MALTREATMENT AND MENTAL HEALTH IN INSTITUTIONAL CARE-COMPARING EARLY AND LATE INSTITUTIONALIZED CHILDREN IN TANZANIA

The next 1000 days: building on early investments for the health and development of young children

Following the first 1000 days of life that span from conception to two years of age, the next 1000 days of a child's life from 2-5 years of age offer a window of opportunity to promote nurturing and caring environments, establish healthy behaviours, and build on early gains to sustain or improve trajectories of healthy development. This Series paper, the first of a two-paper Series on early childhood development and the next 1000 days, focuses on the transition to the next 1000 days of the life course, describes why this developmental period matters, identifies the environments of care, risks, and protective factors that shape children's development, estimates the number of children who receive adequate nurturing care, and examines whether current interventions are meeting children's needs. Paper 2 focuses on the cost of inaction and the implications of not investing in the next 1000 days. In low-income and middle-income countries (LMICs), only 62 million children aged 3 and 4 years (25·4%) currently receive adequate nurturing care during the next 1000 days, leaving 181·9 million children exposed to risks that jeopardise their healthy development. Inputs across nurturing care dimensions of health, nutrition, protection, responsive care, and learning vary substantially across countries. In LMICs, although 86·2% of children have a healthy weight in this period, less than one in three children have access to developmental stimulation or are protected from physical punishment, and only 38·8% have access to early childhood care and education services. Intervention research in LMICs in the next 1000 days is scarce. The continuity of developmentally appropriate nurturing care, coordination across health, education, and protection sectors, and the implementation of interventions to support caregivers and improve the quality of education and care remain top priorities in this period. These sectors play key roles in promoting quality early care and education for this age group, which will help maximise developmental potential and opportunities of children globally and help progress towards the achievement of the Sustainable Development Goals.

Feasibility of Developing Audiovisual Material for Training Needs in a Vietnam Orphanage: A Mixed-Method Design

Disabled children living in orphanages in low-income countries may not have access to the therapy they need. The COVID-19 pandemic has complicated the situation dramatically, making online training activities a possible innovative option to meet the real needs of local staff. This study aimed to detect the training needs of the local staff of an orphanage in Vietnam, as well as develop an audiovisual training material and measure its feasibility. Training needs were identified through a focus group carried out by the volunteers of Fisios Mundi, a nongovernmental organization. The audiovisual training material was developed to meet these specific needs. Lastly, its feasibility was evaluated, in terms of both content and format, through an ad hoc questionnaire. Nine volunteers participated in the project. Twenty-four videos were created and structured around five themes. This study expands the body of knowledge on how an international cooperation project can be developed in a pandemic situation. The audiovisual training material content and format created in this project was considered by the volunteers as very feasible and useful for training the staff of a Vietnamese orphanage.

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.

Swatantra Clinic: A descriptive study on the specialized child mental health service for children in difficult circumstances at a tertiary care center in India

In India, children in difficult circumstances, like institutionalized children have higher mental health morbidity and complex psychosocial concerns than the non-institutionalized children. To cater to the complex needs of these children referred by the Juvenile Justice System, a specialized service called 'Swatantra Clinic' was initiated by the Department of Child and Adolescent Psychiatry at the National Institute of Mental Health and Neurosciences, India. This article thereby aims to describe the psychosocial characteristics of these children, along with the array of specialized interventions provided during the first year of its inception in June 2018. It was found that majority of these children were girls and were from lower socio-economic, urban background, primarily referred for externalizing or internalizing concerns. The majority of them reported experiences of physical and verbal abuse along with family stressors and almost half of them had a diagnosable psychiatric condition. The nature of the psychosocial services rendered at the clinic mostly comprised of brief, individual and family counseling along with liaison work with various governmental agencies for rehabilitation services. These form the key components of a comprehensive, collaborative, time-bound and holistic care model to cater to the distinct psychosocial issues of this vulnerable population of children in low - middle resource settings. Policy implications are discussed.

Prevalences of and correlations between childhood trauma and depressive symptoms, anxiety symptoms, and suicidal behavior among institutionalized adolescents in Vietnam

OBJECTIVES

We investigated the prevalence rates of childhood trauma, depressive symptoms, anxiety symptoms and suicidal behaviors among Vietnamese adolescents and compared the differences between institutionalized adolescents (IAs) and noninstitutionalized adolescents (NIAs). In addition, we examined the multidimensional associations between childhood trauma and psychopathology among IAs.

