DRAFT Best Practices for Institutional Care Kelley McCreery Bunkers Child Protection Consultant Addis Ababa, Ethiopia kelleybunkers@gmail.com Victor Groza, PhD Grace F. Brody Professor of Parent-Child Studies Mandel School of Applied Social Sciences Case Western Reserve University Cleveland, OH 44106 victor.groza@case.edu -2- 1) Abstract Institutions have been one of the main placement options for orphaned, abandoned or vulnerable children (OAVC) for centuries; although today, most institutionalized children live in low resource countries (Rosas & McCall, 2009). Over eight million children are in residential care (United Nations, 2006). Many children in low resource countries with little or no child protection system are living in institutions and there is ample evidence on the proliferation of group care facilities throughout Africa (Howard, 2008). There is ample research available on the negative effects that institutional care has on children, especially their physical, social and intellectual development. There is growing global consensus on the need to promote familybased alternatives to institutional care for children and adolescents. Yet, in the interim, until those systems and family-based care options are secured for children, institutional care will be a reality for many low resource countries. Therefore, it is the goal of this paper to present characteristics of institutional care that promote positive development of children, or at least don’t have as many negative effects on children’s development. It is not the goal of this paper to justify nor promote institutional care of children but rather acknowledge that institutional care will continue to be a care option for a certain population of children until the end goal of establishing family-based alternatives within a continuum of care can be established, especially within low-income countries. Improving institutional care so that it is less detrimental to children is a means to an end; the end being the establishment of strong child protection systems which promote family-based alternatives for orphaned and vulnerable children. -3Introduction Institutions have been one of the main placement options for orphaned, abandoned or vulnerable children (OAVC) for centuries; today, most institutionalized children live in low resource countries (Rosas & McCall, 2009). In industrialized countries, alternative care options are usually family-based (children are in some type of alternative family) and not institutionalbased (children are in some type of group care); foster care, subsidized or unsubsidized kinship care, and adoption are more readily utilized. In many low resource countries in Africa, Asia and several countries in the region of Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS), foster care and adoption are not the main alternatives due to cultural beliefs, lack of child welfare systems, limited resources for child welfare funding, or lack of political will (Rosas & McCall , 2009; Dickens & Groza, 2004). The term institutionalization used in this paper refers to short-term or long-term placement of a child into any non family-based care situation. Similar terms referring to institutionalization are residential care, group care, congregate care, or orphanage care. Common elements of institutionalization include care by paid, unrelated personnel living with other nonrelated children, children clustered by age group (i.e. homogenously), periodic transitions to new caregivers and age mates, a high child-to-caregiver ratio and lack of or limited stimulating and responsive interactions between child and caregiver (Rosas & McCall, 2009). One of the most common characteristics of institutional life is the lack of stable, long-term relationships between a child and a caregiver (Dobrova-Krol et al., 2008; Rosas & McCall, 2009). Yet, the reality is that institutional care is and for the foreseeable future will be the one of the main alternative care option for many children, particularly in low resource countries. A 2003 UNICEF report found that 143 million single orphans (only one parent died) and double orphans -4(both parents died) were living in 93 countries in the world (Rosas, & McCall, 2009), and eight million children are in residential care (United Nations, 2006). Many children in low resource countries with little or no child protection system are living in institutions and there is ample evidence on the proliferation of group care facilities throughout Africa (Howard, 2008). This increase in institutional care could be the result of various issues including cultural and economic barriers (Rosas & McCall, 2009), as well as the devastation caused by HIV and AIDS, chronic poverty, conflict and a myriad of other political, cultural and economic factors (Tolfree, 2005). Based on the considerable research documenting the numerous negative effects of institutionalization, one is led to believe that components of “good institutions” must be an oxymoron. Rosenthal, Bauer, Hyden and Holley (1999) caution that the danger of improving institutional care may inadvertently strengthen an outdated and less than ideal system. Critics of institutionalization assert that children “thrive better in bad homes than in good institutions” (Moore & Moore, 1977). The other side of the spectrum includes those who argue that in certain countries institutions can be a better physical environments than those provided by families (Wolff & Fesseha, 1998, 1999). Yet it is imperative to have a pragmatist view that recognizes that institutional care, although not the ideal option for children without parental care, must be acknowledged as a reality and therefore be improved upon in the short-term. The long-term goal should absolutely be a system built on family- and community-based services where institutionalization does not have to exist but, until that occurs concurrent work to improve the conditions of institutional care using evidence-based guidance on the essential components of a “good institution,” is a must, especially for children for whom it is the only option,. Many high resource countries took several decades to develop functioning family-based care systems and it will most likely take