De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward

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De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
Working paper

De-institutionalisation and
quality alternative care for
children in Europe
Lessons learned and the way forward
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
Find this document online at http://tinyurl.com/d-i-workingpaper

            Eurochild is a network of organisations         o give children and young people
                                                           T
            and individuals working in and across          in Europe a voice by promoting
            Europe to improve the quality of life of       participatory methods in child and
            children and young people.                     family services, raising children’s
                                                           awareness of their rights and
            We envisage a Europe where every child         supporting child and youth led
            grows up happy, healthy and confident,         organisations.
            and respected as an individual in his/her
            own right. We work :                         Eurochild currently has 117 full and 36
                                                         associate members across 35 European
               o promote wide recognition of
              T                                          countries. For more information:
              children as individual rights holders;
              To convince policy and decision           Eurochild, Avenue des Arts,
               makers to put the best interest of the    1-2 - B-1210 Brussels - Belgium
               child in every decision affecting them;   T +32 (0)2 511 70 83
               To encourage all those working with      F +32 (0)2 511 72 98
                and for children and their families to   info@eurochild.org
                take a child-centred approach;           www.eurochild.org

            Acknowledgments
            This Working Paper was written by            The work is financially supported by
            Michela Costa (Eurochild Policy Officer)     Hope and Homes for Children, UK and
            with valuable inputs from members of         by the European Union Programme
            the Eurochild Thematic Working Group         for Employment and Social Solidarity
            ‘Children in Alternative Care’.              - PROGRESS (2007-2013). For more
                                                         information see: http://ec.europa.eu/
            Contact:                                     progress. This publication is produced
            Michela Costa, Policy Officer                with the support of the European
            +32 2 211 05 59                              Commission but does not necessarily
            michela.costa@eurochild.org                  express its views.

            October 2012

2
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
Table of contents
Executive summary                                                              4

Glossary                                                                       6

1. De-institutionalisation in the European context                             8
		         1.1. The origin and development of institutions in Europe           8
		         1.2. Transition towards family and community-based care             9

2. Why should we close the remaining children’s institutions in Europe?       10
		         2.1. Evidence from child development literature and neuroscience   10
		         2.2. Equity and social inclusion                                   12
		         2.3. Human rights framework and EU commitments                     14
		         2.4. Long term cost-effectiveness of reforms                       16

3. The way forward: prevention and quality alternatives                       18
		         3.1. Preventing separation of children from their families         18
		         3.2. Quality family and community-based care                       21
		         3.3. Leaving care                                                  25

4. How can de-institutionalisation be achieved in practice?                   27
		         4.1. Lessons learned at national level                             27
		         4.2. Use of the structural funds                                   30

5. Conclusion and recommendations                                             32

References                                                                    34

                                                                                   3
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
Executive summary

    Eurochild is a network of organisations                   factors, disability and discrimination
    and individuals working in and across                     rather than to protection from abuse and
    Europe to improve the quality of life                     neglect.
    of children and young people. Our
    work is underpinned by the principles                     Children without parental care
    enshrined in the United Nations                           continue being placed in segregating
    Convention on the Rights of the Child.                    residential care facilities, also known
    We have 117 full and 36 associate                         as institutions, in environments that
    members in 35 European countries1.                        are utterly inappropriate for their
                                                              emotional, physical, intellectual and
    Eurochild focuses on the inter-linkages                   social development. We all remember
    between poverty, social exclusion                         the horrors displayed by media and
    and children who are in, at risk of                       documentaries about institutions for
    going into, or leaving alternative care2,                 children in Central and Eastern Europe
    and believes that the transition from                     after the fall of authoritarian regimes.
    institutional to community-based care                     A lot has changed over the last decades,
    (‘de-institutionalisation’) is an urgent                  and several EU countries have taken
    priority for EU action3.                                  steps to dismantle their institutional care
                                                              systems. However, institutionalisation
    The UN Convention on the Rights of                        of children is still a reality in several
    the Child (UNCRC) clearly recognises                      Member States and much more needs
    that the ideal setting for a child to grow                to be done before it becomes history
    up is within a family environment that                    in Europe.
    provides an atmosphere of happiness,
    love and understanding4. The family                       Despite progress, a dual approach
    “should be afforded the necessary                         continues to prevail in many countries
    protection and assistance so that it can                  currently engaged in reforming their
    fully assume its responsibilities within                  childcare systems. Large numbers
    the community”5.                                          of children are transferred into family
                                                              and community-based care, but
    Two decades after the entry into force                    institutions are still perceived as
    of the UNCRC, these principles are still                  good enough for certain groups,
    unevenly understood and implemented                       such as children with disabilities.
    across the EU. Too many children are                      Furthermore, a clear disconnection
    separated from their families, and too                    exists between the reforms taking
    often without appropriate reasons.                        place in the childcare system and the
    In a climate of financial crisis and                      situation of adult services: many de-
    widespread cuts on essential services,                    institutionalised children end up being
    the entry of children into alternative care               re-institutionalised when they grow up,
    is frequently linked to socio-economic                    an experience which is particularly tragic
                                                              and detrimental for their well-being.

