Children’s Rights, Deinstitutionalisation and the Development of Foster Care Services across the World

Abstract

In many countries, foster care is an established system for looking after children who cannot live with their birth families. It is accepted as a preferable form of provision when compared to institutional arrangements. Deinstitutionalisation is founded upon theories of child development, most particularly attachment theory, which suggest that children are more likely to flourish in family settings as opposed to institutions. The implementation of a foster care system accords with the United Nations Convention on the Rights of the Child and the associated recommendations. But is it feasible to apply these rights and recommendations across the world? How transferable is the system of foster care? By making use of the literature, this paper draws attention to some of the challenges and complexities that accompany attempts at implementing this child care strategy in some of the world’s regions.

Keywords:

• attachment theory
• children’s rights
• deinstitutionalisation
• foster care

Introduction

The United Nations Children's Fund (UNICEF), a United Nations agency with responsibility for providing humanitarian and developmental aid to children around the world, has summarised the United Nations Convention on the Rights of the Child, with Article 20 (children unable to live with their family) stating the following:

If a child cannot be looked after by their immediate family, the government must give them special protection and assistance. This includes making sure the child is provided with alternative care that is continuous and respects the child’s culture, language and religion (UNICEF undated).

The United Nations General Assembly (UNGA), which is the main policy making component of the United Nations, has recommended family-based care as the alternative to care in institutions. Institutions may be defined as follows: ‘any large congregate care facility in which round-the-clock professional supervision supplants the role of family-like caregivers’ (Berens and Nelson 2015: 389). Whilst deinstitutionalisation may mean closing institutions and placing children with alternative families, it may also mean providing services that maintain the unity of birth families in the first instance (Rogers 2014).

Guidelines concerning the provision of alternative family-based care have been produced by the UNGA (see UNGA 2009 cited in Davidson et al. 2017). These Guidelines are ‘non-binding Instruments’: they ‘… shape how policy-makers, decision-makers and professionals’ approach both the prevention and provision of alternative care for children' (Cantwell et al. 2012: 14). However, understanding the ways in which these guidelines or instruments might be implemented in practice, is best understood by means of subsequent publications (see for example Cantwell et al. 2012). These intentions to protect the rights of the child are to be applauded, but how has the policy of deinstitutionalisation and the provision of alternative care been introduced across the world? This question underpins this narrative review of the associated literature. The review intends to provide a broad perspective that contextualises practice in the light of the policy, theory and research. It is important to note that the paper summarises the literature identified by electronic searches carried out during 2019 and 2020, and is not a systematic account of all practice across the world: that is, the available literature addressed some geographical regions, but not others. Put another way, the paper addresses the policy and practices in some countries only. Following an articulation of the theoretical and empirical evidence that supports the importance of alternative family-based care, the paper describes ways in which the policy is being implemented and the challenges encountered.

Theoretical and Empirical Evidence for Deinstitutionalisation and the Provision of Alternative Family-Based Care

Attachment theory frequently underpins the recommendation for policies that promote family-based provision (see for example, Al. et al. 2012; Biryukova and Sinyavskaya 2017; and Berens and Nelson 2015).

Attachment is the strong, affectionate tie we have with special people in our lives that leads us to experience pleasure and joy when we interact with them and to be comforted by their nearness in times of stress. By the second half of the first year, infants have become attached to familiar people who have responded to their needs (Berk 2013: 428).

The origins of this theory are attributed to John Bowlby who was a psychoanalyst and a member of the British group of object relations theorists. These theorists were developing an explanation of the way in which the relationship between the primary carer and the child created the structure and processes of the child’s mind. Bowlby, however, shifted away from focusing on psychoanalytic theory only, to linking it with knowledge gained from studying animals, and the practicality of care received by the human infant.

According to Bowlby, the infant’s relationship with the parent begins as a set of innate signals that call the adult to the baby’s side. Over time, a true affectionate bond forms, supported by new emotional and cognitive capacities as well as a history of warm, sensitive care (Berk 2013: 429).