METHODS

Five hundred forty-six participants were recruited into two groups (IAs and NIAs) matched by age, sex and grade. They completed a childhood trauma questionnaire, depression scale, anxiety scale, and 3 suicide-related questions. The chi-squared test and logistic regressions were performed.

RESULTS

The prevalences of anxiety symptoms and suicide attempts among IAs was higher than that among NIAs (25.6 % vs 14.7 %, p = 0.001 and 8.1 vs 3.7, p = 0.03, respectively), while the prevalences of other psychopathologies did not differ significantly. In the IA group, high prevalences of victimization through physical abuse (22.3 %), emotional neglect (57.9 %), and physical neglect (72.9 %) were found, and 58.6 % of the participants had experienced more than one type of trauma. These figures were significantly higher in IAs than in NIAs. Depression and suicidal ideation were more strongly correlated with emotional abuse and neglect than other types of maltreatment, while anxiety, suicide planning and suicide attempts were more strongly correlated with physical abuse. IAs who experienced more than two categories of trauma or greater intensity of trauma were more susceptible to developing depression, anxiety, and suicidal behaviors.

CONCLUSIONS

Childhood trauma was multidimensionally associated with adverse psychological outcomes. We suggest that various aspects of childhood trauma, as well as psychopathologies, must be routinely assessed.

Holes in the wall: Examining gaps in knowledge in child and adolescent mental health in Tanzania - Scoping review

OBJECTIVES

To perform scoping review of the existing literature available specific to child and adolescent mental health in Tanzania.

METHODS

An extensive literature search of PubMed, Scopus, MEDLINE and EMBASE was undertaken to identify studies that focussed specifically on mental illness in children and young people in Tanzania. This included neurological and functional disorders, affective disorders, psychosis, epidemiological, intervention and treatment-based studies. Qualitative analysis of the studies was then undertaken to assess what is currently known about the subject and how reliable this information is and to identify areas for further research.

RESULTS

Of 23 studies were included in the final synthesis, which could be broadly split into studies focussing on the prevalence and incidence of child and adolescent mental illness, hypothesised causes and correlations, identified treatments and interventions and qualitative studies of human experience.

CONCLUSION

There is a dearth of published research regarding child and adolescent mental health in Tanzania. Although some high-quality studies allow us good insight into the epidemiology of mental illness, interventional studies are often small and low-power, and significant correlational relationships are yet to be drawn. There is significant scope for further child and adolescent mental health research in Tanzania.

Explaining the accumulation of victimization in vulnerable children: Interpersonal violence among children traumatized by war and disaster in a children's home in Sri Lanka

Research in postconflict settings indicated that children's exposure to war and natural disaster is a significant predictor of experiencing violence within their families. However, it is unclear if this effect is driven by characteristics of traumatized children or their parents. To disentangle these different factors we conducted a survey in a children's home in Sri Lanka. A total of 146 institutionalized children (aged 8 to 17) were interviewed using standardized questionnaires administered by local senior counselors in order to assess children's exposure to mass trauma, family violence, and violence in the institution as well as their mental health. Linear regression analyses revealed that, controlling for potential confounds, previous exposure to civil war was a significant predictor of violence by guardians in the children's home. In addition, previous exposure to family violence was a significant predictor of violence by peers in the institutions. A mediation analysis showed that children's internalizing and externalizing behavior problems partly mediated the relationship between violence prior to the admission to the children's home and violence in the children's home. The findings of our study provide evidence for the assumption that the transmission of mass trauma into interpersonal violence can occur independently from parents through children's psychopathology.