    1	Eurochild, at http://goo.gl/qL62g                          Member States and candidate countries in relation
    2	Eurochild, Call for Action on Quality of Alternative       to institutional care reform. The Group’s work
       Care for Children Deprived of Parental Care,               encompasses children, people with disabilities
       March 2010.                                                including people with mental health problems, the
    3	Since 2010 Eurochild is also member of the European        elderly, families and service providers.
       Expert Group on the Transition from Institutional to   4   United Nations Convention on the Rights of the Child
       Community-based Care, which aims to serve as                (UNCRC), Preamble.
4      an informal advisory body to European institutions,    5    Idem.
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
This paper aims to raise awareness                         alternatives is often less expensive
on the perverse effects of                                 and certainly more effective than
institutionalisation on children and                       investment in institutional care, but
it calls for comprehensive system                          additional costs arise during the
reforms, starting with a transition                        phase of transformation (infrastructure
towards family and community-based                         costs, retraining and recruitment of
care. The UN Guidelines for the                            social workers, strengthening of child
Alternative Care of Children clearly                       protection systems, development of
speak in favour of such evolution:                         prevention strategies and alternative
“where large residential care facilities                   services, etc.). Rapid progress only
(institutions) remain, alternatives should                 happens when additional resources
be developed in the context of an overall                  are mobilised.
de-institutionalisation strategy, with
precise goals and objectives, which will                   By financing de-institutionalisation
allow for their progressive elimination”6.                 and supporting the creation of quality
                                                           services for families and communities,
In the past decades, Eurochild                             the European Structural Funds can
members have been involved in                              allow Member States to dismantle the
closing down institutions, supporting                      obsolete system of institutions while
children and families through early                        shifting towards prevention and high
intervention, prevention services and                      quality alternative care. Negotiations for
gatekeeping and providing quality                          the new Cohesion Policy 2014-2020
alternative care. Experience shows that                    represent an extraordinary momentum
de-institutionalisation is possible                        for achieving a profound transformation
and States can achieve structural                          of children’s services across Europe,
transformations in order to offer every                    and all efforts must be mobilised to
child a better life. Building on these                     catalyse lasting change.
experiences, the paper collects key
messages and lessons learned                               Last but not least, the upcoming
which could inspire the restructuring of                   European Commission
children’s services on the ground.                         Recommendation on child poverty
                                                           and child well-being, due to be
Eurochild strongly believes that the                       adopted in 2013, creates a window of
EU is in the position to support and                       opportunity to address the linkages
coordinate Member States’ actions in                       between poverty, social exclusion and
this regard. The upfront investment in                     children in alternative care.
de-institutionalisation is absolutely
critical, with immediate positive and                      Eurochild calls for a renewed political
sometimes lifesaving outcomes on                           engagement - coupled with an
children in institutions but also long-                    investment of European and national
term effects for the society at large,                     resources - to prevent separation of
including reduction of dependency                          children from their families, to protect
and higher social inclusion. However,                      the rights of children in alternative care
in many countries an important barrier                     and to improve the quality of the care
to reforms is the high cost of transition                  provided to them.
from the old system of institutions to a
reformed one7. Investment in prevention                                            Eurochild, October 2012
and family and community-based

6	Resolution adopted by the General Assembly 64/142,      7	Other obstacles are the lack of political will, the
   Guidelines for the Alternative Care of Children, June      persistence of evident conflicts of interest, the fear of
   2009, par. 23.                                             losing jobs for the care professionals, the tendency to
                                                              stigmatise families in difficulty, etc.

                                                                                                                      5
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
Glossary

    Abandonment                                             Family-based care
    Act by which the child has been left with               A form of alternative care in which the
    no care whatsoever, for example on the                  child is placed with a family other than
    street or in an empty dwelling. Often                   his/her family of origin (e.g. kinship care,
    colloquially used as a synonymous of                    foster care).
    relinquishment, i.e. the act by which the
    child has been surrendered to the care                  Foster care
    of others, for example in a maternity                   Situations where children are placed
    hospital8. (See also Separation, below).                by a competent authority for the
                                                            purpose of alternative care in the
    Alternative care                                        domestic environment of a family
    Care provided to children who are                       other than the children’s own family
    deprived of parental care.                              that has been selected, qualified,
                                                            approved and supervised for providing
    Community-based services                                such care10. Foster care placements
    Services directly accessible at the                     can respond to a number of diverse
    community level, such as:                               situations (e.g. emergency foster care,
      Family strengthening services:                       temporary foster care, long-term foster
       parenting courses and sessions,                      care, therapeutic foster care, parent
       promotion of positive parent-child                   and child foster care, etc).
       relationships, conflict resolution
       skills, opportunities for employment                 Gatekeeping
       and income generation and, where                     Set of measures put in place to
       required, social assistance, etc.;                   effectively divert children from
       Supportive social services, such as                 unnecessary initial entry into alternative
        day care, mediation and conciliation                care or, if already in care, from entry
        services, substance abuse treatment,                into an institution11 (e.g. family support
        financial assistance, and services for              as a prerequisite for the placement of
        parents and children with disabilities9.            children in alternative care, legal bans,
                                                            moratoria and economic disincentives
    De-institutionalisation of children                     for institutionalisation, etc.)
    Policy-driven process of reforming a
    country’s alternative care system, which                Institutional care
    primarily aims at:                                      Care taking place in (often large)
      Decreasing reliance on institutional                 residential settings that are not built
       and residential care with a                          around the needs of the child nor close
       complementary increase in family and                 to a family or small-group situation, and
       community-based care and services;                   display the characteristics typical of
       Preventing separation of children from              institutional culture (depersonalisation,
        their parents by providing adequate                 rigidity of routine, block treatment,
        support to children, families and                   social distance, dependence, lack of
        communities;                                        accountability, etc.).
        Preparing the process of leaving
         care, ensuring social inclusion for
         care leavers and a smooth transition
         towards independent living.

    8	UNICEF, At Home or in a Home? Formal Care and        11	
                                                               See UNICEF, At Home or in a Home? Formal Care
       Adoption of Children in Eastern Europe and Central      and Adoption of Children in Eastern Europe and
       Asia, 2010, pp. 52- 53.                                 Central Asia, 2010. See also Better Care Network
    9	See UN Guidelines for the Alternative Care of           website.
       Children, June 2009, par. 34.
    10	
       See UN Guidelines for the Alternative Care of
       Children, June 2009, par. 29

6
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
Kinship care                                             Separation
Family-based care within the child’s                     Separation of children from their parents
extended family or with close friends of                 following a decision from a competent
the family known to the child, whether                   authority or agency when there are
formal or informal in nature12.                          reasonable grounds to believe the child
                                                         is at risk15 (removal). In non-functional
Prevention                                               systems, parents in difficulty might
Intervention in the family or community                  decide to entrust their children to the
that enables children to stay in their                   care of the State due to insufficient
families as an outcome13, if this is in                  help or support (e.g. inability to cover
their best interest. Support can be                      food- or clothes-related expenses, pay
provided in several areas such as                        rent in order to avoid eviction or bills for
living conditions, family and social                     water, gas and electricity, etc.)16. In such
relationships, education, physical and                   circumstances, the term ‘separation’ is
mental health, household economy, etc.                   preferable to the term ‘abandonment’,
                                                         since the latter “tends to imply that
Residential care                                         these children have been completely
Care provided in any non-family-based                    deserted by their family and have little
group setting, such as places of safety                  or no hope of being reunited with their
for emergency care, transit centres in                   parents17”.
emergency situations, and all other
short- and long-term residential care                    Small group home
facilities, including group homes14.                     A type of residential care in which a
                                                         small group of children live in a house
                                                         in the community, and are cared for in
                                                         an environment that is as family-like as
                                                         possible18.

