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.     

Caregivers’ Level of Trust in Their Children's Health Care Providers

Trust in healthcare providers is associated with clinical outcomes among adult patients. Children with disabilities have complex health needs that place stress on caregivers. Consequently, they are increasingly likely to rely on their children's health care providers to ensure children's health care needs are met. However, no studies have explored factors affecting caregivers’ trust in their children's providers. We assessed caregivers’ trust in their children's providers and identified predictive factors of trust. The results indicate that children's disability condition, functional status, age, the providers’ specialty, and the type of health care plan are significant predicators of caregiver's trust. Specifically, caregivers of children with emotional/behavioral disabilities and children with poor physical or emotional/behavioral functioning reported less trust in their children's providers compared to caregivers of children without physical disabilities or no disability and those having higher levels of physical or emotional/behavioral functioning. In addition, caregivers of younger children had more trust compared to caregivers of older children. Caregivers of children enrolled in a managed care plan for physical health care reported less trust compared to caregivers of children in other organizational arrangements. Finally, caregivers reported more trust in physical health providers compared to mental health providers.     

An educational intervention improves developmental progress of young children in a Romanian orphanage

From 1991 to 1994, a group of Romanian and American colleagues undertook an experimental and humanitarian effort to try to improve the quality of life, mental health, and developmental progress of young children in a Romanian orphanage. In the context of institutional care, we experimentally introduced stable adult–child relationships, small group size, and a protocol of enriched caregiving and educational activities. These procedures were adapted from an intervention in childcare centers in the United States that had been proven effective in reducing intellectual decline in at‐risk children. Developmental scores for orphanage children were derived from the Denver II (a revision of the Denver Developmental Screening Test; Frankenburg & Dodds, 1990), which was translated into Romanian and administered as a pre‐ and posttest to the experimental subjects and comparison groups in the same institution. Mixed models combining both within‐ and between‐subject heterogeneous variance‐covariance structures were utilized to analyze the impacts of time, intervention/control group assignment, child sex, child age, and interaction of Group × Time on the developmental scores. For the developmental outcome variables, the effects of group assignment (experimental vs. comparison) were highly significant. There also was a Group × Time interaction effect. We conclude that an educational intervention which includes the addition of resources and training can be initiated and sustained in an orphanage for young children as a way of improving institutional care. ©2005 Michigan Association for Infant Mental Health.     

Kinship Foster Care from the Perspective of Quality of Life: Research on the Satisfaction of the Stakeholders

A quality of life studies perspective has guided the design and implementation of research on kinship care as a placement resource within the child protection system in Catalonia (Spain). This research was carried out gathering the points of view of the three main stakeholders: kinship caregivers, children who are placed in extended family and practitioners of the EAIAs (Childhood and Adolescence Interdisciplinary Care Teams). Satisfaction involved in kinship care has been explored. In this article the main stakeholders’ satisfaction with kinship care is presented, and on the other hand, children’s satisfaction with life as a whole and with five specific domains in life is analysed: Education received from their caregiver, their school, their friends, their time enjoyment and their health. As expected, practitioners show the lowest evaluations with this kind of service. Surprisingly, evaluations by children referred to kinship care and to education received by caregivers are higher than those in the normative population aged 12–16 in relation to their own natural family. The findings show implications for practice and they imply challenges for quality-of-life research.     

Legal,Tender: The Deferred Romance of Pedagogical Relation in <Emphasis Type="Italic">The Paper Chase</Emphasis>

Films depicting educational relationships typically emphasize personal connections between students and teachers over the educational goals that such relations facilitate. In doing so, these films raise the question of how teachers stand in relation to their institutional roles in such a way as to inspire students’ desires for knowledge. In this paper, in order to examine the influence of institutional roles in defining teacher–student relationships, we analyze “The Paper Chase,” a film in which teacher and student have no personal connection but in which the drama of student desire is nonetheless clearly featured. Drawing from Plato’s erotics, in which the soul is shaped by desire for that which it lacks, and from Jacques Lacan’s theories of desire and transference, we argue that “The Paper Chase” portrays educational desire as rooted in the differential of authority between teacher and student.     

The effects of an improved residential nursery on the development of young Japanese children

The author, acting both as a researcher and a staff member, intervened at the residential nursery to facilitate the development of the children. The main goal of the intervention was to establish attachment relations between infants and their caretakers. The living environment of the institution simultaneously improved with the home-like atmosphere of small group care. Children's developmental status was examined before and after the intervention. The improved organization of the nursery was significantly correlated with the social (fear of stranger) and verbal (single word; first sentence) development of infants. This study showed how to facilitate normal development in children by improving residential nursery life. The results of two follow-up surveys in family-like residential nurseries, conducted independently in Germany and Japan, showed that early negative family experiences may be offset by favorable influences later in life, even at institutions. These findings suggests that quality of substitute care and family-like conditions, rather than residential care itself, may be the more important influences on children.     

