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.
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
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
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.
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.”
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
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
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
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.”