12	
   UN Guidelines for the Alternative Care of Children,   16	
                                                            See Hope and Homes for Children Romania, Best
   June 2009, par. 29.                                      Practice Guide for the Prevention of Child Separation
13	
   See Hope and Homes for Children Romania, HOW             from Families, 2012, p 6.
   TO DEINSTITUTIONALISE? HHC model for DI – brief       17	
                                                            See UNICEF, At Home or in a Home? Formal Care
   description of process, 2012.                            and Adoption of Children in Eastern Europe and
14	
   UN Guidelines for the Alternative Care of Children,      Central Asia, 2010, p. 7.
   June 2009, par. 29.                                   18	
                                                            See Save the Children UK, Child protection and Care
15	
   UN Guidelines for the Alternative Care of Children,      Related Definitions, October 2007.
   June 2009, par. 39.
                                                                                                                7
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
1.	De-institutionalisation
        in the European context
    1.1.	The origin and development
          of institutions in Europe

    Until the development of public social                       of children with disabilities was almost
    systems, families and communities                            automatic, while the model of care was
    shouldered the main responsibility                           predominantly medical and focused
    for taking care of their children and                        on deficiencies to be treated, instead
    relatives. Between the 19th and the 20th                     of individual rights and needs to be
    century a paradigm shift took place in                       fulfilled. The same medical approach
    the culture of services across Europe,                       was used also for the care of newborns
    as the State began to assume                                 and young children under the age of
    responsibility to provide food, shelter,                     three, clearly lacking understanding of
    clothing and treatment for different                         attachment theories and the importance
    categories of individuals. Large                             of individualised care.
    residential facilities were established
    for children without parental care,                          It is hard to outline a common definition
    persons with mental health problems,                         of ‘institutions’ applicable to the wide
    persons with disabilities and old people,                    diversity of national contexts across
    often hosting hundreds of users.                             Europe. However, a few recurring
                                                                 elements seem to characterise
    Initially seen as a positive intervention                    institutional care and constitute what
    by public authorities, institutionalisation                  has been referred to as ‘institutional
    rapidly became a ‘one size fits all’                         culture’19:
    solution for all sorts of social issues:
    poverty, disability, social exclusion, lack                     epersonalisation
                                                                   D
    of services in the community, parents’                         Rigidity of routine
    inability to reconcile family and work,                         Block treatment
    neglect and abuse. In socialist regimes                          Social distance
    from Central and Eastern Europe,
    ‘dysfunctional’ families and individuals    Dependence, lack of accountability
    were often perceived as not willing to      and social, emotional and
    be integrated into the society. Parents’    geographical isolation are also typical
    difficulty to care for their children was   of this kind of care settings. Size and
    seen as an individual failure to be solved  number of residents are not the only
    through State intervention, with public     elements to classify a residential care
    authorities openly encouraging parents      facility as an institution, although they
    to place their children in institutions and do appear to be proportionally related to
    even using it as a measure to sanction      the presence of an institutional culture:
    dissenting behaviour.                       “the larger the setting, the fewer the
                                                chances are to guarantee individualised,
    As a consequence, large-scale,              needs-tailored services as well as
    segregating institutions proliferated       participation and inclusion in the
    across the region. The institutionalisation community”20.

    19 R
        eport of the Ad Hoc Expert Group on the Transition      20	
                                                                    Report of the Ad Hoc Expert Group on the Transition
       from Institutional to Community-based Care, 2009, p. 9.      from Institutional to Community-based Care, 2009, p. 9.

8
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
1.2.	Transition towards family
      and community-based care

Nowadays, there is growing consensus                     De-institutionalisation, therefore,
that institutional care is simply not                    is a strategy to get children out of
compatible with a human rights                           institutions but also to avoid new
approach. The mass-treatment typical                     placements. A thorough assessment
of institutions is utterly inadequate                    of the needs of each child should
for providing services in a modern                       be conducted to provide alternative
society, failing to recognise individual                 care solutions based on his/her best
requirements or empower users, families                  interest. Reforms should tackle the
and communities. Certainly, it is not a                  root causes of neglect, abuse and child
suitable system to meet children’s                       abandonment, and aim at preventing
rights and developmental needs.                          unnecessary separation of children from
                                                         their families through a broad range of
A number of countries have started to                    support measures.
progressively dismantle their institutional
care systems re-integrating children in                  The ultimate goals of the systemic
their families and communities, but the                  reforms are therefore to prevent the
process is still far from completion.                    need for alternative care, to protect the
De-institutionalisation – also known                     rights of children living in alternative
as the transition from institutional                     care and to improve the quality of the
to family and community-based                            care provided to them. The Guidelines
care - can be defined as a policy-                       for the alternative care of children, a
driven process of reforming a country’s                  United Nations framework (hereafter
alternative care system, which primarily                 referred to as ‘UN Guidelines’) shall
aims at:                                                 represent the fundamental framework
                                                         of reference21.
   ecreasing reliance on institutional
  D
  and residential care with a
  complementary increase in family and
  community-based care and services;
  Preventing separation of children from
   their parents by providing adequate
   support to children, families and
   communities;
   Preparing the process of leaving
    care, ensuring social inclusion for
    care leavers and a smooth transition
    towards independent living.