A socioemotional intervention in a Latin American orphanage

A pilot intervention that emphasized training and technical assistance to promote warm, sensitive, and responsive one‐on‐one caregiver–child interactions primarily during feeding and bathing/changing was implemented using regular staff in a depressed orphanage for children birth to approximately 8 years of age in Latin America. Despite a variety of unanticipated irregularities in the implementation of the intervention, many beyond the researchers' control, ward environments improved; caregivers displayed more warm, sensitive, and responsive interactions with children; and children improved an average of 13.5 developmental quotient (DQ) points after 4+ months' exposure to the completed intervention. Furthermore, 82% of the children had DQs greater than 70 before the intervention, but only 27.8% did so afterward. Although the training for all caregivers was aimed at children birth to 3 years, the number of different caregivers was reduced, and technical assistance was provided only to caregivers serving children less than 3 years, younger and older children (3–8 years) improved approximately the same amount. However, children who were transitioned from a younger to an older ward during the intervention improved less than did children who remained in either a younger or an older ward, the first evidence suggesting that the common orphanage practice of periodically graduating children from one homogeneous age group to another may impede their development. The study is consistent with others that have shown that orphanages can be changed, and increases primarily in warm, sensitive, responsive caregiver–child interactions can produce improvements in children's development.     

Perceived Social Support and Caregiver Strain in Caregivers of Children with Tourette’s Disorder

The research on Tourette’s disorder (TD), a neuropsychological disorder consisting of motor and phonic tics, has largely focused on individuals with TD and not on the caregivers of children with TD. We investigated the effects of several variables on caregiver strain of caregivers of children with TD, including perceived social support, caregiver characteristics, and characteristics of the child’s disorder. An online survey was completed by 140 caregivers of children with TD between the ages of 6 to 18 years. We performed a path analysis to examine the outcome of caregiver strain in relation to the research variables. Our results indicated that caregiver age, symptom severity of the child’s TD, and perceived social support accounted for variance in caregiver strain, and that perceived social support was a partial mediator of child’s symptom severity and caregiver strain. Symptom severity and caregiver strain were also related to the presence of other comorbid disorders, such as Oppositional Defiant Disorder (ODD), anxiety, or Attention Deficit Hyperactivity Disorder (ADHD) when compared to children either having no other comorbid disorders or other types of disorders.     

Parenting After a Natural Disaster: A Qualitative Study of Norwegian Families Surviving the 2004 Tsunami in Southeast Asia

How do parents support their children after a high-impact disaster? To answer this question, face-to-face interviews were conducted with 51 Norwegian parents. These parents and children were all severely exposed to the trauma of the tsunami disaster. The analyses show how parents interpret their children’s signs of distress, as well as their own strategies of support in the aftermath. The main strategies described by the parents were watchful waiting, careful monitoring of the children’s reactions and a sensitive timing when providing support. Such monitoring, and interpretation of signs of distress, served as an aid for the parents in determining what needs their children had and what support they therefore needed to provide. A range of support strategies were employed, including re-establishing a sense of safety, resuming normal roles and routines, and talking to their children. Parents who were themselves severely impacted by the disaster reported a reduced ability to assess their children’s reactions and thereby were unable to provide optimal care in the aftermath. Interestingly, the parents’ support strategies mirror the early intervention recommendations put forward in the NICE guidelines and in the Psychological First Aid guidelines which is a well accepted and promising practice for helping children after disasters.     

Improvements in early care in Russian orphanages and their relationship to observed behaviors

This article describes a unique study that attempts to promote positive social‐emotional relationships and attachment between caregivers and children in orphanages in St. Petersburg, Russia. The children who reside in these orphanages are typically between birth and 48 months of age; approximately 50% are diagnosed with disabilities, and approximately 60% leave through foreign adoption. Initially, their orphanage caregivers showed a high level of current anxiety and depression and were detached from and communicated little with the children. Likewise, during baseline observations, the children demonstrated poor attachment behaviors such as indiscriminant friendliness, lack of eye contact with adults, aggression, and impulsive behavior. Two interventions were used in a quasiexperimental design: (a) training of caregivers to promote warm, responsive caregiving and (b) staffing and structural alterations to support relationship building, especially increasing the consistency of caregivers. The methodology required that both the training and staffing interventions be provided to one orphanage, only the training to a second, and neither to a third. (At any one time, ns = 80–120 in each condition.) Initial informal observations reveal positive behaviors for both the caregivers and the children, such as increased two‐way conversations, animated and enthusiastic emotional responses, and positive social and language interactions. Early data analyses show an increase in the consistency and stability of caregivers and increased scores for caregivers on every subscale of the HOME Scales. Children showed improvements in physical growth, cognition, language, motor, personal‐social, and affect, with children having severe disabilities improving the most. The implications of these findings suggest that training staff with modest educational backgrounds and structural changes are effective, can increase socially responsive caregiving behaviors, and improves social interactions of children, at least temporarily. ©2005 Michigan Association for Infant Mental Health.     

