Global priority for the care of orphans and other vulnerable children: transcending problem definition challenges

BACKGROUND

Tens of millions of children lack adequate care, many having been separated from or lost one or both parents. Despite the problem's severity and its impact on a child's lifelong health and wellbeing, the care of vulnerable children-which includes strengthening the care of children within families, preventing unnecessary family separation, and ensuring quality care alternatives when reunification with the biological parents is not possible or appropriate-is a low global priority. This analysis investigates factors shaping the inadequate global prioritization of the care of vulnerable children. Specifically, the analysis focuses on factors internal to the global policy community addressing children's care, including how they understand, govern, and communicate the problem.

METHODS

Drawing on agenda setting scholarship, we triangulated among several sources of data, including 32 interviews with experts, as well as documents including peer-reviewed literature and organizational reports. We undertook a thematic analysis of the data, using these to create a historical narrative on efforts to address children's care, and specifically childcare reform.

RESULTS

Divisive disagreements on the definition and legitimacy of deinstitutionalization-a care reform strategy that replaces institution-based care with family-based care-may be hindering priority for children's care. Multiple factors have shaped these disagreements: a contradictory evidence base on the scope of the problem and solutions, divergent experiences between former Soviet bloc and other countries, socio-cultural and legal challenges in introducing formal alternative care arrangements, commercial interests that perpetuate support for residential facilities, as well as the sometimes conflicting views of impacted children, families, and the disability community. These disagreements have led to considerable governance and positioning difficulties, which have complicated efforts to coordinate initiatives, precluded the emergence of leadership that proponents universally trust, hampered the engagement of potential allies, and challenged efforts to secure funding and convince policymakers to act.

CONCLUSION

In order to potentially become a more potent force for advancing global priority, children's care proponents within international organizations, donor agencies, and non-governmental agencies working across countries will need to better manage their disagreements around deinstitutionalization as a care reform strategy.

Fostering an affiliative environment in residential youth care: A cluster randomized trial of a compassionate mind training program for caregivers enrolling youth and their caregivers

BACKGROUND

Affiliation has a positive role on well-being and human development. Most children and youth living in residential youth care (RYC) experienced maltreatment from significant others, becoming a particularly vulnerable group. Their complex needs require well trained caregivers who help them to heal and thrive.

OBJECTIVE

This cluster randomized trial sought to test the Compassionate Mind Training program for Caregivers (CMT- Care Homes) effectiveness on affiliative outcomes across time.

PARTICIPANTS AND SETTING

A sample of 127 professional caregivers and 154 youth from 12 Portuguese residential care homes (RCH) participated on this study.

METHODS

RCHs were randomized to treatment (n = 6) and control (n = 6) groups. Caregivers and youth completed self-report measures at baseline, post-intervention, and 6-month follow-up on social safeness and emotional climate. Caregivers were also evaluated on compassion outcomes.

RESULTS

MANCOVA indicated large multivariate time X group effects. Univariate results suggested that caregivers from the treatment group showed improvements in compassion towards others and in self-compassion across time, while the control group gradually deteriorated in both variables. Youth and caregivers from the treatment group noticed a more soothing and safer RCH emotional climate, as well as feeling safer within relationships. At 6-month follow-up, improvements were retained by caregivers, but not by youth.

CONCLUSIONS

The CMT- Care Homes brings a new model to RYC, that represents a promising approach in promoting safe relationships and affiliative environments in RCHs. Supervision should be provided to monitor care practices and sustain change across time.

Trauma of separation: the social and emotional impact of institutionalization on children in a post-soviet country

BACKGROUND

In the former Soviet Union (fSU) region, which has the highest rate of institutional care worldwide, 'social orphans' -indigent children who have one or both parents living-are placed in publicly run residential institutions to receive education, food, and shelter. Few studies have focused on understanding the emotional effects of separation and life in an institutional environment on children who grow up with their families.

