Shining a light on the injustice of institutionalization and the damage it causes to children – to promote care reform across the globe

 The Lancet Commission on Institutionalisation and Deinstitutionalisation of Children

Across the world between 5-6 million children and young people live in non-family based institutional facilities – many in extremely impoverished conditions lacking many resources, experiences and opportunities necessary for normal human development. Such a situation is recognised as a major threat to normal child development and mental health, a drain on human capital within communities and wider societies and an infringement of the rights of the child to grow up in a family. Great progress has been made in some countries at addressing this scandal by reducing the reliance of institutional options and replacing them with safe family-based alternatives. However, the problem is still very serious in other regions.

Motivated to shine a light on this often overlooked problem, and the need to highlight the global scale and significance of its impacts on the mental health and wellbeing of children across the world, the editors of The Lancet Psychiatry and The Lancet Child & Adolescent Health, Niall Boyce and Jane Godsland, approached me to set up a Lancet Group Commission. They knew me from my work demonstrating the long-term adverse effects of institutional care the ERA study published in The Lancet in 2017. My initial brief back in autumn of 2017 was to put together a team of world authorities on child-care research, practice and policy to write an evidence-based policy-focused review addressing the issue of institutional care across the globe. Of course, I agreed – excited by the opportunity that this would have to reshape the international discussion about institutional care and to promote real change in real people’s lives across the globe. There was also a certain sense of trepidation – given the daunting scale of the task at hand. The publication of the two yolked papers of the Lancet Commission represents the fruits of the labour of a wonderfully talented and hard-working set of colleagues (too many to list individually here) – who through their efforts they have clearly demonstrated their humanity through their commitment to the world’s most vulnerable children and their families.

At the core of our work was the conviction that policy and practice reform in this, as any other areas, must be based on a rigorous evaluation of evidence: The first step was therefore to carefully examine the claims of the negative effects of institutional care and the benefits of deinstitutionalisation.  We saw very quickly how fragmented and scattered that evidence was. It came in very different forms of study using myriad different designs. So, we quickly realised that a full systematic review was going to be required. This meant some seriously heavy lifting. In Marinus Van Ijzendoorn and Marian Bakermans-Kranenburg and their team, we were blessed with the world’s leading experts in this area of work.

As the review started to take shape our policy experts got to work. Again, the enormity of the challenge became apparent very quickly. In particular, we needed to create a comprehensive framework if we were going have an impact on the lives of institutionalised children – we needed to motivate change at every level of the political and social care system – addressing powerful global organisations, national governments as well as local policy-makers and practitioners. This recognition shaped our work and eventually structured our commission’s recommendations. What was very striking to me as Chair of the Commission and a non-expert on policy reform, was how readily consensus about the key recommendations was achieved. Although, all authors played a vital part in developing our policy recommendations – I would like to highlight in particular the pivotal role that Philip Goldman – without his drive it’s unlikely this would have come together.

The hard work is done now the hard work begins! It’s vital that this Commission is not simply lauded and then forgotten, or its impact only felt in academic papers or within high level policy documents – its recommendations need to have the legs to impact the grass roots in order to  transform the lives of children, their families and communities. The long road of dissemination-to-implementation starts now.

Access the papers and the executive summary here free of charge. Please note that these articles are available free of charge via The Lancet website, though registration is required to access them.

https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30089-4/fulltext

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30399-2/fulltext

https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(20)30060-2/fulltext

Professor Edmund J S Sonuga-Barke, FBA, FMedSci

King’s College London, UK

Chair of the Lancet Group Commission on Institutionalisation and Deinstitutionalisation of Children.