Caring for children with an intellectual disability: An exploratory qualitative study

This study explored family caregiver experiences of children with an intellectual disability in a rural South African day-care centre. The family caregivers (N = 15; mothers = 60%; age range = 35 to 68 years) completed in-depth interviews regarding their experiences providing care to children with intellectual disability. Data collection and analysis was done using phenomenological methods. The following themes emerged to characterise the family caregiver experiences: deeper understanding of intellectual disability; disability disclosure conditions; and social and economic support needs. Family support emerged as an important factor in the relationship between caregivers’ psychological stress and well-being.     

Parental stress, coping styles, and social supports in chinese families with hepatitis-b-carrying children

The purpose of the study was to examine the hypothesis that parents’ psychological well-being can be affected by a child’s illness and their social situations. In this study, we discuss the roles of coping, social support and situational context related to stress. These factors cannot only affect stress levels but can also influence whether the individual adopts a certain type of coping style for stressful events. Parental stress, coping styles and social support were compared between groups of parents of Hepatitis B virus (HBV) carrier children or healthy children. Results showed that parents of affected children were significantly more stressed and psychologically at risk, and tended to mobilize personal resources and to rely more on themselves to solve stressful life events. They also sought help from social resources more often than did parents of healthy children. Parents of healthy children had a higher number of close friends and relatives available to them. Ninety Chinese parents and their HBV or healthy children participated in this study. These families were all living in the city of Guangzhou, China.     

Parents, infants, and day-care teachers: Interrelations and implications for better child care

Many young children are reared today in both family and child-care settings. The relation that exists between these two settings has important implications for child care. Bronfenbrenner's (1979) ecological model is used as a way to view the interrelations among children, families, and child-care programs. Data from a study of infants in day care provide information on the time infants spend in family and day-care contexts, how parents and caregivers view children's behavior in these two settings, and rates of otitis media (ear infections) and other illnesses for these children. Results show that infants spend about twice as many hours per day awake with parents as in day care. Regarding child behaviors, parents and caregivers seem to have similar behaviors they like and dislike, but they each see particular children quite differently with respect to these behaviors. Finally, infants in this sample were diagnosed with illnesses 60% to 70% of the time. Findings are discussed in terms of the ecological model with particular attention given to relations between parents and caregivers.     

Parental stress, coping styles, and social supports in chinese families with hepatitis-b-carrying children

The purpose of the study was to examine the hypothesis that parents’ psychological well-being can be affected by a child’s illness and their social situations. In this study, we discuss the roles of coping, social support and situational context related to stress. These factors cannot only affect stress levels but can also influence whether the individual adopts a certain type of coping style for stressful events. Parental stress, coping styles and social support were compared between groups of parents of Hepatitis B virus (HBV) carrier children or healthy children. Results showed that parents of affected children were significantly more stressed and psychologically at risk, and tended to mobilize personal resources and to rely more on themselves to solve stressful life events. They also sought help from social resources more often than did parents of healthy children. Parents of healthy children had a higher number of close friends and relatives available to them. Ninety Chinese parents and their HBV or healthy children participated in this study. These families were all living in the city of Guangzhou, China.     

Psychosocial Well-being of Children in HIV/AIDS-Affected Families in Southwest China: A Qualitative Study

We investigated the psychosocial well-being of children in HIV/AIDS-affected families in rural China from the child’s and caregiver’s perspectives. Semi-structured interviews were conducted among children living in HIV/AIDS-affected families (n = 16), their caregivers (n = 16) and key community informants (n = 5). Our findings showed that all of the children relied heavily on caregivers and peers to gain psychological support. Children’s psychosocial problems included fear, anxiety, grief, and loss of self-esteem and confidence. Stigma towards children existed, including isolation, ignorance and rejection. Our study illustrates that HIV/AIDS has impacted negatively on the psychosocial well-being of children. These findings can be used as preliminary data supporting more researches to profoundly explore the psychosocial impact of HIV/AIDS on children and appropriately indicate the need for interventions.     