low-resource countries a significant amount of time as well. -5Although important data exists that would promote the closure of institutions, there is also evidence such as the St. Petersburg-USA Orphanage Research Team study (2008) that demonstrated that orphanages can be improved to at least not be as significantly detrimental to children’s physical, intellectual and psychosocial development. Redesigning current institutions that incorporate key concepts and standards of care based on the organizational reports and academic research is a crucial component within the process of developing child welfare systems incorporating a continuum of care approach. Significant “gray literature” has been developed around this topic by international bodies such as United Nations Children’s Fund (UNICEF) and International Non-Governmental Organizations (INGOs) such as Save the Children Alliance members and International Social Services (ISS). Efforts to improve the quality of institutional care are an important beginning point, but this “transformation” of institutions must be done in conjunction with the development and scaling-up of family-based alternatives such as family preservation or reunification, kinship care, temporary foster care, and domestic adoption with a strong focus on quality of care provided in those care settings (Tolfree, 2005; Julian and McCall, 2009). Article 22 of United Nations Guidelines for the Appropriate Use and Conditions of Alternative Care for Children (Draft) supports this view by stating that where large child institutions remain, alternatives should be actively developed in the context of an overall deinstitutionalization strategy that will allow for their progressive elimination (United Nations, 2007). This paper, while using a pragmatic framework to discuss improving institutional care, leads us down a precarious path. There is a real danger that attempts to modernize child welfare systems to be family-based will be ignored or cast aside as efforts and resources are allocated toward improving group care. From a systemic perspective, the longer an institution runs in a -6community, the less likely it is to close or change. It becomes a major employer; it removes from the public eye the plight of OAVC, and takes on a culture and life of its own. It is perpetuated by foreigners who are willing to donate for bricks and mortar but not sponsor a child or a family to live in the community. Standards, Accreditation, Inspections and Monitoring for Quality Care The development, appreciation and application of children’s rights have become an integral part of child protection philosophy and practice in many countries around the world. The United Nations Convention of the Rights of the Child (UNCRC) has had significant impact on child welfare policy development, standards of care, and programming related to institutional care. Many of the standards related to institutional care that have been developed in the past two decades have been based on the UNCRC and the articles therein (United Nations, 2007; IFCO, SOS Kinderdorf & FICE, 2007; Browne & Mulheir, 2007). The Convention was designed to protect children’s rights by setting standards in the areas of health, education, protection, and legal services (UNICEF, 2008). This framework has had and will continue to have a significant impact on the way that child protection and child welfare is practiced around the world. It has especially influenced how institutional care is implemented and the role it serves within the child welfare continuum. Standards: An essential component of quality institutional care is public policy that establishes professional standards for both services and personnel. Professional standards or guidelines set the type and quality of services to be delivered to the child by the social service agency, in a child-centered/child rights framework. Standards should exist for all alternative care placements -7within a continuum of care; including family preservation and support, kinship care, temporary foster care, domestic adoption, intercountry adoption and institutionalization. Personnel standards establish professional employment requirements (knowledge, values and skills) necessary to perform the duties with the highest level of expertise. Standards reflect and promote evidence-based child development strategies and child care practices. Standards provide goals for the continuing improvement of services to children and their families. Standards promote nationwide consistency. They serve as a resource for people in other fields who are concerned with the care and protection of children - legislators, judges, attorneys, educators, health and mental health professionals, law enforcement personnel, opinion shapers in the media, child advocates, faith leaders, and the general public. Standards provide the basis for licensing and accreditation nationwide. From a rights-based perspective, children living outside of parental care have the right to be cared for by qualified personnel who adhere to standards that are based on ensuring quality and conditions of care are conducive to maximize a child’s development (United Nations, 2007). A best practice model for developing standards is to work at the Ministry or central authority level that is responsibility for the group care of children. This is not as simple as it appears. Typically children of certain ages or children with different disabilities are under the care and management of different authorities, as was the case in Romania in the early 1990s (Groza, Ileana, & Irwin, 1999; Gavrilovici & Groza, 2007) and in the Ukraine (Groza, Komarova, Galchinskaya, Gerasimova, & Volynets, in press). In order to develop standards it is better for all the children in institutions to be under one government authority. When this is not possible, and standards are developed for children only under one authority, it creates strife and competition between authorities. This derails attempts to improve quality care. Such a situation -8currently exists in Ethiopia where accreditation of institutions, supervision and oversight of those institutions are divided among three different government bodies (Ministry of Justice, Bureau of