21	
   UN Guidelines for the Alternative Care of Children,
   June 2009

                                                                                                 9
De-institutionalisation and quality alternative care for children in Europe - Lessons learned and the way forward
2.	Why should we close the remaining
         children’s institutions in Europe?
     2.1.	Evidence from child development
           literature and neuroscience

     Research has largely demonstrated                              and impersonality typical of this form
     that institutional care is harmful for all                     of care, the insufficient children-staff
     individuals but in particular for children22,                  ratio, the limited availability of qualified
     causing long-term effects on their                             professionals and the inherent nature
     health and psychosocial development23.                         of shift work24. Under-stimulation can
     Children need much more than decent                            cause long-lasting deficiencies in terms
     material conditions: even the most                             of motor skills and physical growth25,
     modern and well-equipped institutions                          while absence of interaction and other
     fall short to provide the stimulation                          unresponsive care-giving practices
     and individualised attention, the                              result in poor cognitive performance
     educational and professional                                   and lower IQ scores, particularly when
     counselling, and when needed                                   institutionalisation takes place at an
     the customised early therapy and                               early age26.
     rehabilitation indispensable for a
     child to thrive.                                               Institutional care is particularly
                                                                    dangerous for infants between 0
     Children growing up in institutions                            and 3 years: “Early childhood, the
     are deprived of the possibility to                             period from 0 to 3 years, is the most
     develop a continuous attachment to a                           important developmental phase in
     primary caregiver, due to the rigidity                         life. The interactive influence of early

     22	OHCHR, Forgotten Europeans, Forgotten Rights –                damage”. Report of the Ad Hoc Expert Group on
         The Human Rights of Persons Placed in Institutions,           the Transition from Institutional to Community-Based
         2011, p.6.                                                    Care, 2009, p. 12.
     23	K. Browne, The Risk of Harm to Young Children in           26	
                                                                       R. Johnson et al, Young children in institutional
         Institutional Care, Save the Children, 2009, pp. 9 – 17.      care at risk of harm, 2006. See also the Bucharest
     24	J. Williamson, A. Greenberg, Families, Not                    Early Intervention Project, which examined the
         Orphanages, Better Care Network Working Paper,                effects of institutionalisation for brain and behavioral
         2010, pp. 5 - 6.                                              development on a sample of young children. Results
     25	“The effects of institutionalisation for children - even      showed that children raised in institutional care have
         where the institutions in question have good material         significantly lower IQs. Bucharest Early Intervention
         conditions and qualified staff - can include poor             Project, Caring for Orphaned, Abandoned and
         physical health, severe developmental delays, (further)       Maltreated Children, 2009, PowerPoint available
         disability, and potentially irreversible psychological        http://goo.gl/kQLVy.

10
experience and gene expression affect                     of several institutions for children with
the architecture of the maturing brain.                   disabilities unveiled a shocking scenario
(…) Impact on physical and cognitive                      of malnutrition and negligence, resulting
development, on emotional security and                    in an appalling number of child deaths29.
attachment, on cultural and personal
identity and developing competencies                      In the same line, the UN Secretary
can prove to be irreversible”27. The                      General’s study on Violence against
harmful effects of institutionalisation                   Children explicitly recommended
are evident also on older children, often                 that family-based care should be the
proportionally to the length of stay.                     only option for infants and very young
                                                          children30. Finally, the UN Committee
Furthermore, institutions display a grim                  on the Rights of the Child recognised
record of neglect, abuse and violence.                    that institutions are a particular setting
In 2009, Eurochild’s member Nobody’s                      “where children with disabilities are more
Children Foundation conducted a survey                    vulnerable to mental, physical, sexual
to illustrate the patterns of violence                    and other forms of abuse as well as
against children in institutions, reporting               neglect and negligent treatment”31.
an incidence of sexual abuse equal to
twice that in the general population28. In
another Member State, the inspection

27	
   UNICEF, Call for Action: End placing children under       dimensions of the violence against children raised in
   three in institutions, 2011. According to the UN          the residential institutions, Warsaw, 2009-2010.
   Committee on the Rights of the Child, the definition   29	
                                                             Y. B. Tavanier, Someone must be held responsible,
   of early childhood should be extended to encompass        Bulgarian Helsinki Committee, 24 September 2010.
   all children below the age of eight: Committee on      30	
                                                             United Nations Secretary-General, Report on Violence
   the Rights of the Child, General Comment No. 7 -          against Children, 2006, par. 112.
   Implementing child rights in early childhood, 2005,    31	
                                                             UN Committee on the Rights of the Child, General
   par. 4.                                                   Comment No. 9 - The rights of children with
28	
   Nobody’s Children Foundation, Sexual violence             disabilities, 2006, par. 47.
   against children - Study of the phenomenon and

                                                                                                              11
2.2.	Equity and social inclusion

     Not only too many children still enter              of factors, such as: poverty, inadequate
     the system of institutional care: too               housing, single parenthood, lack of
     often, they are separated from their                gynaecological coverage and family
     families without appropriate reasons.               planning (resulting in unwanted/
     Poverty, ethnic origin and disability               unmonitored pregnancies), lack of
     are still important factors leading to the          parenting skills, lack of access to welfare,
     placement of children across Europe,                lack of support from the extended family,
     proving the need to act upon the issue              unemployment, lack of access to day-
     as a fundamental question of non-                   care and specialised services for children
     discrimination and equal opportunities.             with disabilities, health conditions of
     According to recent studies, children               children or parents, substances misuse,
     of Roma origins are overrepresented in              stigma and discrimination. If these
     institutional care in several EU countries          factors are not properly addressed, the
     and experience less favourable treatment            situation in the family can escalate and
     during their stay in the alternative care           lead to neglect, abuse and violence.
     system, as well as lower chances to be
     transferred into family-based settings32.  To complicate matters, institutions
                                                often put a label of stigma on children -
     Mostly, the cause for institutionalisation regardless of their age or circumstances
     is not a single issue but a combination - and heavily reduce the chances of

     32	
        European Roma Rights Centre, Bulgaria Helsinki
        Committee, Milan Šimečka Foundation and
        osservAzione, Life Sentence: Romani Children
        in Institutional Care, 2011.