Family Concerns and Involvement During Kindergarten Transition

The transition from preschool to formal schooling constitutes an important developmental milestone for children and their families. Very few empirical studies investigating the kindergarten transition for typically developing children have been published, and fewer have examined transition experiences from the perspective of caregivers. The aims of our study were to investigate: (1) parent concerns during transition, (2) perceived needs during transition, and (3) parent involvement in kindergarten preparation activities. Parents/caregivers of 86 general education students transitioning to kindergarten completed a survey assessing their concerns, needs, and involvement in transition preparation activities. Results suggest that although the majority of parents expressed few concerns regarding their child’s kindergarten transition, a subset (i.e., 27.9%) reported significant concerns. The areas of concern most often cited by families in this sample were socio-behavioral in nature. Parents in this sample expressed a desire for various types of information during transition. Parents most often reported engaging in low intensity transition practices characterized by generic forms of contact, rather than more individualized and intensive practices often cited in the literature as best practices. In addition, parent involvement in transition preparation activities differed by family socioeconomic status as well as district locale. This study offers practical suggestions and policy implications for coordinating family and school efforts during children’s kindergarten transition.     

Anger, Spiritual Meaning and Support from the Religious Community in Dementia Caregiving

This study explores the relationships between spiritual meaning and social support from the religious community and problem behaviors, anger and depression in 128 dementia caregivers. The results suggest a mediating role of anger in the relationship between the appraisal of problem behaviors and depression. Support from the religious community is directly and negatively associated with anger, but the relationship between spiritual meaning and anger is mediated by caregivers’ appraisals of problem behaviors, suggesting that spiritual beliefs might help caregivers to find meaning in caregiving experiences and thus appraise care recipients’ behavioral problems as less stressful.     

Training in Mindful Caregiving Transfers to Parent–Child Interactions

In an earlier study, we provided mindfulness training to three caregivers of individuals with profound multiple disabilities. We measured levels of happiness displayed by the individuals during the 8 weeks of mindfulness training of the caregivers, as well as during the 16 weeks following the termination of training. We found that happiness increased markedly when an individual interacted with a caregiver who had received training in mindfulness as opposed to a control caregiver who did not receive such training. In this study, we investigated whether the increased mindfulness of the three caregivers would transfer to interactions with their own children. The children’s non-compliance with their mother’s requests was used as an indirect index of the effects of training their mothers received in mindfulness. Although the ages of the children and their baseline levels of non-compliance were variable, the data showed a decrease in non-compliance during mindfulness training of the caregivers and further decreases following the completion of training. Our data provide preliminary evidence of transfer of mindfulness training from caregiving to parent–child interactions. We speculate as to why this may occur in mindfulness training.     

Assessing Psychosocial Impairment in the Pediatric Emergency Department: Child/Caregiver Concordance

The objective of this study was to examine the level of agreement between child- and caregiver-reports of the child’s psychosocial problems presenting to a Pediatric Emergency Department (PED) using a validated screening tool. This was an anonymous, prospective, cross-sectional, multi-informant (child and caregiver) study assessing cognitive, emotional, and behavioral problems and physical complaints in children and adolescents presenting to a PED. Three-hundred and fifty-eight children and adolescents (8–18 years old) and their caregivers participated. Children completed the Youth-Pediatric Symptom Checklist (PSC-Y), while their caregivers completed the Pediatric Symptom Checklist–35 (PSC-35) to measure psychosocial impairment. The child’s physical complaints (e.g., chief complaint, chronicity, other medical problems, medications) and demographic information were assessed using an investigator-developed patient background questionnaire completed by the caregivers. Physical complaints (e.g., chief complaint, chronicity, other medical problems, medications) were assessed using an investigator-developed patient background questionnaire. Agreement between child- and caregiver- reports was analyzed using Cohen’s kappa coefficient. Differences between child and caregiver-reported scores were determined by t-tests. Poor to moderate agreement was found between child- and caregiver-reports of attention problems (κ = .355), externalizing problems (κ = .340), internalizing problems (κ = .065), and total PSC score (κ = .410). Both children and caregivers should complete the psychosocial screener to maximize the accuracy of assessment and the identification of impairment.     

Withholding Hydration and Nutrition in Newborns

In the twenty-first century, decisions to withhold or withdraw life-supporting measures commonly precede death in the neonatal intensive care unit without major ethical controversy. However, caregivers often feel much greater turmoil with regard to stopping medical hydration and nutrition than they do when considering discontinuation of mechanical ventilation or circulatory support. Nevertheless, forgoing medical fluids and food represents a morally acceptable option as part of a carefully developed palliative care plan considering the infant’s prognosis and the burdens of continued treatment. Decisions to stop any form of life support should focus on the clinical circumstances, not the means used to sustain life.