Labor and Social Affairs, and the Ministry of Women’s Affairs), making it difficult for effective monitoring and evaluation of institutional care and challenging the development of comprehensive standards (Family Health International, et al, 2009). When developing standards it is important to view the process as comprehensive and include all alternative care options in the process. There is a tendency to develop standards for institutional care in isolation from other alternative care options. This stand-alone development of institutional care may be problematic as it could keep institutionalization operating and separate from the other care options within the continuum. If the end goal is a system based on a continuum of care, with institutionalization being the last option, it is critical that the standards reflect the prioritization of family-based care and that standards for all forms of care are uniform and part of a comprehensive care package. Accreditation & Licensing Developing standards is only the first step. Concurrent with developing standards must be a national study of institutions. The country must know how many institutions they have, where they are located, and how many children are in each institution. A recent example of this type of study is the work of Perez (2008) in Guatemala. Up until this study, there were estimations but no specifics. Even in the former communist countries of Romania and Ukraine, getting the specifics about children in institutional care was a moving target because not all locations were known and numbers were manipulated based on who was asking and how the information was to be used. If it was the government in order to allocate funding, numbers were -9higher. If it was an investigation, the numbers were lower. In Romania when the country moved to foster care, court orders were required in some locations to remove children from institutions and only with the authority of the police were the exact number of children discovered. Once a country has standards, they must move toward accrediting and licensing institutions to care for children. Accreditation requires that the institution document, in writing, how they meet or exceed the standard with the evidence to support their claim. Once a written report is received, a review panel of professionals with no ties to institutional staff or political decision-makers should review the report and schedule a visit. The visit is designed to provide further evidence of compliance with stated standards, highlighting strengths and areas for improvement. For example, if the audit of compliance asserts that staff is trained every month, records of the topic of training, who was trained, who attended the training, and evaluations of the training must be on file. Cases should be randomly pulled to ascertain that all the assessment and planning documents are in place, signed and dated. A predetermined threshold or minimum set of requirements must be met in order to accredit and license an institution. If they don’t meet the threshold, they are not accredited. A second review can be scheduled in 30 or 60 days to see if the institution can meet standards; if it cannot, it should be closed. If it can meet standards, then routine re-accreditation and licensing should be established on a yearly or bi-annual basis, utilizing established standards and both unannounced and announced inspections and monitoring of the quality of care. Inspections and Monitoring Quality of Care Setting up a system which is able to monitor implementation and adherence to national standards is just as important as developing standards. Ethiopia is a good case in point. The National Guidelines for Alternative Childcare were developed in 2002. The standards were - 10 based on the UNCRC and the development of those standards was viewed as a positive step towards unifying good practice, especially within child residential institutions. Unfortunately, the standards have not been formally approved by the Government and an accompanying monitoring system is not in based to ensure that standards are adhered to. A recent study conducted by Family Health International and UNICEF found that the majority of child care institutions were not even aware of the existence of the standards. What may be perceived as a positive step forward in developing standards was severely limited by lack of approval, dissemination and inexistence of necessary monitoring and evaluation systems (Family Health International, et al, 2009). One of the major concerns that should be dealt with in the creation of standards and monitoring processes is child abuse within institutional care. Children in care are already in a vulnerable state when they enter the institution. Children have been abandoned, neglected, spent years in institutional care, or in some cases have been living on the streets or in child-headed households. Children in institutional care are especially vulnerable to physical punishment from staff, bullying from other residents, and sexual exploitation (Gavrilovici & Groza, 2007). Any mistreatment negatively shapes the environment for all residents whether or not they are a victim of abuse or neglect (Groze, 1990). If the mistreatment is a pattern, it undermines the ability of institution to carry out its mission and goals (Sundrum, 1996). One problem in determining the incidence and prevalence of mistreatment in institutional settings is the lack of uniform definitions of what constitutes abuse or neglect. A second problem is even if maltreatment occurs there is no reporting or investigation system in most countries. Fear of reprisal is a major deterrent for staff to report problems and most governments lack an adequate system for child maltreatment within the family, so a system for documenting, investigating and remedying - 11 maltreatment within institutions is even less likely to exist. If there is no adequate system to respond to the problem there can never be an accurate assessment of scope and depth of the problem. There can also never be a solution to the problem. So, the most vulnerable OAVC are made even more vulnerable. It is for this reason that any country using group care as a major child welfare