A Systematic Review of the Outcome of Child Abuse in Long-Term Care

The aim of the systematic review described in this article was to determine the outcome of child maltreatment in long-term childcare and the scope of the evidence base in this area. Searches of 10 databases were conducted. Forty-nine documents describing 21 primary studies and 25 secondary studies were selected for review. Searches, study selection, data extraction, and study quality assessments were independently conducted by two researchers, with a high degree of interrater reliability. Participants in the 21 primary studies included 3,856 abuse survivors and 1,577 nonabused controls. In six primary studies, survivors were under 18 years, and participants in the remaining primary studies were adults with a mean age of 54 years. Reviewed studies were conducted in the United Kingdom, the United States, Finland, Romania, Tanzania, Canada, Ireland, Australia, the Netherlands, Germany, Austria, and Switzerland. Participants were abused in religious and nonreligious residential care centers and foster care. There were significant associations between the experience of child abuse in long-term care and adjustment across the life span in the domains of mental health, physical health, and psychosocial adjustment. Evidence-based trauma-focused treatment should be offered to child abuse survivors. Future research in this area should prioritize longitudinal studies.

Marte Meo Counselling given to African caregivers of institutionalised infants a three-case study

BACKGROUND

Studies from Western countries state that video interaction guidance programmes can support caregiver sensitivity in infant-caregiver dyads.

OBJECTIVES

The aim of this study was to investigate if Marte Meo, which is such a programme, could contribute to increasing emotional and social support towards motherless infants at an institution for motherless infants in rural Africa.

METHOD

Three caregivers participated in five Marte Meo Counselling sessions. The first guidance naïve film and the last film were analysed qualitatively and quantitatively and organised according to two supportive categories: 1) caregiver responds to infants' initiative, 2) caregiver takes initiative to supportive interaction, and two non-supportive: 3) caregiver behaves in an intrusive manner and 4) caregiver does not respond to the infants' initiative.

RESULTS

After receiving Marte Meo Counselling, all three caregivers showed impressive augmentation of awareness and sensitivity in their care towards the infants' emotional and social needs.

CONCLUSION

We found indications that professional caregivers of institutionalised infants in an African country can profit on Marte Meo Counselling, showing positive effects on augmenting caregivers' sensitivity towards the infants, and thereby meet the infants' need of emotional and social support.

Prevalence and number of children living in institutional care: global, regional, and country estimates

BACKGROUND

Children living in institutionalised settings are at risk of negative health and developmental outcomes, as well as physical and emotional abuse, yet information on their numbers is scarce. Therefore, the aim of our study was to estimate global-level, regional-level, and country-level numbers and percentages of children living in institutional care.

METHODS

In this estimation study, we did a systematic review of peer-reviewed publications and a comprehensive review of surveys and unpublished literature to construct a dataset on children living in institutional care from 136 countries between 2001 and 2018. We applied a wide range of methods to estimate the number and percentages of children living in institutional care in 191 countries in 2015, the year the Sustainable Development Goals were adopted. We generated 98 sets of estimates for each dataset, with possible combinations of imputation methods for countries with different available data points. Of these 98 sets, we report here five types of global-level estimates: estimates with the highest values, those with the lowest values, those with median values, those with uncertainty levels, and those derived from methods with the smallest root-mean-square errors (RMSE).

FINDINGS

Global estimates of children living in institutions in 2015 was highly sensitive to the methods and data used, ranging from 3·18 million to 9·42 million children, with a median estimate of 5·37 million. When selecting the method with the lowest RMSE, the global estimate was 4·21 million, whereas with negative binomial regression with bootstrapping, the global estimate was 7·52 (95% CI 7·48-7·56) million. We also observed large variations in country-level estimates. Compared with other regions, estimates in south Asia, sub-Saharan Africa, and Latin America had larger variations in values when switching between estimation methods. High-income countries had the highest average prevalence of institutionalisation, whereas low-income countries had the lowest average prevalence. Estimates from the full data with the smallest RMSE method showed that south Asia had the largest estimated number of children living in institutions (1·13 million), followed by Europe and central Asia (1·01 million), east Asia and Pacific (0·78 million), sub-Saharan Africa (0·65 million), Middle East and North Africa (0·30 million), Latin America and the Caribbean (0·23 million), and North America (0·09 million). North America consistently had the lowest estimates among all regions.

INTERPRETATION

Worldwide, institutional care places millions of children at elevated risk of negative health and developmental outcomes, highlighting the need for deinstitutionalisation. However, there is considerable uncertainty regarding the number of children living in institutions. To improve estimates of the size of this population, we need to standardise the definition of institutional care and improve data collection, particularly in countries with large child populations.

FUNDING

Lumos Foundation.

