.” Evidence from Eastern Europe shows that more children leave large-scale orphanages with disabilities than enter them, suggesting that orphanage care can actually cause disability in children.
- While abuse and neglect are documented in many settings, including families, research has shown that children are more likely to be abused in orphanages. A global study on violence against children found that children living in orphanages were some of the most vulnerable to violence, abuse, and exploitation.
- Many orphanages utilize volunteers to augment caregiving functions or to fill a human resource gap. This constant flow of short-term volunteers exposes children to repeated departures and can increase the risk of potential abuse and exploitation. These practices, although often well-intentioned, can be detrimental to children’s social and emotional development and result in attachment issues in the long term.
Early and Long-Term Placement in Institutional Care Has the Most Severe Effects
Negative effects associated with orphanages are more severe the longer that a child remains in large-scale residential care, and are most critical in younger children, especially those under three years of age. The first three years of life are a “sensitive period” when a child requires close emotional contact. If this is not present, there is a high risk that development will be significantly impaired. Failing to place a child in family-based care before the age of six months can have devastating consequences. The Guidelines for the Alternative Care of Children currently suggest that, in general, children under three should be cared for in a family setting: In accordance with the predominant opinion of experts, alternative care for young children, especially those under three, should be provided in family-based settings.
Exceptions to this principle may be warranted in order to prevent separation of siblings and in cases where the placement is of an emergency nature or is for a predetermined and very limited duration, with planned family reintegration or other appropriate long-term care solutions as its outcome.
Risks of Institutional Care on Later Life
When children are in families, they do not “age out” of care. They remain connected to their parents, siblings, and community and have a social support network. This is rarely the case with children living in orphanages. When children reach a certain age, usually 18, they must leave the orphanage. These youth (care leavers) are frequently unprepared for independent life. This can result in unemployment, homelessness, conflict with the law, sexual exploitation, and poor parenting, requiring increased expenses associated with health, education, and legal services that may result in longer-term costs to society.
Ethiopian youth who had left care said that they felt that their orphanage would “be their home forever” and was not prepared for independent living outside it. They require support and training in practical life skills, such as how to manage money, find a job, or rent a house, skills typically learned when living in a family. Additionally, care leavers report feelings of depression, isolation, and hopelessness. One study of children leaving orphanage care found that there is a chronic lack of attention given to this population, leaving them with feelings of isolation that were compared to “living on an island without service to promote integration into society.”
Examples of deinstitutionalization efforts have shown that a minimum package of support is needed for a successful transition. This is true for children being reintegrated into families and for older care leavers who are transitioning to independent living situations. Support should include material or financial assistance to the family or youth, as well as a preparation period to ensure that the child and the family are ready for reunification or that the youth is helped to be self-supporting in the community.
Trained social workers should facilitate a process that addresses the psycho-social needs of children and youth before, during, and after the process, an essential component of reunification and leaving residential care that is often overlooked.