intervention needs to develop definitions of mistreatment. Sexual abuse means any sexual activity prohibited by law, including sexual exploitation—the use of a child by a person responsible for her or his health or welfare for personal gratification—or procuring or knowingly causing or permitting any person to sexually abuse or exploit the child, including other children. Neglect means the willful act of omission which directly results in the child suffering or being exposed to risk of suffering physical or emotional injury. This includes but is not limited to the failure to provide food, clothing, appropriate shelter, bedding, or medical care to the child. Inappropriate treatment means harm or threatened harm to a child’s safety, health or welfare which is caused by violating state, local or program rules, laws, policies, procedures or statues. It includes the failure to provide care for the child in manner consistent with universal professional standards and practices, including anything that violates the right of a child that is not classified as abuse or neglect, that injures a child or puts a child at-risk for harm (see Groze, 1990). Inappropriate treatment is unique to the institutional setting, adding the additional level of expectation for those working in these settings. . Structural Characteristics A common trait of institutions is homogenous groups, specifically children clustered together based on age (Rosas & McCall, 2009). In Russia and Romania, institutions were - 12 divided into age groups. Children aged 0-3 were in one orphanage; ages 4-7 were in another orphanage; and finally from age 7-18 were in another institution (Groza, Ileana, & Irwin, 1999). This homogeneity is detrimental to children and their development for several reasons. The first is that the grouping together of children by age groups and then transferring them to another institution creates a scenario whereby children have to leave familiar caregivers and surroundings. Secondly, grouping homogenously frequently results in little to no individualized attention from caregivers (Rosas& McCall, 2009). As indicated above, Institutions across the globe have common characteristics (Rosas & McCall, 2009) including large group sizes, high child: caregiver ratios, homogeneous age and disability groupings, many and frequently changing caregivers, caregiver work schedules in which individuals work long hours and then are off for 2-3 days, and transitioning children from one ward or institution to another when they reach certain milestones of development (e.g., crawling, walking, social play). The research literature on non-residential early care and education suggestions that each of these characteristics is associated with poorer development in young children (St. Petersburg-USA Orphanage Research Team,2008). In addition, there is often an “institutional mentality” in which caregivers do not get close to children and carry out their caregiving duties in a rather perfunctory, businesslike manner with little in the way of warm, caring, sensitive, and contingently responsive interaction with children. This set of characteristics means that children have little consistency in their caregivers or in the way adults respond to them and have little opportunity to experience typical adult-child interactions and certainly not relationships with caregivers. Some have speculated that these characteristics may be among the most corrosive aspects of institutional care for children’s development (e.g., St. Petersburg-USA Orphanage Research Team, 2008). - 13 There is some evidence that these characteristics can be changed to provide more consistent care and better social-emotional caregiver-child interactions and such changes can be maintained on the institution’s original budget in some cases. For example, the St. PetersburgUSA Orphanage Research Team (2008) changed essentially all of these characteristics in an institution for children birth to four years and produced very substantial improvements in children’s physical and behavioral development. Specifically, group sizes were reduced from 1014 to 5-7 by physically dividing each living room in half (the 10-14 children still all slept in one room). Two primary caregivers and a substitute were assigned to a subgroup who worked five days a week in staggered shifts so that one was present during nearly all of the children’s waking hours. Groups were made heterogeneous by age, and transitions to new wards were stopped. Groups were also integrated with respect to the disability status of children. A family hour in the morning and in the afternoon was established in which no visitors (including specialists) were allowed and children and caregivers were to be together. In addition, caregivers were trained to provide sensitive, responsive care, especially during routine caregiving duties. The results showed that typically developing children increased in Battelle total DQs from an average of 57 to 92 = 45 DQ points, perhaps the largest increase reported for any intervention in the literature. Children also increased in height, weight, and chest circumference, more children showed organized attachments to their caregiver, and children displayed more mature social and emotional behaviors with caregivers. Moreover, this institution has maintained these changes in the three years since the intervention project ended without additional funding and children’s developmental scores have remained at or above the levels at the end of the intervention project. While there are certain costs to dividing rooms and providing training, most of these changes can be implemented for - 14 modest or no additional costs, but they do require the commitment of the institution’s administrators and staff to making such changes. While all of these changes worked toward providing children with a few consistent caregivers who behaved in a sensitive and contingently responsive way, age integration provided special benefits. Instead of feeding 10-14 infants or toddlers all at once and conducting all other daily activities en masse, which stressed caregivers for parts of the day and left them with nothing to do while children slept at other parts of the day, age integration