Implementing Changes in Institutions to Improve Young Children's Development

An estimated 8 million children, mostly birth to approximately 6-8 years of age, live in institutions worldwide. While institutional environments vary, certain characteristics are common, including relatively large groups; high children:caregiver ratios; many and frequently changing caregivers; homogeneous grouping by age and disability status; periodic graduations to new groups of peers and caregivers; and an "institutional style of caregiving" that minimizes talking, provides rather dispassionate perfunctory care, and offers little warm, sensitive, contingently-responsive caregiver-child interactions. The development of children in residence is usually delayed, sometimes extremely so, in every physical and behavioral domain. Although efforts are being made in many countries to care for children without permanent parents in family environments (e.g., domestic adoption, foster and kinship care, reunification with biological parents), it is not likely that transitions to family alternatives will be completed in all countries in the near future; thus, institutions are likely to exist for many years if not decades. But institutions need not operate in the current manner; they can be modified to be substantially more family-like in structure and in the behavior of caregivers. Research indicates that when such changes are made the development of children, both typically developing and those with special needs, is improved substantially. Based on the available literature and the authors' experience, this paper describes steps that can be taken to implement such changes in residential institutions for infants and young children.     

Navigating Family Roles Within An Institutional Framework: An Exploratory Study In One Private Chinese Orphanage

Current research in child development has espoused the benefit of family-like routines in institutional orphanage care. However, the institutional framework evident in large-group orphanage care often hampers the creation of nurturing, family-like environments. This qualitative study is part of a larger case study exploring how one private Chinese orphanage infuses a family-like structure into an institutional setting. Data is examined from an ecocultural viewpoint, looking at how caregivers and directors’ attitudes and behaviors reflect universal caregiving practices and how they reflect the distinct cultural forces within this private Chinese orphanage. Data came from conversation-like interviews with the director, co-director, and two direct caregivers. This information was combined with observations that resulted from me living within the orphanage for a period of ten days. Results indicate the family-like environment was created primarily through the staff’s articulation of and identification with family roles (father, mothers, brothers, sisters rather than director, co-director, caregivers, and children). Family-like roles often involved levels of intimacy not typically found in institutional settings such as the culturally accepted practice of co-sleeping with younger children. Results are presented in textual format followed by implications for institutional frameworks.     

John Lind memorial symposium

John Lind, Professor of Pediatrics at the Karolinska Institute, emphasized that “the family is born in the maternity hospital.” He had a warm concern for all parents and infants and was extremely influential in both pediatric and child-rearing practices in Sweden and in the promotion of infant and caregiver-infant interaction research. Lind initiated and/or stimulated the scientific study of the infant's cry, parent-infant interactions, the role of the father in the perinatal environment, fetal and neonatal perception, and perinatal hospital practices. In many respects, his work predated contemporary emphases on perinatal coaching programs, social support (doula) during labor and delivery, parent education on childrearing, the use of ethnographic data for contemporary perinatal practices, interdisciplinary team approaches to study of infant care and development, changes in newborn nursery practices, and, above all, care and sensitivity to the initial synchronization of the parent-infant interaction system. This paper honors John Lind's contributions to our knowledge of infant development and parent-infant interaction, his influences on the field of pediatrics and the interdisciplinary study of infancy, and his commitment to enhancement of the quality of life for infants and their families. Although his life has ended, his ideas will continue to inspire and challenge the study of early human development for many years to come.     