12
successful future integration. The                       The impact of the economic crisis
effects of institutionalisation are likely               is clearly perceptible across Europe,
to continue after the child reaches                      and its effects will be felt long after
eighteen years old, triggering a range of                the economy has started to recover.
problems in adulthood and affecting the                  Rising unemployment and widespread
youngster’s adaptation to “other related                 cuts on social benefits and services
environments, like that of the educational               are hitting hard on the most vulnerable
system, and later, the very adaptation to                families, putting a growing pressure
social and professional life”33. As a result,            on parents’ ability to provide for their
the population of care leavers ranks                     children. Anecdotal evidence35 already
particularly high on statistics of school                shows an increase of referrals to the
dropouts, unemployment, homelessness,                    child protection system, with worrying
criminality and unstable parenting                       indications that some families are forced
patterns34, originating a vicious circle                 to place their children in alternative care
of intergenerational transmission of                     because of long-term unemployment and
poverty and social exclusion.                            severe material deprivation - including
                                                         malnutrition and homelessness36.

33	
   Hope And Homes For Children Romania, Save The         35	See Eurochild Report, How the economic and
   Children Romania, Procedure Guide for the Social          financial crisis is affecting children & young people
   Integration of Youngsters Leaving the National Care       in Europe, January 2011.
   System/H.H.C. Romania, Baia Mare: Europrint,          36	C. Hadjimatheou, The Greek parents too poor
   2006, p. 9.                                               to care for their children, BBC World Service, 10
34	
   See also E. Munro, M. Stein (eds.), Young People’s        January 2012, at http://goo.gl/qWBk5, See also
   Transitions from Care to Adulthood, International         Spiegel TV: http://goo.gl/4ZNsQ.
   Research and Practice, Jessica Kingsley, 2008.

                                                                                                                     13
2.3.	Human rights framework and EU commitments

     The EU and the Member States have                  The rights and principles enshrined
     important responsibilities concerning              in the UNCRPD do not replace, but
     protection and promotion of children’s             reinforce the provisions of the UNCRC:
     rights. All Member States have ratified            the UNCRPD’s Preamble clarifies that
     the UN Convention on the Rights of                 “children with disabilities should have
     the Child (UNCRC), while following the             full enjoyment of all human rights and
     entry into force of the Lisbon Treaty              fundamental freedoms on an equal
     the promotion of the rights of the child           basis with other children”, and recalls
     became one of the objectives of the                “obligations to that end undertaken by
     Union. The treaty also incorporates the            States Parties to the Convention on the
     Charter of Fundamental Rights, which               Rights of the Child”40.
     states that “every child shall have the
     right to maintain on a regular basis a             In addition to international covenants,
     personal relationship and direct contact           non-binding instruments such as the
     with both his or her parents, unless that          UN Guidelines for the Alternative
     is contrary to his or her interests”37.            Care of Children represent an essential
                                                        reference, clarifying that “States should
     In addition, the EU and a majority                 develop and implement consistent and
     of Member States have ratified the                 mutually reinforcing family-oriented
     UN Convention on the Rights of                     policies designed to promote and
     Persons with Disabilities (UNCRPD),                strengthen parents’ ability to care
     which upholds the equal right of all               for their children”41. The Council of
     persons with disabilities to live in the           Europe Recommendation on the
     community38. Art. 23 of the UNCRPD                 rights of children living in residential
     provides a clear framework of reference            institutions42 establishes important
     concerning children and alternative                principles to be applied whenever a
     care: “States Parties shall, where the             child is placed outside the family, while
     immediate family is unable to care for a           the WHO European Declaration on the
     child with disabilities, undertake every           Health of Children and Young People with
     effort to provide alternative care within          Intellectual Disabilities and their Families
     the wider family, and failing that, within         puts emphasis on the right to grow up in
     the community in a family setting”. The            a family environment43.
     Convention clarifies that “in no case shall
     a child be separated from parents on the           In parallel to legal requirements,
     basis of a disability of either the child or       there is a clear connection between
     one or both of the parents”39.                     de-institutionalisation and political

     37	
        Charter of Fundamental Rights of the European   41	
                                                           UN Guidelines for the Alternative Care of Children,
        Union, art. 24.                                    June 2009, par. 33.
     38	
        UN Convention on the Rights of Persons with     42	
                                                           Council of Europe, Recommendation on the rights of
        Disabilities (UNCRPD), art. 19.                    children living in residential institutions, 2005.
     39	
        UNCRPD, art. 23.                                43	
                                                           WHO, European Declaration on the Health of Children
     40	
        UNCRPD, Preamble.                                  and Young People with Intellectual Disabilities and
                                                           their Families, 2010.

14
commitments undertaken by the EU                            The disproportionate representation
across different policy areas. Within                       of Roma children in institutions
the Europe 2020 strategy to become                          should also be a major concern when
a smart, sustainable and inclusive                          implementing the EC Communication
economy in the coming decade, the                           ‘An EU Framework for National Roma
EU and the Member States have                               Integration Strategies up to 2020’47.
pledged to deliver high levels of social                    The long-term benefits of high-quality
cohesion and identified specific targets                    education and care in early years for
for improving education and fighting                        children coming from a disadvantaged
against poverty and social exclusion44.                     background were also outlined by the
                                                            EC in a Communication on Early
The links between poverty and children                      Childhood Education and Care48.
in alternative care must be taken into
account by the Europe 2020 Strategy.                        Regrettably, recent work of the European
The European Platform against Poverty                       Commission’s DG Justice hasn’t given
and Social Exclusion acknowledged                           due attention to children in/at risk of
that over 20 million children are at risk                   entering alternative care, who were not
of poverty in today’s Europe45: Eurochild                   singled out as a vulnerable group nor
advocates that the upcoming European                        were acknowledged by the EU agenda
Commission’s Recommendation on                              on the rights of the child49. Current
Child Poverty and Well-being should                         efforts addressing priority groups such
include a strong commitment for the de-                     as missing children, children victims
institutionalisation of children, including                 of violence, trafficked or sexually
prevention and support to vulnerable                        exploited should be more underpinned
families.                                                   by a comprehensive strategy to support
                                                            families and children at risk and prevent
The European Commission made                                children and infants from being taken
further commitments towards de-                             into care, as this group of children is
institutionalisation in the context of the                  particularly likely to be experiencing the
European Disability Strategy 2010-                          most extreme violations of their rights.
2020, by proposing to use Structural                        The 2011 report of the EU Agency for
Funds and Rural Development Fund                            Fundamental Rights, in fact, outlined the
to support community-based services                         persistence of several cases of violence
and pledging to raise awareness of the                      against children in institutions across EU
situation of persons with disabilities                      Member States, which was recognised
living in residential institutions, especially              as a particularly heinous form of child
children and elderly people46.                              abuse50.