evened out the distribution of caregiver time. Caregivers had to feed only 2 or 3 infants at a time and the older children could play independently; when the infants slept, caregivers had time to play with the older children. Surveys indicated that while caregivers were initially concerned about age integration, they soon found it provided a less stressful and more satisfying job environment.” As another example, Bharatiya Samaj Seva Kendra (BSSK) in Pune, India operates a congregate care program for children. BSSK has an explicit philosophy of giving children the best stimulation, nutrition, medical care, warmth, love and emotional security. Children are cared for by a team of child development specialists, social workers, caretakers, nurses, doctors, psychologists, teachers and volunteers. Infants under one month are given special care in their ‘Neonatal Nursery’. The Neonatal Nursery accommodates 10 to 12 babies, with specially trained BSSK nurses in attendance. After one month, the children are either shifted to foster family care or to another room. Child development workers give each child the appropriate emotional, motor and speech stimulation. A home like environment is created to encourage learning and normal growth, attachment and bonding. The caretakers change, clean, bathe, feed, sing, talk and tell stories to the babies and children. A clinical psychologist does the DQ/IQ testing of the children and keeps a close watch on each child's development. For the older - 15 children, school classes are conducted every morning by volunteers and trained staff. Children learn the alphabet, numbers, nursery rhymes, reading, writing, and painting. Festivals are celebrated with gaiety and enthusiasm. Most importantly every child's birthday is celebrated and documented. Children are also taught dance, drama, music and art by the trained volunteers and staff. Picnics to places like the zoo, a garden and a farm are arranged for children from time to time. Children address the ayahs as ‘Aai’ - ‘mother’ the other staff members and volunteers as ‘tai’ - ‘sister’, helping to create an atmosphere of warmth and affection. Even as a model program, there is one observation one can make; even good group care does not work for every child. For resilient children, they can survive and thrive in more difficult circumstances. For a small group of children, group care cannot meet their needs; they engage in rocking and other self-stimulating behaviors even when they are a group of 4 children to 1 staff. It begins a negative developmental trajectory. Due to their vulnerability, come more problems which get worse the longer they remain in congregate care. In Eritrea, Wolff and colleagues (Wolff, Dawit, & Zere, 1995; Wolff, Tesfai, Eyasso, & Aradom, 1995; Wolff & Fesseha, 1999) designed an intervention to restructure an institution so that children were mixed by age and group size was reduced. A consistent primary caregiver was assigned to live in each room, and two assistants were permanently assigned to each group; similar to the model utilized by SOS Kinderdorf. Results were mixed. On the one hand, the number of behavioral symptoms decreased. On the other hand, mood disturbances such as depression and anxiety were more prevalent. The problem in interpreting this study is to know whether the effect was due to changing the mix of ages or changing a caregiver. Still, the combination of age differences and a consistent caregiver did have some positive effects. This is an area for further research. - 16 - Personnel Standards Consistent caregivers should be evaluated, trained and monitored by appropriate regulating authorities with a special focus on positive care-giving, provision of individualized attention, and early cognitive stimulation of children. Article 73 of the UN Guidelines for the Appropriate Use and Conditions of Alternative Care for Children states that special attention should be paid to the quality of alternative care provision; both in residential and family-based care, particularly in regard to the professional skills, selection, training and supervision of carers. Their role and functions should be clearly defined and clarified with respect to those of the child’s parents or legal guardians (UN, 2007, pg. 13). For optimal developmental outcomes, children need consistent caregivers that are trained and monitored by appropriate regulating authorities. There are challenges to ensuring professional, well-trained staff in low-resource countries. This was the case in Guatemala where Perez (2008) found that 80% of children’s shelters operate in accordance with available resources and do not guarantee that ideal, qualified personnel will be present to provide services to institutionalized children. For infants and toddlers, staff training resulting in changed behavior for as little as 5 minutes a day for 5 days a week from 1 to 6 weeks has a significant positive impact immediately on children’s development, cognition or health (Sayegh & Dennis, 1965; Hakimi-Manesh, Mojdehi & Tashakkori, 1984; Kim, Shin, & White-Traut, 2003); staff training and changes in behavior may also have advantages at least up to 6 months after the intervention (HakimiManesh et al, 1984). The aforementioned Rosas & McCall study showed that if these minimal improvements in staff interaction are stopped, the positive effects displayed by children will not - 17 continue, emphasizing the need for consistency and continuity of positive caregiver interactions (Rosas &McCall, 2009). Even if staff training does not improve child health and developmental outcomes, it might prevent children from getting worse (Brossard & Décarie, 1971; Casler, 1965). Programming Standards Assessment at Entry Point Any child welfare service must begin with a good child assessment; any ongoing service must have continuous, regular child assessment in multiple domains of functioning. Regardless of the reason for a child to enter the child protection system, before any long-term decisions can be made, assessments must be completed and recorded in the case file. Of course, this assumes that every child has a file. At a minimum, there should be a medical evaluation (physical exam) by licensed medical