From his research, Bowlby concluded that the role of the primary carer is to provide the infant with a sense of safety: a secure base from which to thrive and flourish. The secure base is formed by consistent, warm, reliable care and by means of the emotional sensitivity of the parent/carer who is (ideally) attuned to the child’s needs. Infants and children adapt psychologically and behaviourally to the provision or absence of the secure base. These adaptations have been categorised by Mary Ainsworth in terms of the quality of attachment – either secure or versions of insecure (see Ainsworth et al. 1978). Over the years, attachment theory has been refined, and has evolved partly as a result of empirical experiments. For example, Crittenden has refined the categorisations and articulated a lifespan developmental model of attachment (Crittenden 2000 and 2000a). More recently, Fonagey and Campbell (2016) have developed further still the ideas associated with the concept of ‘attunement’ and articulated the process of ‘mentalisation’ in relation to the way in which the carer contributes relationally to the construction of the infant/child’s mind. Neuroscientists such as Porges (2011) explain the way in which the attuned parent/carer, by means of relational interaction, constructs the infant’s/child’s brain. For a more fulsome discussion of the evolution of attachment theory see Harlow (2021). Irrespective of theoretical nuance, however, the principles of attachment theory are key to the question of deinstitutionalisation and alternative family-based care. In short, the quality of the earliest relationship(s) will inform (though not determine) the way in which the child (and later the adult) develops, relates to others, and makes the most of life’s opportunities. Early adversity informs rather than determines, as empirical research provides evidence of heterogenous outcomes: that is, a minority of infants and children demonstrate resilience, and in the longer term, fare better than might be expected (Rutter 2006 and 2006a). Also, and of particular relevance to the policy of deinstitutionalisation, new relationships and experiences have the potential to create positive change (see Schofield and Beek 2018).

Despite the ubiquity of attachment theory, there are critics who suggest that it is a white Western construct and not transferable to other parts of the globe. However, Mary Ainsworth’s initial study of maternal care occurred with the Ganda tribe in Uganda (Ainsworth 1967 cited in Howe 2011). According to Howe (2011) reviews of cross-cultural studies on child development and attachments have been undertaken by Prior and Glaser (2006), van IJzendoorn and Sagi-Schwartz (2008) and van IJzendoorn and Bakermans-Kranenburg (2010). It has been concluded therefore, that attachment behaviour is universal across the world, though there are subtle variations in accordance with cultural context (Howe 2011). These conclusions support the position of attachment theory as a foundation to UNGAs policies on the care of children.

Based on attachment theory and empirical research, Bakermans-Kranenburg et al. (2011) and Dozier et al. (2012) marshal evidence to argue that institutional care can rarely, if ever, provide the quality of relationships necessary for optimal child development: child to caregiver ratios are high; caregivers are often low paid, untrained, and working on rotas; care is often regimented as opposed to sensitive to a child’s individual needs; and carers are unlikely to invest psychologically in the children:

Older children may be able to develop adequately in a setting that does not allow for close care-giver relationships. However, interactions with consistent and committed caregivers are key to the development of children (Dozier et al. 2012: 4).

Although little understood, there is some agreement that there are ‘sensitive periods’ for developmental growth during infancy and early childhood (Kreppner et al. 2007). Evidential support for this principle is provided by Kreppner et al. (2007) who, having researched the developmental consequences for children who had started life in Romanian orphanages during the Ceaușescu regime, concluded that ‘… profound institutional deprivation lasting longer than the first six months of life has major effects on patterns of impairment at age 11′ (Kreppner et al (2007: 942). Whilst the stage of early infancy may be developmentally significant, Bakermans-Kranenburg et al. (2011) argue that the length of time a child remains in institutional care is less significant than the quality of the ‘microcare’ provided. This is in keeping with the principles of attachment theory. Based on their empirical research, both Kreppner et al. (2007) and Bakermans-Kranenburg et al. (2011) conclude that for the majority of young children, being reared in institutions leads to developmental delay. Whilst the age of the child’s experience of institutional care may be significant, as well as the length of stay and quality of care provided, it is important to note that removal and placement in a secure and nurturing family environment can mean that developmental progress is made (see Kreppner et al. 2007). Berrens and Nelson (2015) conclude:

Across diverse contexts, studies have shown that institutionalised children have delays or deficits in physical, cognitive, emotional and social development. Developmental catch-up among fostered and adopted children suggest hope for recovery with targeted intervention, particularly in the earliest months and years of life (Berens and Nelson 2015: 395).