44	
   European Commission Communication ‘EUROPE                47	European Commission Communication ’An EU
   2020 - A strategy for smart, sustainable and inclusive       Framework for National Roma Integration Strategies
   growth’, March 2010.                                         up to 2020’, April 2011.
45	
   European Commission Communication ‘The                   48	European Commission Communication ‘Early
   European Platform against Poverty and Social                 Childhood Education and Care: Providing all our
   Exclusion: A European framework for social and               children with the best start for the world of tomorrow’,
   territorial cohesion’, December 2010.                        February 2011.
46	
   European Commission Communication ‘European              49	European Commission Communication ‘An EU
   Disability Strategy 2010-2020: A Renewed                     Agenda for the Rights of the Child’, February 2011.
   Commitment to a Barrier-Free Europe’,                    50	European Union Agency for Fundamental Rights
   November 2010.                                               (FRA), Annual Report ‘Fundamental rights: challenges
                                                                and achievements in 2010’, 2011, pp. 70-72.

                                                                                                                    15
2.4.	Long term cost-effectiveness of reforms

     There is a common misperception that                    box below). Nonetheless is it important
     large residential settings are much                     to remember that high quality family
     cheaper than family and community-                      and community-based care can be
     based alternatives. The concept of                      expensive, particularly for children with
     ‘economy of scale’ is often recalled in                 complex and special needs. The quality
     this regard, with scarce consideration for              of life of the child should be recognised
     quality standards and fundamental rights                as an essential component of the cost-
     entitlements.                                           benefit analysis.

     The comparison is of course flawed.                     However, quite aside from the human
     Poor quality institutional care can be                  rights argument, providing the best
     cheaper than high quality family and                    quality care alternatives possible is
     community-based care51 but is likely                    cost-effective from a complete systems
     to be more costly to public authorities                 approach. A comprehensive reform of
     in the long-term due to social welfare,                 children’s services - with a strong focus
     health and public security costs. In                    on early intervention, family support
     countries with well-equipped residential                and re-integration - can allow public
     care services, the costs are likely to                  authorities to make substantial savings
     be higher or comparable to family and                   in the long-term.
     community-based alternatives (see

     51	
        “Community-based alternatives (…) can provide           the basis of comparable needs of residents and
        better results for users, their families and the        comparable quality of care”, Report of the Ad Hoc
        staff while their costs are comparable to those         Expert Group on the Transition from Institutional to
        of institutional care if the comparison is made on      Community-based Care, 2009, p. 5.

16
Comparing the cost of alternative care solutions
According to a UK study from 2008,                     costs of all aspects of social care
the average cost for maintaining a child               (capital and revenue costs). The
for a week in a residential placement is               publication indicates that the average
4.5 times that of an independent living                cost of residential care is £2,689 per
arrangement, 8 times that of the cost for              child per week, as compared with
foster care, 9.5 times that of a placement             foster care which is £67653.
with family and friends, and more than
12.5 times that of a placement with own                A report from the Estonian National
parents. 8 children could be placed in                 Audit Office showed that the state
foster care for every child placed in a                pays between 10,000 and 16,000
residential unit52.                                    kroon per month for each child raised
                                                       in a substitute home, compared to
The Department of Health in England                    3000 kroon per month for each child
funds research every year into the unit                in foster care54.

             52	
                H. Ward, L. Holmes, J. Soper, Costs and                53	
                                                                          University of Kent, Personal Social Services Research
                consequences of placing children in care, Jessica         Unit, Unit Costs of Health and Social Care 2010,
                Kingsley Publishers, 2008, in Report of the Ad Hoc        (Compiled by L. Curtis), 2010, pp. 106 - 108.
                Expert Group on the Transition from Institutional to   54	
                                                                          Estonian National Audit Office, at:
                Community-Based Care, 2009, p. 13.                        http://goo.gl/tEGmN.

                                                                                                                           17
3.	The way forward: prevention
         and quality alternatives
     3.1.	Preventing separation of
           children from their families

     Comprehensive prevention strategies                          ervices for parenting capacity-
                                                                 S
     can be extremely effective to ensure                        building;
     child well-being, build positive social                     Emergency services to work with
     capital and ensure that no child is taken                    parents at risk (e.g. counselling,
     into alternative care as a consequence                       parenting support, emergency
     of poverty, disability, prejudice or social                  reception centres where children at risk
     exclusion. Support services must be                          of neglect or abuse can be placed on
     put in place to strengthen parental                          a short term basis, emergency foster
     responsibility, empower families most at-                    care);
     risk and avoid escalation of problems.                       Out of school programmes, after
                                                                   school care;
     Universal measures and benefits                               Specialised services and financial
     should be coupled with targeted                                support for children with special/
     support for families and children at risk.                     complex needs (including educational
     A broad range of services should be                            centres and temporary foster care
     available in order to address problems                         offering respite to parents);
     arising at different stages, including:                        Community centres for facilitating
                                                                     the search of employment for both
        amily planning;
       F                                                             children coming out of institutions
       Pre-natal care;                                              (young adults) and family/community
        Preventing abandonment at birth                             members.
         (e.g. emergency support at the level
         of maternity wards – social workers,                  The services can be concentrated in a
         psychologists, medical professionals                  local centre (‘one-stop-shop’ model),
         etc., rooming in55, breastfeeding                     serving the whole community and
       support, Mother and Baby Units, parent                  providing a wide range of options for
       and child foster care placements, etc.);                help and support, while at the same
         Early childhood services (e.g. day-care              time encouraging inclusion56. Financial
          centres where children can learn and                 transfers, child benefits, disability
          play while their parents find work to                allowances, social housing and other
          support their family, early education for            anti-poverty measures are also crucial to
          children with disabilities, etc.);                   prevent family separation.

