This interview focuses primarily on the mental health needs of children in care and, with this objective, has been divided into three sections: exploring institutional care, family and community-based care, and the context in South Asia, respectively.Institutional Care
Children in institutional care have suffered significant trauma in separation, as well as with issues embedded in dysfunctional families, prior to entering care. What are some of the impacts of institutional care on the mental health of children? How do they influence their growth and developmental outcomes?
The course of world de-institutionalisation policies began when international child researchers studied the effects of deprivation in Romania and Bulgaria in the 1990s (Charles Zeanah, the Michael Rutter Group). These orphanages were substandard and comparable to concentration camps. Children spent most of their time in beds with no stimulation or physical or emotional interaction with caregivers. As a result, the children’s brain development was severely impaired: low brain weight, lack of brain network formation, stunting, dwarfism and extreme infant mortality due to low brain activity.
Surviving children developed ‘institutional autism’, extremely aggressive or withdrawn behaviours, and some developed a psychopathic personality. As an adoption expert and consultant for Danish state, I saw many adoptive families break down, especially overwhelmed by older children’s problems and their inability to attach to new parents. Many children had to be replaced to specialised institutions.
What are some of the factors in institutional care that lead to such outcomes? In your opinion, are these consistently observed across care institutions globally? What are some of the developmental markers for trauma that you consider important for placement?
Even though there is little scientific evidence that group care is less effective than family-based care, the negative experiences described above caused UNICEF to ask all countries in 2009 to close their orphanages, reconfirmed at the December 2019 declaration signed by 193 countries.
The mindsets and role of caregivers, and their continuous training, support and supervision, play an important role in providing safe environments to children. Caregivers must see themselves as parents and not only as care professionals; they should learn to perform relational work and include children in daily activities; they should create social and emotional bonds with each child; and act as secure attachment figures and parental substitutes.
Sixty years of research in lifelong success for placed children shows five dimensions of quality care: a long-term secure attachment relation with one or two close caregivers and a long-term membership of a group of peers; having friends is very important for developing social networking skills as a care-leaver and an adult; one caregiver per four to six children; educated and supervised caregivers.
Caregiver's well-being and knowledge are directly related to their ability to provide loving care; social isolation or overwhelming numbers of children is detrimental to secure care capacity and agreement between shareholders in the child’s placement and attachment. If, for example, divorcing parents fight over a child, or the foster family and biological family, or caregiver staff and social worker are in conflict, the child’s development and school performance declines. ‘Quality in care’ need not necessarily depend on placement type.
Unfortunately, international policies are not focused on quality care standards, but only on de-institutionalisation. This creates a host of challenges. I am not for or against de-institutionalisation, but it has become an ideological mantra project as the cure for all problems, demonising group care in all its forms. In my view, challenges and the concept of improvement vary from country to country and from child to child. For this reason, I prefer an array of solutions and a longer time perspective in implementation.