staff, developmental assessment by child development specialists, social history by trained and accredited social workers, and if the child is school-age, an educational evaluation by a professionally credentialed educator. Photos should be taken of the child and if any relative is available, a comprehensive family history should be obtained with the names, addresses, and phone of all relatives recorded. Assessments should be updated monthly for infants, quarterly for toddlers, and every six months to a year for older children. The reassessment should include the child’s health, development, behavior patterns, social functioning, psychological/psychiatric screening and educational performance (if appropriate). These assessments and re-assessments allow for more appropriate placement, better monitoring of children and for the early identification of problems. A report from each assessment, summarizing strengths as well as child’s needs, must be written. - 18 Due to the high risk for attachment disorders and disturbances in children from institutions (Zeanah, Smyke, Koga & Carlson, 2005), attachment assessments and early care and intervention to promote attachment are critical. Attachment may be a pivotal developmental foundation on which many aspects of emotional and behavioral functioning are based (Boris, Fueyo, & Zeanah, 1999). Children raised in institutions have fewer opportunities to develop selective attachments (Smyke, Dumitrescu, & Zeanah, 2002). Of most concern are indications that children in institutions are at greater risk for disorganized attachment, and disorganized attachment is a serious risk factor for later problems (Dozier, Stovall, Albus, & Bates, 2001; Carlson, 1998). Programming must be altered to allow children to develop and maintain a selective attachment with at least one primary caregiver. Case management Case management or case planning should begin at the earliest possible time and be comprised of meeting both long-term and short-term needs based on the child assessment and congruent with the best interest of the individual child (UN, 2007). Case management has the main objective of getting a child into a family-like, safe and permanent care in the least amount of time. Article 25 of the UNCRC states that children placed outside their own family are entitled to periodic review of all aspects of their placement. This is vital to ensuring that the child’s best interest is being pursued. Good case planning is a critical component of keeping institutionalization temporary; without it, children are much more likely to remain institutionalized long-term (Perez, 2008). Determining the eligibility and appropriateness of alternative care options for an individual child should be addressed within the case plan which is updated a minimum of every six months. Including alternative care options within an institution either as part of the - 19 institution’s own programming or in collaboration with other government and nongovernmental organizations is essential. Life Skills and Transition Services Institutions caring for adolescents should provide youth with the skills, knowledge and resources necessary to be able to live independently after exiting institutional care. Articles 132, 136 and 137 of the Draft UN Guidelines for Alternative Care specifically highlight the necessary provision of care, follow-up and preparation of youth for independent living outside of the institution. Recognizing that institutional life deprives children of the necessary social and educational opportunities that a family setting would provide, institutions should make a concerted effort to provide programs, both educational and vocational, which help young people leaving institutional care, become financially independent. Additionally, institutions should have clear policy and procedures related to after care and follow-up of children leaving care to ensure timely support aimed at successful integration into the community. Children’s Right to Participate in Decisions Incorporating and facilitating appropriate child participation during the time they are in institutional care and specifically in the key decisions that must be made (depending on the child’s age and competency) is a core component of child-rights based standards. Children, as bearers of rights, have an opinion that should be heard and recognized (UN, 2007; UNCRC). Children have a right to be consulted and to have their views duly taken into account in accordance with their evolving capacities, and on the basis of their access to all necessary information. In addition, article 92 of the same document states that “all carers should promote and encourage children and young people to develop and exercise informed choices, taking - 20 account of acceptable risks and the child’s age and according to his/her evolving capacities” (UN, 2007, p. 14). Given the sensitive nature around child participation and the particular role that it plays in different ethnic and cultural environments, it is critical that key personnel such as social workers, psychologists and directors receive training and guidance in how to both promote child participation while at the same time ensuring that the child’s safety, permanency, and well-being is priority. Participation of children in decision-making processes regarding their care is a relatively new phenomenon and many low resource countries are still determining how to address this issue within the cultural and legal frameworks of their countries. A recent International Social Services document (March, 2009) addressed this issue by recognizing a noticeable lack of information regarding active participation of children in determining which type of alternative care was best for them (ISS, March, 2009). Within the same document, there were positive examples cited although the majority were from medium to high-income countries such as Canada, Australia, England and Bulgaria (ISS, 2009). Community-based and Community Involvement Community integration and inclusion in community activities is the foundation of reforming institutional care (see Llorente, Charlebois, Martinez-Mora, Ducci & Farias, 2003). Children in institutional care have a right to be involved with