In summary, attachment theory and empirical evidence are compatible in supporting the international policies of deinstitutionalisation and alternative family-based care (see Davidson et al. 2017). In addition to the guidelines produced by the UNGA, a guide to good practice has been produced by the Daphne Programme and Mulheir (2007) and international and local non-governmental organisations have acted as advocates in order to create change. Whilst this is an important area of activity, challenges and complexities abound (Harwin and Barron 2007). It is to these challenges and complexities that attention is now turned.

Statistical Data on Children Living out of Parental Care

In 2009 UNICEF documented that two million children between the ages of 0-17 years were placed in institutions (UNICEF 2009 cited in Berens and Nelson 2015: 389). In relation to specific countries, the USA has pursued a policy of deinstitutionalisation, with the number of children living in institutions reduced to 5% (of children in the care system) in 1980 from 70% (of children in the care system) in 1930 (Tobis 2011 cited in Frimpong-Manso 2014: 403). Although Bulgaria has had a relatively high rate of infants living in institutions, this downward trend is similarly reflected (Bilson and Larkins 2013; Rogers 2014). These statistics suggest a positive story for the international policy of deinstitutionalisation. However, gaining clarity of specific numbers of children living in institutions across the world is hampered because: many institutions are not registered; under-reporting is commonplace; and in many countries data are not collected. Similarly, calculating the number of children living out of parental care and in different forms of care constitutes a challenge as data may be missing and/or unreliable (Petrowski et. al. 2017 cited in Herczog 2017). Biryukova and Sinyavskaya (2017) offer a detailed analysis of the statistics relating to the children in Russia who are placed out of parental care, but even at this regional level, problems arise (Ovcharova and Yarskaya-Smirnova 2010). This is because statistics are collected by a number of different agencies and inconsistencies occur across the agencies. Furthermore, different definitions of the status of children are used.

Reasons for Children Living out of Parental Care and the Maintenance of Family Unity

Single or double orphanhood creates a risk that a child may have to be raised outside of parental care, but according to Berens and Nelson (2015:191, citing UNICEF 2013) most orphaned children remain in family care. They also argue that reasons for social orphanhood (children with at least one biological parent still living) are context specific: in wealthier areas of the world the cause is most likely to be identified as abuse. In the USA, the most common form of abuse is described as neglect (Berens and Nelson 2015), whilst in Russia the neglect of responsibilities is identified as the main reason for the removing children from their parents and the termination of parental rights (Biryukova and Sinyavskaya 2017). These responsibilities may be financial (as opposed to the direct neglect of the physical or emotional needs of the child). Although the same word ‘neglect’ is used, it appears as though it is deployed differently, in accordance with geographical and policy contexts. Nevertheless, the emphasis in both instances (the USA and Russia) is on family functioning.

In relation to family functioning, Bilson and Larkins (2013), drawing on the work of Tolfree (1995) argue that a systems approach should be taken to the creation of policies and practices that prevent institutional care being seen as the solution to family difficulties. Instead, governments should undertake a gatekeeping role which is comprised of four components. Firstly, children and families should be assessed in order that problems are understood and appropriate solutions identified. Secondly, community-based services should be established as the means by which solutions are provided. Thirdly, decisions taken regarding family problems and solutions should be reviewed independently (to guard against removing children inappropriately or defaulting to institutional child care). Fourthly, the operation of the system should be subjected to monitoring and review (Bilson and Larkins 2013: 1568 summarising the work of Bilson and Harwin 2003: 19-20). In the event of the removal of children from parental care, then by means of routine review and problem resolution, they may be returned home at the earliest opportunity. This general system may have merit, but by reviewing the published evidence Al et al. (2012) conclude that intensive family maintenance programmes may prevent the removal of children for ‘multi-problem’ families, but not in the cases of abuse and neglect.

In the poorer regions of the world, however, the reason why children are not being cared for by their parents is most likely to be described as abandonment. Abandonment may be due to a number of factors, for example, poverty or the child’s disability which in some cultures is associated with stigma, as well as the lack of structural support. Maintaining family unity may be encouraged by providing cash, housing, food, health care, education and social support (Dozier et al. 2012). In general, it may be argued therefore, that:

……de-institutionalisation and transforming children’s services is a collection of activities: it is not just the removal of children from institutions. Rather it is systemic, policy driven change which results in considerably less reliance on residential care and an increase in service aimed at keeping children with their families and communities (Browne et al. 2007: 34 cited in Licursi et al. 2013: 346).

