Researchers in this week’s BMJ express concern over the largely hidden extent of institutional care for children in Europe.

Institutional care for young children is common throughout the WHO European region of 52 countries. Although institutional care for children in need is generally seen as most prevalent in eastern Europe, an estimated 43,842 (14.4 per 10,000) children under 3 are in institutional care within 46 countries of the WHO European countries.

There is convincing evidence that institutional care is detrimental to the mental, behavioural, emotional, and social development of young children.

For example, children in institutional care rarely have the opportunity to form an attachment to a parent figure or carer, and they spend less time on play, social interaction, and individual care than children in a family.

Is this evidence of harm being ignored, ask the authors?

Children who move from institutional into family care before the age of 6 months will probably recover their physical and mental development, but difficulties with social behaviour and attachments may persist, leading to a greater chance of antisocial behaviour and mental health problems, they write.

Although adoption is often used as an alternative to institutional care, adoption agencies and the parents they represent often assume that many children in residential care are orphans. Yet only 4% of young children in residential care have no biological parent living, stress the authors.

They recommend that children less than 3 years old should not be placed in residential care without a parent. In life threatening circumstances emergency institutional care may be essential, but the child should be moved into foster care as soon as possible.

They call for education and training for policy makers and practitioners on the appropriate care and placement of young children facing adversity.

Child protection legislation and interventions to deal with abusive and neglectful parents should also be developed in parallel with community services and alternative family based care for children, they conclude.