and have access to the community, including local schools, medical services, faith-based organizations, and extra-curricular activities. Institutions should be placed within a neighborhood or community as it allows children access to and interaction with local schools, children, extra-curricular activities and other components of day to day life. It also supports the possibility of alternative care options and facilitates access to medical, educational and judicial institutions which assist children and - 21 their placement. Allowing children the opportunity to interact with community members and institutions may positively affect their ability to integrate into that community once they leave the institution. When institutions are placed outside of communities, such as the case of Romanian institutions for children with special needs, the children in care do not benefit from activities, visits, or interactions with community members and institutions. They are hidden from view and are frequently prone to abuse and exploitation because the safeguards provided within a community are absent. Placement in rural or isolated areas keeps children and institutions off of the radar; thus limiting or hindering the communities and competent authority’s ability to monitor activities within the institution. One-on-one interaction between a child in institutional care and an adult is frequently limited. To augment this, institutions may utilize community volunteers. These volunteers must be screened and trained before ever coming in contact with the children to ensure the child’s safety and protection. The volunteers provide an opportunity for children to interact with adults outside of the institutional staff. This kind of interaction should enhance the child’s development and connections with others but volunteers should never become primary caregivers. Use of volunteers for key activities where one-on-one contact is important such as bathing, feeding and play time is a cost effective way of addressing the needs of children and provides an opportunity for children to interact with members of the community. Although volunteer use may be beneficial it may also contribute to instability and prove to be a safety issue as volunteers can be unreliable and in many cases do not have training in child development and other necessary skills (Rosas & McCall, 2009). Therefore, if an institution is going to incorporate volunteers into their program, they must first have a volunteer training curriculum, a program that a volunteer - 22 may complete before working with children, and administrative staff to monitor the volunteer program. A child protection policy must also be understood and agreed to by the volunteer. Access to Educational Services The UNCRC details a child’s right to education as a fundamental right. Therefore, it is imperative that institutions also respect this right and provide children in care with educational opportunities appropriate to their age and capabilities. The Draft UN Guidelines on Alternative Care makes reference to a child’s right to education in Article 83, which states that children should have access to formal, non-formal and vocational education in accordance with their rights, to the maximum extent possible in educational facilities in the local community (UN, 2007). Promoting the inclusion of institutionalized children into public, community-based educational settings fosters community involvement and allows children the opportunity to interact with other children their age. Access to education is not only a right, but it also assists in their later ability to integrate successfully into the community once they leave institutional care. This was demonstrated in Constanta, Romania with the integration of institutionalized children with HIV into public schools. Their integration not only provided them with an opportunity to interact with similar aged children in the community, but it also was essential in giving them the skills necessary for independent living. Integrating the children into public schools has also successfully challenged the discrimination that children living with HIV and AIDS typically face (UNICEF and Innocenti Research Center, 2005). Recognizing that early childhood education and development (ECED) is also an important tool for encouraging child development; it is strongly recommended that institutions include ECED programs for young children. Comprehensive early childhood development programs promote cognition, language, social and emotional development; these skills underpin - 23 school readiness (Anderson et al., 2003). Over the life span, early development has a tremendous impact and early opportunities to develop as completely as possible establishes the foundation for academic success, health and well-being (VanLandeghem, Curgins, & Abrams, 2002). Early childhood programs can identify problems early, minimize the severity of problems if identified and treated early, and/or stop further deterioration if problems are identified (Black, 2002). Early childhood development programs are typically cost-effective and may be an excellent way to encourage interaction between children in institutions and children within the community if the ECED program is community-based. All education programs in institutions for infants and toddler should include an early intervention program. Many children from high risk situations have learning problems and children with a history of institutionalization have learning difficulties (Dalen, 1995). Specialized testing for learning disabilities and appropriate remedial education must be provided to maximize children’s opportunity to learn. Access to Play and Recreation Incorporating a child’s right to play and recreation is an important component of best practice in institutional care. Article 84 of the Draft UN Guidelines states that “Carers should ensure that the right of every child, including children with disabilities or living with or affected by HIV and AIDS, to develop through play and leisure activities is recognized and that opportunities for such activities are created with and outside the care setting. Contacts with the children and others in the local community