Jean-Luc DOUILLARDJean-Luc DOUILLARDClinical PsychologistClinical Psychologist

Regional health program coordinatorRegional health program coordinatorHospital of SaintesHospital of Saintes

FranceFrance

New DelhiNew DelhiMarch-14 March-14

20142014

Standards of Care Standards of Care and Mental Healthand Mental Health

of Institutionalised Childrenof Institutionalised Children

Working together for child protection

Improve our knowledge Share our good practices Encourage politicians to pass laws and to enforce

them Better identify and take better care of children who

suffering Improve initial and continuing training of caregivers Reduce mortality in children and adolescents

Some basic principles to take careSome basic principles to take care

We have first to enact laws for the protection of We have first to enact laws for the protection of children and apply them in each country in the children and apply them in each country in the best interests of each child best interests of each child

Protocols must be written and a social Protocols must be written and a social organization must exist for a collaborative organization must exist for a collaborative evaluation in each decision of placement evaluation in each decision of placement

Many actions of prevention and education to Many actions of prevention and education to health must exist in each country since birth to health must exist in each country since birth to adolescence at the same time that actions of adolescence at the same time that actions of parenting supportparenting support

We must do more researches and exchanges, we We must do more researches and exchanges, we have to take more political decisions and social have to take more political decisions and social institutions have to more engage with local institutions have to more engage with local associationsassociations

Each child at risk should receive high quality care in Each child at risk should receive high quality care in each country of the world , and his rights must be each country of the world , and his rights must be respected, respected, a girl with the same care that a boy a girl with the same care that a boy !!

The society is changing very quickly, we must adapt The society is changing very quickly, we must adapt our practices together with a great respect of each our practices together with a great respect of each culture and religion, culture and religion, and now with reality and tools and now with reality and tools of the digital worldof the digital world

We have all to form and to recognize the caregivers We have all to form and to recognize the caregivers and the volunteers for the great work they do all days and the volunteers for the great work they do all days

Specific duties Specific duties In decisions, procedures, and methods of placementIn decisions, procedures, and methods of placement

The right to their own identity and personalized project in the The right to their own identity and personalized project in the institution, equality of chance and respect for ethnic, religious, institution, equality of chance and respect for ethnic, religious, cultural, family, and social originscultural, family, and social origins

The right to be placed with his brothers and sisters if it is The right to be placed with his brothers and sisters if it is possible and to maintain regular contact with people close to possible and to maintain regular contact with people close to him him

The right to quality care, The right to quality care, especially with psychotherapies, especially with psychotherapies, athletic or artistic practicesathletic or artistic practices

The right to education and job training The right to education and job training opportunities on the same basis as other opportunities on the same basis as other children to become a citizen of the world, active children to become a citizen of the world, active and responsible and responsible

The right to be respected for their human The right to be respected for their human dignity and their physical integrity, including dignity and their physical integrity, including protection against corporal punishment and all protection against corporal punishment and all forms of violence forms of violence

The right to enforce its rights to an identifiable, The right to enforce its rights to an identifiable, impartial and independent authority impartial and independent authority and to participate in making decisions that and to participate in making decisions that affect themaffect them

How to do that ?How to do that ? All welcoming institutions for children and All welcoming institutions for children and

adolescents must be identified , accredited and adolescents must be identified , accredited and regularly assessed by a competent public authorityregularly assessed by a competent public authority

Each child must have a placement based on his Each child must have a placement based on his own abilities, skills and autonomy of each child, own abilities, skills and autonomy of each child, preparing for better future to life outside the preparing for better future to life outside the institution for the future institution for the future

The internal life of each institution shall ensure the The internal life of each institution shall ensure the possible development of the child, whether mental, possible development of the child, whether mental, emotional or physicalemotional or physical

They need stability of ties, many possibilites of They need stability of ties, many possibilites of creations, many relationships with other children creations, many relationships with other children in their families, in their occupations, gamesin their families, in their occupations, games

They need much time and different spaces to be They need much time and different spaces to be able to think of themselvesable to think of themselves

They need caregivers whose accept to be They need caregivers whose accept to be authentics and in the same way, robust, reliableauthentics and in the same way, robust, reliableand that know each other very well and that talk and that know each other very well and that talk to each otherto each other

Small units to a mode almost family life should be Small units to a mode almost family life should be encouragedencouraged

Diversity, multiple competence , stability fool staff are Diversity, multiple competence , stability fool staff are important standards. children must be able to attach important standards. children must be able to attach without fear, let go to their defense mechanisms and without fear, let go to their defense mechanisms and rebuilt with new benchmarks, more stable, and allow rebuilt with new benchmarks, more stable, and allow themselves to have real prospectsthemselves to have real prospects

Multidisciplinary teams must be provided with adequate Multidisciplinary teams must be provided with adequate resources in accordance with international codes of resources in accordance with international codes of deontology deontology

Their living spaces should be safe, comfortable Their living spaces should be safe, comfortable (everyone should have their own space to (everyone should have their own space to invest)invest)

They must have access to appropriate and They must have access to appropriate and varied psychotherapiesvaried psychotherapies

They must have rituals of meeting and They must have rituals of meeting and separation to grow, separation to grow, focus, then separate focus, then separate without tearing again, this is a challenge !without tearing again, this is a challenge !