     55	Rooming in’ is an arrangement in a hospital whereby   56	
                                                                  Hope and Homes for Children, Preventing family
         a newborn infant is kept in a crib at the mother’s       breakdown, at: http://goo.gl/3PRFg.
         bedside instead of in a nursery.

18
High quality, free and accessible pre- and post-natal care and health visits are
good examples of providing services to families in their homes and on an outpatient
basis. A specially trained ‘health visitor’ uses a public health approach that is non-
stigmatising, universal, and helps to identify children at risk. The health visitor has
an obligation to refer the family to social services if needed. Hospital social workers
are another way of preventing institutionalisation of new-borns, by providing the
necessary information and support to the pregnant woman at risk and to her family
prior or after the baby is born. The Sure Start program also offers community-based
programs for families – primarily mothers – with young children57.

It should be specified that family-                         On the contrary, failure to support
support policies are not synonymous                         children coming from specific family
with retrogressive or moralistic policies                   structures can be an important
defending a traditional definition of                       reason for institutionalisation. In some
family. Inclusive family policies must                      countries, 68% of the children entering
put children at the very centre, while                      the alternative care system come from
avoiding stigmatisation of parents and                      single parent families (especially single
discrimination between different family                     mothers), who face higher levels of
structures and family forms (e.g. lone-                     poverty and social exclusion58. Measures
parent families, unmarried couples, same-                   to promote inclusive family policies,
sex partners or parents, families having a                  granting non-discriminatory access to
migrant or refugee background, families                     social benefits, can play a pivotal role in
belonging to ethnic minorities, etc.).                      preventing the need for alternative care.

FARA Romania has been working with abandoned and orphaned children and
young people for 20 years, setting up family style homes, foster parents systems
and programmes to re-integrate young people into society. In order to ensure that
children with complex needs are not abandoned by their birth family, FARA Romania
developed specialist learning and development centres where both the child and
his/her family are provided with the support required to prevent separation. These
services have proven to be vital both for the children and for the parents, who are
now able to better cope with their child59.

57	
   Sure Start Children’s Centres, at: http://goo.gl/c4w0E   59	
                                                               FARA Romania, at: http://www.faracharity.org/
58	
   Data from Lithuania.

                                                                                                               19
Funded by the EU’s DAPHNE Programme, the project of the Social Activities and
     Practices Institute (SAPI, Bulgaria) A smack-free home for every child aims to raise
     parents’ awareness of the negative consequences of corporal punishment and any
     other cruel behaviour towards young children (aged 0-3) in the home environment,
     whilst at the same time enhancing parents’ practical knowledge on positive discipline
     methods. The target groups are:

        xpectant parents and parents of children under 3 years old;
       E
       Parents at risk of child abuse (due to social exclusion, addiction, financial hardship,
        past experience of violence, etc.);
        Professionals who work with parents;
         Policy- and decision-makers.

     Together with its partners Nobody’s Children Foundation (Poland), the Children
     Support Centre (Lithuania) and the Dardedze Centre (Latvia), SAPI raises
     awareness of corporal punishment’s harmful effects, runs a ‘train-the-trainers’
     programme and other educational activities for parents as well as seminars and
     conferences60.

     To make sure that the out-of-home                           Gatekeeping refers also to measures
     placement of children is seen as                            specifically aimed at reducing the
     a measure of last resort, efficient                         number of children entering institutions.
     gatekeeping measures must be put                            This can be achieved through legal
     in place - for instance, by ensuring                        measures (i.e. bans and moratoria - to
     that measures of family support are                         be introduced gradually and in parallel
     implemented as a prerequisite before                        to the development of quality alternative
     children can be moved into alternative                      care), as well as economic measures
     care. “Put differently, the separation of a                 - for instance, by creating incentives for
     child and his or her parents would only                     local authorities to provide preventative
     be possible if all other means of support                   community services instead of covering
     have been proven to be ineffective”61.                      the costs of (generally more expensive)
                                                                 institutional placements.

     60	Social Activities and Practices Institute,                 and Alternative Care. Final Report, Council of Europe
         at: http://goo.gl/NSXqa.                                   Working Group on Children at Risk and in Care, 2004,
     61	B. Gudbrandsson, Children in Institutions: Prevention      p. 48.

20
3.2.	Quality family and community-based care

In parallel to the progressive                                      are placed by a competent authority
dismantlement of institutions, it is a duty                         for the purpose of alternative care in
of public authorities to ensure access for                          the domestic environment of a family
children to family and community-based                              other than the children’s own family
alternative care. Whenever separation                               that has been selected, qualified,
from the parents is in the best interest of                         approved and supervised for providing
the child, an accurate evaluation must                              such care;
be carried out to identify appropriate                           Other forms of family-based or family-
solutions. This assessment of each                                like care placements;
situation must be done on an individual                           Residential care: care provided in any
basis, taking into account children’s                              non-family-based group setting, such
opinions and preferences in accordance                             as places of safety for emergency
with their evolving capacity. In light                             care, transit centres in emergency
of modern attachment theories and                                  situations, and all other short- and
evidence from neuroscience62, Eurochild                            long-term residential care facilities,
is persuaded that family-based care                                including group homes;
should be the only option for babies                               Supervised independent living
and young children (age group 0-3).                                 arrangements63: young people living in
                                                                    a flat, typically under supervision and
With respect to the environment where                               with support from a municipal contact
it is provided, alternative care may take                           person.
the form of:
                                                               Independently from the type of
    inship care: family-based care within
   K                                                           alternative care solution identified as the
   the child’s extended family or with close                   most appropriate for the child, quality
   friends of the family known to the child,                   must be regularly monitored following a
   whether formal or informal in nature;                       clear framework of reference focused on
   Foster care: situations where children                     outcomes for children.

SOS Children’s Villages, IFCO and FICE developed a set of quality standards
for out-of-home child and youth care in Europe, covering the four phases of
decision-making, admission, care-taking and out-of-care/leaving care. The method
of ‘storytelling’ chosen for data collection ensured direct participation of the
interviewees in creating the basis for the standards. The research items were stories
of good practices from parties who have experienced alternative care: children and
young people, parents, caregivers, social workers, lawyers, etc. A total of 332 stories
from 26 countries were collected and analysed. The standards have been widely
recognised at national level and by the international community working in Europe
as a key contribution to the development of policies and practice for children in
alternative care64.