However, an overarching welfare and safeguarding system which aims to maintain the unity of birth families requires financial investment and personnel such as social workers who have to be recruited and trained which constitutes a challenge (Davidson et al. 2017).

When children cannot live with their birth families, maintaining them within their communities may mean facilitating placements with other members of their kin. That is, prior to placing a child in an institution, or in order to remove a child from an institution, placement with a member of their extended family may be an option. Although kinship care policies have been implemented successfully in diverse geographical locations, Frimpong-Manso (2014) illustrates the difficulties encountered in Ghana when attempts were made to remove children from institutions and reunite them with members of their extended family. Firstly, the process of reintegration requires considerable preparation and this was not always carried out. Secondly, children were returned to families who ‘did not always want them or were not in a state to receive them’ (p.405). Poverty meant that, with another child to care for, all children in the family became vulnerable. Thirdly, children’s life chances may be diminished if, as a result of familial poverty, their schooling was terminated, and finally, children returned to kinship care may become subjected to abuse and exploitation. The potentially problematic nature of kinship care has been addressed by Fuentez-Peláez et al. (2015) and an assessment tool proposed as a means of ensuring that extended families are fit to provide the care that is required.

To summarise the literature reviewed, complexities abound as to why children cannot live with their birth families, and diverse efforts are made to maintain the unity of birth families or to reunite them. Material problems may be resolved with the investment of resources and introduction of appropriate systems. Interestingly, relational attachments were not discussed in connection with these endeavours. Despite this, it was clear that birth families are not always able to provide the secure base necessary for optimum child development, and this is most easily seen when birth families (nuclear and extended) subject children to neglect, abuse and exploitation.

Deinstitutionalisation, Developing Foster Care and Some of the Challenges

In order to provide children with alternative family care, foster care services are being established in diverse locations across the world, for example, in China (Glover 2006), the African countries of Togo and Zimbabwe (Davidson et al. 2017) as well as in Russia (Biryukova and Sinyavskaya 2017: 374). Despite this, and UNGAs recommendation for family-based care and deinstitutionalisation, the introduction of foster care is not uniformly popular. Resistance to the policy of deinstitutionalisation may arise from charitable donors, and others who invest in the creation and maintenance of children’s institutions, believing that they are beneficial and serve an important need. In general, there may be an investment in tradition and a resistance to change (Licursi 2013) whilst managers of institutions and their staff may fear unemployment. For example, whilst the principle of deinstitutionalisation has been embraced in Estonia, foster care has not been popular. This according to Sindi et al (2018) is due to the cultural emphasis on individualism and family privacy. In consequence, foster care placements decreased between 2005 and 2015. Instead, there has been a move towards an alternative model of care provision which is seen as neither institutional or familial fostering (for further information on this development see Sindi et al. 2018).

The lack of familiarity with a foster care system might also account for its low usage, a problem encountered in some African countries (Cantwell 2006; George et al. 2003 all cited in Frimpong-Manso 2014). There has also arisen the criticism that introducing these systems constitutes the imposition of Western cultural ideas and practices. In particular, that they reflect an emphasis on the ’individual’ as opposed to the collective and inter-generational approach to living and problem resolution (see Bar-On 1999 and Osie-Hwedie 1993 cited in Davidson et al 2017). Bilson and Westwood (2012) acknowledge this criticism, but argue that the development of social work and foster care services have to include traditional networks, knowledge and resources. These tactics, however, may offer only a superficial response to the criticism.

Developing a system of foster care is organisationally and procedurally challenging. According to the UNGA guidelines (see UNGA 2009), a foster care system should attend to: carers’ conditions of work and motivation; quality assurance in terms of carers’ recruitment, skills, training and supervision; support of carers; and the matching of carers to children and their specific needs (Davidson et al. 2017). Such a system requires the recruitment of specialist personnel, such as social workers, who may not be available (Frimpong-Manso 2014), but also the investment of resources. Although the closure of institutions may release resources, there is a transitional phase when additional investment is required, and this may not be forthcoming. Attempts to recruit formal foster carers in Ghana were only partially successful because they were not going to be provided with material support (Frimpong-Manso 2014).