The Effect of Spiritual Self-care Training on the Quality of Life of Mothers of Preterm Infants: A Randomized Controlled Trial

The present study was carried out with the aim of determining the effect of spiritual self-care training on the quality of life of mothers of preterm infants. This trial was carried out on 60 mothers with premature infants. Mothers were randomly divided into two intervention and control groups. Training for increasing awareness about the condition of the infants was carried out in both groups. In the intervention group, spiritual self-care training was also done. Data were completed in both groups before, immediately after, and two weeks after the intervention by using the standard WHO quality of life questionnaire. Data were analysed using statistical tests, including ANOVA and Repeated Measures. The results showed that the average quality of life of mothers under study was significantly different at different points of measurement in the intervention group (first, second, and third time-points) (P = 0.016). An increase was observed in the intervention group at the second time-point compared to the first time-point (84.2–88.4, P < 0.001) and in the third time-point compared to the first time-point, (87.9), which was also statistically significant (P < 0.001). According to the results of post hoc tests, there was a decrease in quality of life in the control group at the second time-point compared to the first time-point and the average score of mothers decreased from 82.9 to 75.3, which was statistically significant (P < 0.001). Spiritual self-care training can increase the quality of life and can be used as a form of holistic nursing care for mothers with premature infants in neonatal intensive care units.

     

Influences on responsiveness: Interactions between mothers and their premature infants

The responsiveness of mothers to their infants has been found to make an important contribution to children's development. Mothers' cognitive ability, emotional state, and life stresses may influence their responsiveness, as may the medical condition of their infants. The patterns of influence may vary between groups of children with different biological risk conditions and should be examined carefully to determine intervention points for different groups. Forty mothers and their 3-month-old (corrected age) infants with intraventricular hemorrhage (IVH) were observed in free play. Mothers' depressive symptoms, cognitive skills, and the degree of infants' IVH were assessed and expected to be influences on mothers' responsiveness. Results indicated that mothers' depressive symptoms and cognitive skills were associated with their responsiveness, but that depressive symptoms were the stronger predictor. Post hoc analyses suggested that socioeconomic status and depressive symptoms may have related effects on mothers' behavior.     

A call for integrating a mental health perspective into systems of care for abused and neglected infants and young children

A system of care for abused and neglected infants and young children should adopt a comprehensive perspective, with mental health considerations systematically incorporated into policies and decisions affecting children and their families. Children age birth to 5 years have disproportionately high rates of maltreatment, with long-term consequences for their mental and physical health. Research on normal development and developmental psychopathology has shown that early development unfolds in an ecology of transactional influences among biological, interpersonal, and environmental domains. Psychologists should collaborate with other early intervention disciplines to create systems of care based on an ecological-transactional model of development that includes early mental health principles in order to serve the needs of these young children. Didactic courses, practicums, and internships in infant and early childhood mental health should become integral components of undergraduate and graduate curricula in psychology in order to build capacity to achieve this goal. Recommendations are offered for systemic change by integrating infant and early childhood mental health principles into existing systems of care for young children and their families.     

Macropremies: underprivileged newborns

The focus of neonatal intensive care has been on very low birthweight infants, who comprise only 1.4% of neonates. Too little attention is paid to moderately preterm infants that we call macropremies or moderately low birthweight infants (MLBW, with birthweights 1500-2500 grams). Admitting over half MLBW infants to normal nurseries presumes that they have few needs and an excellent prognosis similar to fullterm newborns. It does not take into account the macropremie's vulnerability to complications of prematurity due to immature organ systems. Obstetricians are increasingly willing to deliver these infants prematurely for signs of fetal distress. As many as 25% of children with cerebral palsy referred to a disability clinic in Paris were MLBW, with hypoxic-ischemic-inflammatory associated disorders in one-third. The majority of MLBW infants who required neonatal intensive care at a tertiary care center in Baltimore had complications of prematurity: 47% had respiratory problems, 20% had feeding intolerance and 9% had hypoglycemia. MLBW infants comprise 5-7% of the neonatal population but account for 14% of neonatal deaths, 18-37% of children with cerebral palsy and 7-12% of children with mental retardation. Increasing the level of neonatal care for the macropremie's transition to extrauterine life would be economically feasible if it prevented as few as 30% of cases of major disability. A change in attitude towards this low risk (but not risk free) group of MLBW infants will both reduce morbidity and improve their health and neurodevelopmental outcome. It includes: 1) Providing an intermediate level of neonatal care for a short duration, with close monitoring and prompt intervention as needed, and 2) Neonatal neurodevelopmental screening to allow focused neurodevelopmental followup of MLBW infants with abnormalities.     