METHODS

Semi-structured qualitative interviews (N = 47) were conducted with 8- to 16-year-old children with a history of institutional care placement and their parents in Azerbaijan. Semi-structured qualitative interviews were conducted with 8- to 16-year-old children (n = 21) involved in the institutional care system in Azerbaijan and their caregivers (n = 26). Trained interviewers collected narratives about children's experiences prior to being separated from their families while living in an institution, as well as the impact of institutional placement on their emotional well-being. We applied thematic analysis with inductive coding.

RESULTS

Most of the children entered institutions around the school entry age. Prior to entering institutions, children had already experienced disruptions within their family environments and multiple traumatic events, including witnessing domestic violence, parental divorce, and parental substance abuse. Once institutionalized, these children may have had their mental health further impaired by a sense of abandonment, a strictly regimented life, and insufficiencies of freedom, privacy, developmentally stimulating experiences, and, at times, safety.

CONCLUSION

This study illustrates the emotional and behavioral consequences of institutional placement and the need to address accumulated chronic and complex traumatic experiences that occurred before and during institutional placement, which may affect emotion regulation and the familial and social relationships of children who lived in institutions in a post-Soviet country. The study identified mental health issues that could be addressed during the deinstitutionalization and family reintegration process to improve emotional well-being and restore family relationships.

Case report: Improving quality of care in Kazakhstan institutions

This project is a community case study implemented by local professionals and caregivers to improve the quality of caregiving in two Kazakhstan institutions for infants and toddlers. Local professionals first received comprehensive training by an international team experienced in relevant research-based practices, and then the locals trained institutional staff. Over nearly 2 years, one institution progressively implemented changes in three wards and the other institution in one ward. The changes attempted to make the institution more family-like (e.g., smaller groups and fewer and more consistent caregivers) and caregivers behave more parent-like (e.g., more warm, sensitive, responsive interactions and relationships) without changing nutrition or medical care. Of the 45 children given some exposure to the emerging new wards, 11 experienced the fully revised wards for at least 4 months during their first 2 years of life. They displayed substantial increases in their physical growth, especially those entering in their first year of life, in contrast to the unchanging developmental patterns of 165 children who were reared in the two institutions before the ward changes were made. Physical growth is a commonly used standard of developmental well-being in institutions. Research shows it is sensitive to infants' psychosocial environment, and improvements in physical growth are related to children's cognitive and social-emotional development. Although this pilot community case study had only a few infants fully exposed to the complete ward changes and lacked characteristics of a research experiment, these results are consistent with children's developmental improvements reported in larger scientific studies of similar interventions. This project is an example of how some research-based practices are likely to be implemented in communities in the future. Specifically, it shows that local communities can successfully improve the rearing conditions within institutions, which improve the children's development, and may contribute to the success of their subsequent foster placement and adoption.

Preventing maltreatment in institutional care: A cluster-randomized controlled trial in East Africa

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Interaction Competencies with Children prevents maltreatment in institutional care.

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Feasibility of intervention despite low resources and heterogeneity of institutions.

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Participation in intervention significantly reduced maltreatment of orphans.

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Positive attitudes towards violence declined through intervention participation.

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Participation in intervention significantly increased childcare knowledge.

An increasing number of orphans in low- and middle-income countries are living in institutional care facilities where they experience poor quality of care and ongoing maltreatment. To prevent maltreatment, we tested the effectiveness and feasibility of the intervention Interaction Competencies with Children – for Caregivers (ICC-C). In a two-arm cluster-randomized controlled trial, 203 caregivers (65.5% female, M_age = 36.63 years, SD_age = 12.26) and 356 children (46.1% female, M_age = 9.43 years, SD_age = 1.93) from 24 orphanages in Dar es salaam (Tanzania) participated from August to October 2018 (Baseline) and March to April 2019 (Follow-Up). Orphanages were assigned to the intervention or waitlist-group. Caregivers in the intervention group received the ICC-C intervention to prevent maltreatment through focusing on non-violent caregiving strategies. The primary outcome was the change in self-reported maltreatment by caregivers (Conflict Tactics Scale). Trial registration: ClinicalTrials.gov, NCT03594617, 20 July 2018. Participation in the intervention resulted in a significant reduction in reported maltreatment (f² = 0.153), a decrease of positive attitudes toward violent discipline (f² = 0.248), and an increased level of childcare knowledge (f² = 0.220) in the caregiver sample, each indicating a moderate effect. Caregivers’ training participation did not predict reduced maltreatment reported by children. Aspects of feasibility, including motivation to participate, acceptability, and integration of the new strategies were evaluated positively. The study promises initial effectiveness and feasibility of efforts to improve the situation of children in institutional care settings in resource-poor countries by offering training to care providers.

