Improving Orphanage Quality with Warmth and Sensitivity
The following article was published in the January 2009 issue of OCD's newsletter Developments. To download a PDF of the issue, click here.

The orphanage in Managua, Nicaragua offered little in the way of environment, stimulation, and care that would please a child development specialist. Inside, rooms were spacious enough, but spartan. Furniture was scarce. The few available toys were stored in cardboard boxes that were usually kept in closets, out of sight.. The hard-working caregivers tended to focus on routine caregiving—feeding, bathing, changing. Schedules were rigid. Meals were often rushed. So, few children enjoyed the warmth of an adult.

It was under these conditions that Whole Child International, a non-profit devoted to improving orphanages and children’s development, began a pilot intervention in late 2006 aimed at improving the social-emotional climate of the orphanage and, in turn, the developmental outcomes of children who live within the concrete-and-barbed-wire walls that enclose the compound.

The task proved challenging. However, a recent evaluation conducted by the University of Pittsburgh Office of Child Development found the year-long intervention succeeded in improving both the quality of care the orphanage offered and the developmental scores of children.

"It demonstrated that certain changes that promote consistency of fewer caregivers and the way caregivers interact with infants and young children you can certainly improve the children’s development," said Robert McCall, Ph.D., who with Christina Groark, Ph.D., co-directors of the University of Pittsburgh Office of Child Development (OCD), led the evaluation.

An increased frequency of behavior problems and other developmental delays among children raised in orphanages is an issue worldwide. Studies suggest that the lack of warm, caring, sensitive, and responsive interaction with caregivers is responsible for the delayed development and higher frequencies of long-term behavioral problems seen among these children. Improving such conditions has been the focus of OCD’s work over the past decade in three orphanages in St. Petersburg, Russia. There, a partnership with Russian researchers has led to promising, sustained outcomes, including rearranging staff schedules to provide children with fewer, more stable caregivers and training that has resulted in caregivers providing more nurturing and responsive care and marked improvements in the physical and emotional development of orphanage children.

‘Dismal By Any Standard’

The Managua orphanage was chosen for the pilot intervention by Whole Child International. WestEd, a nonprofit research, development, and service agency, contributed to caregiver training, which sought to enhance the children’s development by improving the way their caregivers interact with them.

Prior to the intervention, OCD traveled to Managua to conduct baseline assessments of the physical and behavioral environment of the orphanage and children’s developmental levels.

The Infant-Toddler Environmental Rating Scale and the Early Childhood Environmental Rating Scale, both common assessment tools, were used to measure the environmental quality of the orphanage. Those assessments found the environmental quality scores in all six wards to be “nearly as low as possible and dismal by any standard.”

The wards, for example, were described as “spartan” and “stark” with each being poorly lighted and empty except for a few adult- chairs. Children were fed on a strict schedule, regardless of age. They were often rushed to finish meals, forbidden to talk at mealtime, and required to use utensils even if they were too young to do so. Caregivers kept a measured distance that few children were allowed to penetrate. They often left children unattended. And it was rare to find them casually talking with children about such things as their day or what they wanted to do. Wards lacked appropriate materials for activities. Staff were afforded few opportunities for professional growth and given no in-service training.

Not surprisingly, the children in the orphanage scored poorly at pre-intervention on the Battelle Developmental Inventory Scores. The total Developmental Quotient for 82% of the children was below 70. Only 2% of parent-reared children in the United States would be expected to score so low.

Taking On The Challenge

The intervention focused on promoting one-on-one warm, caring, sensitive and responsive interactions between caregivers and the children, particularly during routine chores, such as feeding, bathing, and changing. It was designed primarily for children 3 years of age and younger, although caregivers serving older children were trained as well.

Caregivers were given training and technical assistance that reflected best practices in the group care of children and emphad respectful, responsive caregiving. Training was guided by four general principles: Caregiving routines are important moments for adult-child interactions; continuity of care is important; children need freedom of movement to grow and learn; and children should have access to ample safe and developmentally appropriate materials.

Several bumps in the road were encountered during implementation. The directorship of the orphanage changed shortly after the intervention was begun. Although it became clear more technical assistance, monitoring, and encouragement of caregivers needed to be incorporated in the training, that need could not be fully addressed. New arrivals to the orphanage kept the child-caregiver ratio at about 5-to-11 children per caregiver, which is high by U.S. standards.

The orphanage also could not be persuaded to abandon the practice of segregating children by age. In Russia, some orphanage officials were also reluctant to adopt the practice of age integration, but eventually did. “Ultimately, that allowed caregivers to do what we wanted them to do because they didn’t have 12 children to feed at the same time, only 2 or 3 babies to feed. The older kids could play on their own,” Dr. Groark said.

“What is being attempted in Russia and in Managua is to change mindsets and procedures that have existed possibly for decades,” she said. “They have characteristics that have been common for a long time: A lot of different, changing caregivers; homogeneous age groups; large child-to- caregiver ratios; and perfunctory, business-like caregiving – don’t get close to the child.

In view of that, trying to change an orphanage is a monumental task.”

Improvements Are Made

Despite the challenges encountered, OCD’s evaluation of the Managua intervention found that ward environments improved, caregiver-child interactions became more sensitive and responsive and children of all ages increased their Developmental Quotient scores on the Battelle.

However, the challenges and other limitations likely limited the extent of improvement in outcomes. For example, environmental scores rose from a very low 1.14 to 1.83 on a scale from 1 to the highest rating of 7, and caregiver ratings, as measured by an assessment tool developed at OCD, improved from 1.3 to a score of about 2 on a scale of 1 to 3, both results suggesting room for further improvement.

Nevertheless, the children increased their Developmental Quotient scores by an average of 13.5 points, and the percentage of children whose Developmental Quotient scores were 70 points or lower was reduced from 82% to 27.8%. And even though the intervention was designed for children under the age of 3 years, older children’s Developmental Quotient scores improved as much as younger children’s.

But more substantial gains are possible. For example, the larger, more comprehensive intervention implemented in St. Petersburg, Russia, resulted in more significant and sustained improvements in caregiving and ward environment and larger gains in children’s Developmental Quotient scores, which increased from a mean of 57 to 92 points.

Evaluators noted, however, that children who had moved from wards for younger children to wards for older children during the intervention tended to benefit less than children who remained in the same group. Analysis of those children showed their Developmental Quotient scores improved by only about 5 points instead of 13.5. The finding suggests the common orphanage practice of segregating children by age, which often means some children move to a new set of caregivers and peers periodically as they grow older, may slow their development.

Despite limited gains, the Managua pilot is another indication that an intervention that is primarily directed at the social-emotional nature of caregiver-child interactions can improve children’s development in orphanages. It also has implications for early care and education in the United States, said Dr. McCall. “Many have argued that social-emotional relationships and promoting them are actually the way you do skill building in very young children. This is further evidence of the value of developing these relationships and making sure that relationship-building is part of the training of people going into the field of early care and education.”