62	See Attachment theory by John Bowlby, 1969.                64	
                                                                  SOS Children’s Villages, IFCO and FICE,
    See also K. Browne, The Risk of Harm to Young                 Quality4Childen Standards for out-of-home
    Children in Institutional Care, Save the Children, 2009.      child care in Europe, 2007.
63 UN Guidelines for the Alternative Care of Children,
    par. 29.                                                                                                  21
In 2002, the UK Government developed a set of National Minimum Standards for
     Foster care and Fostering Regulations, providing a framework of quality in which
     all fostering providers, local authorities and NGOs should develop their fostering
     services65.

     The UN Guidelines for the Alternative                 in daily activities. There can be a lack
     Care of Children specify that, if residential         of attachment and warmth to living
     facilities are put in place, these should             environments if small group homes
     be small and be organised around the                  are kept tidy and orderly, but without
     rights and needs of children, in a setting            personalising children’s spaces and
     as close as possible to a family or small             without any efforts to make the children
     group situation66.                                    feel ‘at home’. Job cuts reducing the
                                                           personnel often lead to a chronic under-
     According to Eurochild members’                       staffing in small group homes and impact
     experience, when children are placed                  negatively on children’s quality of life
     in new, smaller residential homes the                 and basic care. If new habits, mentalities
     managers of these services are key                    and ways of working with children are
     in relation to their running and the                  not introduced, then a new system of
     way in which children will be socially                family-like alternatives can easily turn into
     involved and encouraged to participate                “small institutions”67.

     65	UK Government, Department for Education,          66	UN Guidelines for the Alternative Care of Children,
         Fostering Services: National Minimum Standards,       par. 123.
         2011, at: http://goo.gl/AHnhj.                    67	Hope and Homes for Children Romania, 2012.

22
Since 1997 the ‘For Our Children’ Foundation (Bulgaria) is active in recruiting
foster parents and providing support to future foster carers throughout the entire
process and afterwards. This support includes:
  Telephone consultations to clarify the general motivation and possibilities that
   foster caring offers;
   Information meetings - meeting the candidates and their families to talk about
    foster care, the opportunities it provides to families and its positive effects for
    children;
    Providing support to collect the documents needed;
     Assessing foster candidates’ capacity, capabilities and parental skills;
      Training for candidates to understand what children expect and to learn more
       about abandonment effects and children with special needs;
       Presentation to the Commission in charge to approve applications in the
        municipality;
        ‘Matching’ the child with the candidate foster parents;
         Holding professional consultations by social workers and psychologists before and
          after the foster care placement (when the family experiences difficult situations,
          dilemmas or problems);
          Supporting trainings in order to help the approved foster carer to learn new things
           and provide quality care to children68.

Working together with the Kyustendil Municipality, the Cedar Foundation (Bulgaria)
successfully closed an institution for children and young adults with intellectual
disabilities even before the official start of the overall de-institutionalisation reform in
the country.

Four semi-detached houses built by the Cedar Foundation and two flats provided
by the municipality were turned into six small group homes in which the 24 former
residents of the institution now live – 4 in each. The services are State-funded, but
the Cedar Foundation has hired additional staff to ensure the quality of care and to
meet the individual needs of every child or young adult, thus bringing the number of
staff to double the mandatory number required by the national methodology for this
type of service. Three of the children are now attending mainstream school and all
of them participate in various activities such as attending a day-care centre, dance
classes and educational sessions outside of their homes. The continuous efforts
and initiative to socially integrate the children and young adults in the community is
paying off, as the community starts to perceive these children and young adults as
community members with the same rights to inclusion and well-being69.

68	For Our Children Foundation, at:            69	
                                                   CEDAR Foundation, at:
    www.detebg.org/en/.                            www.cedarfoundation.org/en/

                                                                                          23
Opened by Hope and Homes for Children Romania as a prevention service, the
     Mother and Baby Unit in Sighetu Marmației (Maramureș County) aims to prevent
     the separation of children from their mothers due to difficult circumstances by
     providing short term (up to one year) accommodation and by teaching them life skills
     necessary for independent living.

     The Mother and Baby Unit (MBU) functions in cooperation with the county’s other
     prevention services as well as with relevant community actors (such as employers
     and/or employment agencies) in order to provide a continuum of services for the
     mothers and their babies. The mothers, who are referred to the MBU or request help
     themselves, are at risk of separation from their child/children due to different reasons,
     the most frequent being lack of financial means, lack of acceptance by the larger
     family (especially if children are born out of wedlock) and abuse from the family,
     the father of the child/children or the current partner. Out of the 41 mothers and 71
     children who benefited from the services of the MBU, 97% were reintegrated in their
     communities with steady jobs (and therefore steady incomes) and with places to live
     (either rented or purchased, or with the birth/extended family)70.

     ARK’s de-institutionalisation programme in Stara Zagora (Bulgaria) focused on
     the prevention of abandonment and the development of alternative care services to
     enable the closure of institutions for children.

     The development of a small group home service was a critical component of
     the programme: “In order to promote de-institutionalisation, a range of alternative
     services are required. Family placement through reintegration to family, adoption
     or foster care will always remain the preferred option when planning for children in
     care. However, there are a significant number of children currently living in institutions
     who are unlikely to be reintegrated or placed with foster or adoptive families in
     the foreseeable future. In order to ensure that these children are not ‘left behind’
     and to make comprehensive de-institutionalisation possible, there is a need to
     develop alternative residential care services. The small group home service in ARK’s
     programme was designed with the aim of providing the best quality care possible
     for as long as necessary, pending the development of other services and whilst
     continuing to work actively to find family placements for all the children”71.

     70	Hope and Homes for Children Romania, at:   71	ARK Bulgaria, There’s no place like home - Creation
         http://hhc.ro/en/projects/.                    of a small group home service in Stara Zagora,
                                                        Bulgaria, 2006-2009.

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