A Systematic Review of Reviews of the Outcome of Severe Neglect in Underresourced Childcare Institutions

The aim of the systematic review described in this article was to determine the outcomes for individuals exposed to severe neglect in congregate care institutions such as orphanages. In this context, severe neglect refers to failure to meet children's basic physical, developmental, and emotional needs due to inadequate resources. In this systematic review of previous systematic reviews and meta-analyses, searches of 10 databases were conducted, 18 papers that met inclusion and exclusion criteria were selected for review, their quality was assessed, and data were extracted and synthesized. The 550 primary studies included in the 18 systematic reviews and meta-analyses were relatively well designed, allowing confidence to be placed in their results. Severe neglect was associated with a wide range of problems in the domains of physical development, cognitive development, attachment, and mental health. The severity of adverse outcomes was partly influenced by the duration and severity of deprivation and a constellation of risk and protective factors. Prevention policies should aim to eliminate large underresourced congregate care institutions for infants. In taking steps toward this, policies should aim to adequately resource congregate care institutions to meet children's developmental needs for nutrition, stimulation, and attachment to a stable primary caregiver with adequate parenting skills and training. Early placement in adoptive or foster families, with access to routine physical and mental health-care service available in developed countries, is the most viable effective intervention for child survivors of severe neglect.

Fostering Child Development by Improving Care Quality: A Systematic Review of the Effectiveness of Structural Interventions and Caregiver Trainings in Institutional Care

Quality of child care has been shown to have a crucial impact on children's development and psychological adjustment, particularly for orphans with a history of maltreatment and trauma. However, adequate care for orphans is often impacted by unfavorable caregiver-child ratios and poorly trained, overburdened personnel, especially in institutional care in countries with limited resources and large numbers of orphans. This systematic review investigated the effects of structural interventions and caregiver trainings on child development in institutional environments. The 24 intervention studies included in this systematic review reported beneficial effects on the children's emotional, social, and cognitive development. Yet, few studies focused on effects of interventions on the child-caregiver relationship or the general institutional environment. Moreover, our review revealed that interventions aimed at improving institutional care settings have largely neglected violence and abuse prevention. Unfortunately, our findings are partially limited by constraints of study design and methodology. In sum, this systematic review sheds light on obstacles and possibilities for the improvement in institutional care. There must be greater efforts at preventing violence, abuse, and neglect of children living in institutional care. Therefore, we advocate for combining attachment theory-based models with maltreatment prevention approaches and then testing them using rigorous scientific standards. By using approaches grounded in the evidence, it could be possible to enable more children to grow up in supportive and nonviolent environments.

The development of postinstitutionalized versus parent-reared Russian children as a function of age at placement and family type

A total of 149 children, who spent an average of 13.8 months in Russian institutions, were transferred to Russian families of relatives and nonrelatives at an average age of 24.7 months. After residing in these families for at least 1 year (average = 43.2 months), parents reported on their attachment, indiscriminately friendly behavior, social-emotional competencies, problem behaviors, and effortful control when they were 1.5-10.7 years of age. They were compared to a sample of 83 Russian parents of noninstitutionalized children, whom they had reared from birth. Generally, institutionalized children were rated similarly to parent-reared children on most measures, consistent with substantial catch-up growth typically displayed by children after transitioning to families. However, institutionalized children were rated more poorly than parent-reared children on certain competencies in early childhood and some attentional skills. There were relatively few systematic differences associated with age at family placement or whether the families were relatives or nonrelatives. Russian parent-reared children were rated as having more problem behaviors than the US standardization sample, which raises cautions about using standards cross-culturally.