Outcomes for Children and Adolescents After Residential Treatment: A Review of Research from 1993 to 2003

The focus of this research review is to determine what factors increase the likelihood that positive individual and systemic changes occur for children and adolescents following discharge from residential treatment. Residential treatment outcome studies from 1993 to 2003 that fulfilled predetermined criteria were located through 4 on-line databases using key word combinations. The research selected was: (a) 7 studies that measured outcome immediately upon completion of treatment and discharge, and (b) 11 studies where outcome progress was assessed at one or more follow-up dates after discharge. Results showed that children and adolescents with severe emotional and behaviour disorders can benefit and sustain positive outcomes from residential treatment that is multi-modal, holistic and ecological in its approach. Similar to the clinical child psychotherapy research, conclusions must be tempered due to the limited number of studies and methodological weaknesses. Future considerations highlight how research results can more realistically reflect intervention effectiveness when elements of the ecological and systemic landscape of care are addressed.     

Peer and parent-child interaction before and after enrollment in nursery school

Forty-five three-year-olds and their parents participated in the research. Twenty-four of the children were observed two months and one week before, as well as two months after, enrollment in a nursery school. The others were observed at comparable intervals, but remained at home in the fulltime care of their parents. On all occasions, the children who were about to enter or had entered nursery school engaged in more positive interaction with and sought more proximity to their parents than the home care children did. These tendencies were unaffected by enrollment in nursery school. There were no differences between nursery school and home care children on measures of peer interaction eithe before or after nursery school began. The need to consider differences between nursery school and home care children that antedate enrollment is emphasized.     

Aboriginal Children and Their Caregivers Living with Low Income: Outcomes from a Two-Generation Preschool Program

The development of preschool children of Aboriginal heritage is jeopardized by the inter-generational transmission of risk that has created, and continues to create, social disadvantage. Early intervention programs are intended to mitigate the impact of social disadvantage. Yet, evidence of the effectiveness of these programs for children of Aboriginal heritage is limited. The purpose of this study was to examine the effects of a two-generation, multi-cultural preschool program on 45 children of Aboriginal heritage and their caregivers. We used a single-group, pretest (program intake)/posttest (program exit) design with follow-up when the children were 7 years old. We used an observational measure of child receptive language (Peabody Picture Vocabulary Test–III) and caregiver-reported measures of child development (Nipissing District Developmental Screen), risk for child maltreatment (Adult-Adolescent Parenting Inventory; AAPI), parenting stress (Parenting Stress Index; PSI), self-esteem (Rosenberg Self-Esteem scale; RSE), and life skills (Community Life Skills scale; CLS). Using paired t-tests we found statistically significant increases in child receptive language scores between intake and exit, and repeated-measures ANOVA showed that these improvements were maintained up to age 7 years. For caregivers, Pearson’s correlations demonstrated that risk for child maltreatment, parenting stress, self-esteem, and life skills were stable over time. Results of this study suggest that children of Aboriginal heritage can benefit from participation in a two-generation, multi-cultural preschool program. Their caregivers may have received greater benefit if issues of intergenerational transmission of the negative influences of residential schools were addressed as part of programming.     

The effects of maternal employment and non-maternal infant care on development at two and four years

Differences in maternal employment during children's first year of life and children's entry into non-maternal care before the age of 1 year failed to predict differences in cognitive and socioemotional development at 2 and 4 years of age, after family background variables were controlled. Two samples were studied: a population sample of 1100 Bermudian children and a smaller subsample of children most of whom were determined to be at risk for developmental problems. To assess the effects of maternal employment, we compared infants with mothers who worked 20 or more hours a week to infants with mothers who worked less than 20 hours a week. To assess the effects of entry into non-maternal care before the age of one, we compared infants who were placed in regular non-maternal care before the age of one versus infants who did not experience regular non-maternal care before the age of one. The results revealed that family background variables frequently predicted many child outcome measures in both the total sample and the smaller research sample. After controlling for family characteristics, no differences were found between children whose mothers worked 20 or more hours a week when they were infants and children with mothers who worked less than 20 hours a week in either sample. In addition, age of entry into non. maternal care before the age of one did not significantly predict any child outcome measures.     