should be encouraged and facilitated” (UN, 2007, pg.15). Promoting opportunities for children to play encourages their physical, psychosocial and intellectual development. Creating play and recreational opportunities within the community also provides an excellent opportunity for children residing in institutional care to interact, in a - 24 positive manner, with other children in the community. Institutions should provide ageappropriate toys for children, which foster development and creativity. Caregivers and other staff of the institutions should also be trained in play techniques and positive interaction with children during play time should be included in a caregiver’s job description. Respectful of cultural, ethnic and linguistic identities of children Cultural and religious practices in alternative care should be respected and promoted to the extent that a full assessment has shown them to be consistent with children’s rights and best interests, and should be modified, discouraged or banned when this is not the case. The process of identifying and assessing these practices and considering the applicability of other systems should be done in a broadly participatory way, involving relevant cultural and religious leaders as well as professionals and civil society actors working with children without parental care, as well as the children themselves (UN, 2007). The language used in care institutions should be the languages of the children. In Guatemala, that could include any and all of the 23 dialects spoken from the indigenous Mayan communities. In Romania where Rroma children are disproportionately in the child welfare system, that means the use of Rroma dialects. Cost of institutionalization Community-based orphan support programs are cost-effective as they enable large numbers of orphans to be supported within their own communities. In the CEE/CIS region, institutional care is twice as expensive as the most costly community residential/small group homes; three to five times as expensive as foster care (depending on whether it is provided professionally or voluntarily), and around eight times more expensive than providing social services-type support to vulnerable families. In Africa, Desmond & Gow found that institutional - 25 care is nearly nine times more expensive than community-based care (Desmond & Gow, 2001). The cost per visit of a child is US$1.55, much lower than the US$14 to $38 per visit reported in some Zambian home care programs (Chela et al., 1994). This is largely because visits are carried out by volunteers who live in the same communities as the beneficiaries (Drew, Makuf & Foster, 1998). Skeels (1966) compared 13 children removed from group care (age 7-30 month; IQ ranged from 35 to 89) into foster care to a matched group of 12 children (age 12 to 22 months; IQ ranged from 50 to 103) who remained in an orphanage for the mentally handicapped. Two year later, those in foster care gained 28.5 IQ points while those who remained in orphanage care lost 26.2 IQ points. After 21 years, all cases were located. Those raised in family care completed a median grade of 12 while those in group care had a median grade of three. The cost of care for children in group care was five times the cost for children in family care. In urban Bangladesh, according to a study by Ashworth and Khamun (1997) 437 children with severe malnutrition aged 12-60 months were sequentially assigned to either in-patient care, day care, or family care. They found that average institutional costs to achieve 80% weight-forheight were respectively $156, $59 and $29 per child (US$). As a proportion of the overall costs, staff salaries were the largest component, followed by laboratory tests. Family care was 1.6 times more cost-effective than day care, and 4.1 times more cost-effective than in-patient care (Ashworth & Khamun, 1997). As part of a project to develop a model procedure for returning residents of institutions to the community, the Commonwealth of Virginia developed a methodology for conducting a costbenefit analysis of institutional versus community living. The methodology was used to project costs and benefits over a ten-year period for 52 clients successfully placed in the community - 26 through the project. The results showed an average net saving for each client of $20,800 over a ten-year period (Murphy & Datel, 1976). Conclusion and Recommendations The most fundamental questions to be answered are (1) can institutions be improved to be comparable to family living, and (2) should they be improved? There is growing global consensus on the need to promote family-based alternatives to institutional care for children and adolescents. Yet, in the interim, institutional care will be a reality for many low resource countries still working within inadequate or antiquated legal frameworks related to alternative care, cultural attitudes which at times promulgate only the benefits of institutional care and not the negative effects, and a donor community which has been slow to recognize that providing funds for family and community-based care is more cost effective and beneficial to the majority of OVAC than institutional care. Recognizing these factors does not justify institutionalization; rather, it is acknowledgement of a current dynamic which must be dealt with in the longer term goal of promoting family-based care as priority within the continuum of care. Therefore, a pragmatist approach includes the development of a child welfare strategy with both short-term and long-term plans that include a continuum of care approach with the bulk of care options being family-based. Institutional care should be considered only in exceptional and emergency circumstances and until a system of family-based alternative care can be established. Institutional care should not be the preferred option but rather the last resort. However, when it is provided as an option, there are components to that care, outlined in this article, which should be included within the organizational and programmatic structure. The components are vital to children’s - 27 physical, psychosocial and intellectual development and wellbeing. 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