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Abstract In this paper we examine the characteristics of preschool attention deficit hyperactivity disorder (ADHD) from both mental disorder and developmental psychopathology points of view. The equivalence of preschool and school‐aged hyperactivity as a behavioral dimension is highlighted together with the potential value of extending the use of the ADHD diagnostic category to the preschool period where these behaviours take an extreme and impairing form (assuming age appropriate diagnostic items and thresholds can be developed). At the same time, the importance of identifying pathways between risk and later ADHD is emphasized. Developmental discontinuity and heterogeneity are identified as major characteristics of these pathways. We argue that models that distinguish among different developmental types of early‐emerging problems are needed. An illustrative taxonomy of four developmental pathways implicating preschool hyperactivity is presented to provide a framework for future research.

Millions of children worldwide are brought up in institutional care settings rather than in families. These institutions vary greatly both in terms of their organi­sational principles and structure, and in terms of the quality of care provided. Although institutions are universally recognised as providing suboptimal care­giving environments, consensus is still needed on how to interpret the evidence relating to the size, range, and persistence of the effect of institutional care on the development and wellbeing of children. This absence of consensus has led to disagreement as to whether policy should focus on eliminating, transforming, or improving institutions.We reviewed the literature on child institutionalisation and deinstitutionalisation from a global perspective. This review included a survey of historical and cultural trends and estimates of current numbers of children in institutional care, a systematic review and meta­analysis of developmental sequelae, and a largely qualitative review of factors found to predict individual variations in such outcomes. The numbers of children in institutional care have varied enormously over the years and from region to region, driven by a range of political, cultural, and socioeconomic factors. Millions of children worldwide are known to be housed in institutions.1 We found strong negative associations between institutional care and children's development, especially in relation to physical growth, cognition, and attention. Significant but smaller associations were found between institutionalisation and socioemotional development and mental health. Leaving institutions for foster or family care is associated with significant recovery for some developmental outcomes (eg, growth and cognition) but not for others (eg, attention). The length of time in institutions was associated with increased risk of adverse sequelae and diminished chance of recovery. However, we could not disentangle the association between developmental outcomes and the duration of institutional care as opposed to its timing, which would be required to establish the precise boundaries of sensitive periods of development.Every effort should be made to minimise children's exposure to institutional care. Reducing the number of children entering institutions and increasing the number leaving institutions is urgently needed. Where institutional care is considered absolutely necessary, the length of stays should be as short as possible, even if care is adequate. To this end, preventive approaches should be promoted, keeping children in birth families when possible. When not possible, care alternatives that are family based should be supported, including extended kinship networks, adoption, and stable, high­quality fostering. Policy recom­mendations to support the implementation of these care reform goals at the global, regional, and local levels are set out in a linked policy Lancet Commission2 published in The Lancet Child & Adolescent Health.

Worldwide, millions of children live in institutions, which runs counter to both the UN-recognised right of children to be raised in a family environment, and the findings of our accompanying systematic review of the physical, neurobiological, psychological, and mental health costs of institutionalisation and the benefits of deinstitutionalisation of child welfare systems. In this part of the Commission, international experts in reforming care for children identified evidence-based policy recommendations to promote family-based alternatives to institutionalisation. Family-based care refers to caregiving by extended family or foster, kafalah (the practice of guardianship of orphaned children in Islam), or adoptive family, preferably in close physical proximity to the biological family to facilitate the continued contact of children with important individuals in their life when this is in their best interest. 14 key recommendations are addressed to multinational agencies, national governments, local authorities, and institutions. These recommendations prioritise the role of families in the lives of children to prevent child separation and to strengthen families, to protect children without parental care by providing high-quality family-based alternatives, and to strengthen systems for the protection and care of separated children. Momentum for a shift from institutional to family-based care is growing internationally—our recommendations provide a template for further action and criteria against which progress can be assessed.