Quality care in residential placement for children and youth with developmental disabilities

There is a growing concern for quality care in residential placements outside of the natural family for children and youth with developmental disabilities. Ideally, children with developmental disabilities should remain with their natural parent or parents of parents with appropriate supports until the age when children typically leave home. In reality, parents of children and youth with development disabilities are not always able or willing to care for their children at home, and alternate residential placements must be found. This paper will discuss some of the issues surrounding the provision of quality care in out-of-home residential placements for children and youth with developmental disabilities.     

Evaluating the vermont system of care: Outcomes associated with community-based wraparound services

Evaluation of innovative community-based interventions is becoming a high priority for child and adolescent mental health service system research. The present study examined outcomes for a sample of Vermont children (N=27) experiencing emotional and behavioral problems and receiving individualized, wraparound services. One year after initiation of wraparound care, incidence of negative behaviors rated as placing a child at risk of removal from the community had decreased significantly, compliance behavior had increased, and a significant decline in Total Problem Behavior scores on the Child Behavior Checklist was observed. In addition, though 70% of the participants had previously required inpatient or residential treatment, 89% were maintained in the community after one year of services, and the total cost of services was less than that of out-of-state residential care. Although further comparative research is needed, this study suggests that for many of these children, wraparound services may be a more efficient intervention than long-term psychiatric hospitalization or residential treatment.     

Chinese Children's Relationships with Mothers During the Transition to Nursery Care: Changes and Associations with Later Growth in Social Competence

Based on a longitudinal sample of 115 Chinese children, the present study examined changes in mother–child relationships (closeness and conflict) during the transition to nursery care and how these relationships were associated with later growth in children's social competence. The results did not indicate significant changes in mother–child relationships at the mean level but revealed significant individual variations in such changes. These variations were associated negatively with mother–child relationships at 3 months after nursery entry. Social competence showed positive linear growth across the nursery and junior kindergarten years, and significant individual variations in such growth. Initial conflict in mother–child relationships at 3 months after nursery entry positively predicted later growth in social competence. In contrast, initial social competence did not significantly predict changes over time in mother–child relationships. Findings are discussed in terms of how to help children navigate the transition to nursery care and develop their social competence.     

Developmental effects of an intervention for preterm infants of teenage mothers

Since preterm infants and infants born to teenage mothers are noted to be at risk for developmental delays, a group of infants who were both preterm and born to teenage mothers was provided a sensorimotor exercise intervention program for the first year of infancy. The development of these infants was compared to the development of preterm infants without intervention and term infants of teenage mothers as well as term and preterm infants of adult mothers to determine the degree to which developmental delays were prevented. The intervention infants showed more optimal growth, cognitive development, temperament and play behaviors during interactions with their mothers across the first year of development.     

Effect of developmental care for very premature infants on neurodevelopmental outcome at 2 years of age

BackgroundTo determine the effect of developmental care on neurodevelopmental outcome in formerly preterm infants at a corrected age of 2 years.MethodsA prospective phase-lag study was performed at an Austrian neonatal intensive care unit (NICU). From January 2003 to December 2005 (study period of conventional care) and January 2007 to December 2009 (study period of developmental care), we enrolled all infants born in Tyrol at less than 32 weeks of gestation. During this period a total of 261 of 359 preterm infants (participation rate 72.7%) completed the follow-up visit at 2 years of age; there were 124 children in the conventional and 137 in the developmental care group. The association between developmental care and delayed motor or mental development (Bayley Scales of Infant Development II; psychomotor or mental developmental index <85) was analyzed by means of logistic regression analysis at a corrected age of 24 months.ResultsChildren in the developmental care group showed less psychomotor delay than did those in the control group (developmental care group: 16.1%, conventional care group 27.4%; adjusted odds ratio 0.37 [95% confidence interval: 0.19–0.74], P = 0.005). Not smoking in pregnancy and higher gestational age were also significant predictors for a better psychomotor outcome at 2 years of age. Regarding cognitive outcome, no significant difference was observed between these two groups.ConclusionOur data implicate that developmental care may result in an improved 2-year psychomotor outcome in formerly preterm infants.     