In FranceIn France Children who are the subject of an act of abuse (victims of Children who are the subject of an act of abuse (victims of

physical abuse, sexual abuse, emotional abuse, severe neglect physical abuse, sexual abuse, emotional abuse, severe neglect with serious consequences for their physical and mental with serious consequences for their physical and mental development)development)

Children who have to face a situation of risk associated with Children who have to face a situation of risk associated with conditions of life likely to endanger their health, safety, morals, conditions of life likely to endanger their health, safety, morals, education, without necessarily being abused education, without necessarily being abused

Foster children by a parent who does not want or can not care Foster children by a parent who does not want or can not care for himfor him

The orphaned or abandoned childrenThe orphaned or abandoned children

Delinquent childrenDelinquent children

100,000 children are declared at risk annually in France100,000 children are declared at risk annually in France

Social services 55,000 children are in institutions in Social services 55,000 children are in institutions in France from birth to 21 yearsFrance from birth to 21 years

Host Families 70 000 children annually, Host Families 70 000 children annually, family assistant family assistant has agréement for 5 years by the General Councilhas agréement for 5 years by the General Council

There is a specific law for the protection of children up to There is a specific law for the protection of children up to 21 years which is The 21 years which is The Judicial Protection of YouthJudicial Protection of Youth (383,000 (383,000 children and young adults (92,000 criminal justice and 291,000 children at risk or youth children and young adults (92,000 criminal justice and 291,000 children at risk or youth protection major) protection major)

Each department is responsible for the organization Each department is responsible for the organization supported under the responsibility of the statesupported under the responsibility of the state

There are also specialized institutions for juvenile There are also specialized institutions for juvenile offendersoffenders

Children and adolescents with severe personality Children and adolescents with severe personality disorders or psychiatric disorders or somatic diseases disorders or psychiatric disorders or somatic diseases are treated in specialized hospitalsare treated in specialized hospitals

For the social institutions, a National Observatory for For the social institutions, a National Observatory for Children in Danger created in France for 10 years Children in Danger created in France for 10 years (ONED)(ONED)

Social child's homeSocial child's home1115 small or big structures, between 10 and 65 places1115 small or big structures, between 10 and 65 places75 percent have less than 30 seats75 percent have less than 30 seatsThey are public or associativeThey are public or associative Children's homes Children's homes 210 small or big structures between 10 and 120210 small or big structures between 10 and 120placesplaces Social nurseriesSocial nurseries31 small institutions between 10 to 30 places31 small institutions between 10 to 30 placesMostly children from 0 to 3 yearsMostly children from 0 to 3 years Holiday villages Holiday villages 21 structures about 40 and 60 places21 structures about 40 and 60 places Places to livePlaces to live385 structures between 3 et 7 places385 structures between 3 et 7 places

Orphans and abandonned children

2100 Children They are necessarily subject to an adoption,

they are welcomed by a host family awaiting adoption

This is the state that is responsible The suffering of these children is more

difficult to support, narcissistic wounds are very deep and multifaceted

They are more vulnerable to psychological They are more vulnerable to psychological distress and the distress and the impact of trauma for each impact of trauma for each orphaned child must be correctly evaluate, it will orphaned child must be correctly evaluate, it will depend on :depend on :

– The age and sex of the child at the time of loss The age and sex of the child at the time of loss

– The nature and quality of the links before the break The nature and quality of the links before the break

– The context of early breaks The context of early breaks

– Violence suffered Violence suffered

– The quality and diversity of care The quality and diversity of care

– Self-esteem and resilience of each child and the quality Self-esteem and resilience of each child and the quality of careof care

– Somatic disordersSomatic disorders Eating disorders, skin lesions, respiratory disorders, digestive Eating disorders, skin lesions, respiratory disorders, digestive

disorders, sphincter disorders, psychomotor disordersdisorders, sphincter disorders, psychomotor disorders

– Attachment disordersAttachment disorders Unable to attach or permanent fusion attachmentUnable to attach or permanent fusion attachment

– Behavioral and thinking disordersBehavioral and thinking disorders Mood disorders, delinquency, impulsivity, inhibition, violence, failures Mood disorders, delinquency, impulsivity, inhibition, violence, failures

in learningin learning

– Against self-injury and suicide attemptsAgainst self-injury and suicide attempts Cuts, burns, bites….Cuts, burns, bites….

Prostitution, drug addiction, homelessnessProstitution, drug addiction, homelessness Suicide Suicide

– Psychiatric disordersPsychiatric disorders Anorexia, anxiety neurosis and traumatic childhood psychosesAnorexia, anxiety neurosis and traumatic childhood psychoses

The most frequent disordersThe most frequent disorders

The limits of our practicesThe limits of our practices Difficulties in identifying children who need careDifficulties in identifying children who need care

Difficulties for individualized and Difficulties for individualized and multidisciplinary assessments, concerted multidisciplinary assessments, concerted

The lack of trainings for the caregivers and the The lack of trainings for the caregivers and the lack of places in institutions lack of places in institutions

The lack of courage of some governments to The lack of courage of some governments to enact key legislation and to give much money enact key legislation and to give much money for child protectionfor child protection

The lack of knowledge of resources in the The lack of knowledge of resources in the territories and too small links between territories and too small links between professional in institution and volunteers in professional in institution and volunteers in associationsassociations

Lack of time and clinical reflections Lack of time and clinical reflections

The urgency of certain crisis situations, and The urgency of certain crisis situations, and sometimes impossible to anticipate.sometimes impossible to anticipate.

Suicidality, major in abandoned or orphaned Suicidality, major in abandoned or orphaned children, especially orphans by suicidechildren, especially orphans by suicide

The lack of resources to develop new projects The lack of resources to develop new projects and build small structures with proper guidance and build small structures with proper guidance in a society who has changedin a society who has changed

The increase in intra family violence situations The increase in intra family violence situations Increasing insecurity and povertyIncreasing insecurity and poverty

Each child is different than another, for the Each child is different than another, for the same history, they will not react by the same same history, they will not react by the same way, we need to adapt our practicesway, we need to adapt our practices

There is no suffering that can not be appeased There is no suffering that can not be appeased with quality carewith quality care