In some of the countries where foster care has been established, the experience has given rise to an appreciation of the need for different types of foster care. Without this appreciation problems may arise. For example, tension has arisen when social workers have attempted to remove children from foster care and return children to their family of origin: that is, foster carers have not seen the move as in the child’s best interests. In consequence, there is need for clarity on the kind of care that is required and being offered, for example, respite care, emergency foster care, short-term foster care, specialist foster care and long-term foster care (Clapton and Hoggan 2012 cited in Davidson et al 2017).

The frequently temporary nature of foster care might deter families from taking on the role, but it might also cause conflict as children might retain loyalties to their families of origin. According to Biryukova and Sinyavskaya 2017: 374) older children ‘have more trouble adapting to replacement families, as well as establishing enduring attachments and contact with adults who replace parents’ Biryukova and Sinyavskaya 2017: 371). This may account for why some foster care arrangements break down and children are returned to institutions. In this scenario, foster care does not offer a stable option:

Removing children from institutions, or preventing them from being so placed by the creation of foster-placements, may seem straight forward at first sight but it introduces multiple families into children’s lives. Children may be cared for in one family, but to whom do they look for their identity and in which long-term family will they live their adult life? Resolving those questions, are the quest for ‘permanence‘or even stability for children, is an issue than [sic] manifests itself in many ways when fostering becomes the dominant form of placement (Davidson et al. 2017: 761).

Foster care may not be an option for all children as foster carers may be reluctant to take certain children. For example, younger children are preferred and ‘children challenged in terms of health and vital functions, or with developmental disabilities, have very little chance to get a family placement’ (Biryukova and Sinyavskaya 2017: 379). This conclusion is echoed by Berens and Nelson (2015), whilst Herczog (2017) notes that in Europe, it is children with complex needs, who are unaccompanied or refugees, that are most likely to be accommodated in institutions.

Conclusion

The United Nations’ children’s rights agenda which relates to deinstitutionalisation, is informed by attachment theory and empirical evidence, which suggests that a child’s development is most likely to be enhanced by familial rather than institutional care. In consequence, in diverse locations across the world, efforts are being made to provide community support and resolve problems in order that family unity is maintained. Should this not be possible, temporary care with suitable members of the extended family may be arranged until reunification can occur. Should this be deemed inappropriate (for example, in cases of abuse), the child’s care with a foster family may be the most relevant option, and such services are becoming established.

Foster care, however, is an intricate system, which requires its own set of regulations, requiring professional personnel responsible for implementing them, as well as extensive funding – all of which might be difficult to arrange or secure. Closing institutions might free up resources for the funding of community and foster care services, but in the initial stages, a larger investment of funds is required, and there may be local resistance to such measures. Even when efforts have been made to introduce a foster care system, it is not always popular or successful: foster care may not be understood or fit comfortably within a specific cultural context. In this brief review, examples have been provided where a foster care system has been described as too individualist (in some African countries) or not individualist enough (as in Estonia). Importantly, children are not a homogenous group, and children who are older or have complex needs, may be rejected by potential foster carers and therefore remain accommodated in institutions.

Despite all of this, and the complexity of the statistical evidence available, it appears that alternative family care is being made available to children across the world. Whilst recognising that global change and upheaval gives rise to new familial problems, as well as the displacement and exploitation of children, it may be appropriate to acknowledge that commitment to this particular component of the universal children’s rights agenda, has achieved a degree of progress. Nevertheless, it is appropriate for researchers and those with leadership responsibilities, to retain a reflective stance, and interrogate the practicalities associated with its application. In short, vigilance is essential if we are to promote the optimum provision of alternative care, and the continued pursuit of the rights of children.

Disclosure Statement

The opportunity to produce this paper arose from knowledge transfer funding provided by the Martin James Foundation. The Martin James Foundation https://martinjames.foundation/ is a not for profit organisation that promotes the policy of deinstitutionalisation across the world.

Additional information

Notes on contributors

Elizabeth Harlow

Professor Elizabeth Harlow, PhD, BA, CQSW, FHEA, is a Professor of Social Work at the University of Chester. She worked as a practitioner before beginning her academic career in 1988. Focussing primarily on the organisation, management and delivery of services to children and their families, she has led research projects and evaluations and published her work over the last three decades.