Maternal anxiety and depression and development of prematurely born infants in the first year of life

The purpose of this study was: (a) to assess and to compare anxiety and depression symptoms in mothers of preterm neonates during hospitalization in the Neonatal Intensive Care Unit, after discharge, and at the end of the infants' first year of life; and (b) to assess the child's development at 12 months of chronological corrected age (CCA). Thirty-six mothers, with no psychiatric antecedents assessed with the SCID-NP, were evaluated by STAI and BDI. The infants were assessed with Bayley-II Scales. There was a significant decrease in clinical symptoms of state-anxiety in mothers (p = .008), comparing the period during hospitalization and after discharge of the infants. Clinical symptoms of anxiety and depression were observed in 20% of the mothers at the end of the infants' first year of age. The majority of the infants exhibited normal development on Bayley-II at 12 months CCA; however, 25% of the infants displayed cognitive problems and 40% motor problems. The mothers' anxiety and depression symptoms decreased at the end of the first year of life of the pre-term infants and the children showed predominately normal development at this phase.     

Effects of differential reinforcement on the behavior and self-esteem of children with emotional and behavioral disorders

Students in a residential special school for children with emotional and behavioral disorders participated in a study designed to reduce their levels of inappropriate behavior. The residential care staff rated the students' behavioral problems and their class teachers rated their overt self-esteem pre and post intervention. In addition, the students completed self-ratings of their self-esteem. The students were divided into two groups, experimental and control. A multiple baseline across behaviors design was used to assess behavioral changes in the experimental group. Both groups received tangible rewards to the same level but only the experimental group received them contingent upon behaving appropriately. Results showed that the experimental group students made substantial reductions in their levels of inappropriate behavior, which were maintained at a three-month followup. Also, ratings of their behavioral problems by residential child care staff suggested that this improvement in behavior had generalized beyond the classroom to the residential setting. However, no significant differences were found between the pre- and post-intervention ratings of their self-esteem or teacher ratings of their overt self-esteem.     

The Michigan infant mental health home visiting model

Selma Fraiberg's pioneering work with infants, toddlers, and families over 40 years ago led to the development of a field in which professionals from multiple disciplines learned to work with or on behalf of infants, very young children, their parents, and the relationships that bind them together. The intent was to promote social and emotional health through enhancing the security of early developing parent–child relationships in the first years of life (Fraiberg, 2018). Called infant mental health (IMH), practitioners from fields of health, education, social work, psychology, human development, nursing, pediatrics, and psychiatry specialize in supporting the optimal development of infants and the developing relationship between infants and their caregivers. When a baby is born into optimal circumstances, to parents free of undue economic and psychological stressors and who are emotionally ready to provide care and nurturing for an infant's needs, an IMH approach may be offered as promotion or prevention, with the goal of supporting new parent(s) in developing confidence in their capacity to understand and meet the needs of the tiny human they are coming to know and care for. However, when parental history is fraught with abandonment, loss, abuse or neglect, or the current environment is replete with economic insecurity, threats to survival due to interpersonal or community violence, social isolation, mental illness, or substance abuse, the work of the IMH therapist may require intervention or intensive treatment and becomes more psychotherapeutic in nature. The underlying therapeutic goal is to create a context in which the baby develops within the environment of a parent's nurturing care without the psychological impingement that parental history of trauma or loss or current stressors such as isolation, poverty, or the birth of a child with special needs, can incur.