Reducing violence by teachers using the preventative intervention Interaction Competencies with Children for Teachers (ICC-T): A cluster randomized controlled trial at public secondary schools in Tanzania

The high global prevalence of school violence underlines the need for prevention. However, there are few scientifically evaluated intervention approaches that aim at preventing violence by teachers. We evaluated the feasibility and efficacy of the preventative intervention Interaction Competencies with Children for Teachers (ICC-T). In a cluster randomized controlled trial we assessed attitudes towards and use of violence by teachers (self-reported and reported by students) at eight schools in four regions in Tanzania. Two regions were randomly assigned as intervention regions. Data were assessed in the months before and three months after intervention. In total, 158 teachers (58% females; age: 32.08 years, SD = 5.65) and 486 students (54% females; age: 15.61 years, SD = 0.89) participated in this study. The feasibility was very good: Participants' acceptance was high and they reported a good integration of the core elements in their working routine. The significantly stronger decrease in the use of emotional and physical violence reported both by teachers and students as well as the stronger decrease in positive attitudes of teachers towards physical and emotional violence in the intervention schools at follow-up provide initial evidence of the efficacy. However, further evidence for the sustainability of its effect is needed.

Reducing violence against children by implementing the preventative intervention Interaction Competencies with Children for Teachers (ICC-T): study protocol for a cluster randomized controlled trial in Southwestern Uganda

BACKGROUND

An adolescent's school is often the second most important place for his development and education after the home. However, reports highlight the recurrence of the use of violent discipline in schools. There are few school-based interventions that aim at reducing violence at school that have been implemented and evaluated in sub-Saharan Africa. To reduce violent disciplinary measures used at school, we aim to implement and evaluate the feasibility and efficacy of the preventative intervention Interaction Competencies with Children for Teachers (ICC-T).

METHODS/DESIGN

The study will be conducted in six randomly selected districts of the Ankole region in southwestern Uganda. We shall randomly select two mixed-day secondary schools from each district that fulfill our inclusion criteria. Schools will be randomly assigned to the intervention condition, where ICC-T will be implemented, and control schools (no intervention). Sixty students between the ages of 12 and 17 years and at least 15 teachers per school will be included in the trial. We aim to collect pre-assessment data directly before the intervention (t1) and 3 months after the intervention (t2) in both intervention and control schools. Using self-administered questionnaires, we will measure students' exposure to violence using the Conflict Tactics Scale (CTS), their psychological well-being using the Strengths and Difficulties Questionnaire (SDQ), and teachers' positive attitudes towards violent disciplining and teachers' use of violent disciplinary methods (CTS). The implementation feasibility of ICC-T in the cultural context of southwestern Uganda will be assessed with purpose-built measures that follow the guidelines for feasibility studies assessing the demand, applicability, acceptability, and integration of core elements in the daily work.

DISCUSSION

The proposed study will allow us to test the feasibility and efficacy of a preventative intervention seeking to reduce violent disciplinary measures in school settings using a scientifically rigorous design. The proposed study provides the opportunity to contribute to the attainment of goal number 16.2 of the United Nations' Sustainable Development Agenda 2015-2030, which aspires to end all forms of violence against children.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03051854 . Registered on 14 February 2017.

Mental health problems and their association to violence and maltreatment in a nationally representative sample of Tanzanian secondary school students

PURPOSE

Little is known about the prevalence of mental health problems among adolescents in Sub-Saharan Africa. Research consistently determined violence and maltreatment to be important risk factors. In this study, we examined the prevalence of mental health problems among adolescents in Tanzania, as well as the association with exposure to violence and maltreatment.

METHODS

We administered a set of questionnaires (e.g., strength and difficulties questionnaire; conflict tactic scale) to a nationally representative sample of 700 Tanzanian secondary school children (52% girls; age 14.92 years, SD = 1.02) and 333 parents or primary caregivers (53% females; age 43.47 years, SD = 9.02).

RESULTS

41% of the students reported an elevated level of mental health problems (emotional problems 40%, peer problems 63%, conduct problems 45%, hyperactivity 17%) in the past 6 months. Concordantly, 31% of parents reported observing an elevated level of mental health problems in their children (emotional problems 37%, peer problems 54%, conduct problems 35%, hyperactivity 17%). After controlling for other risk factors, we found significant associations between physical violence by parents and adolescent's mental health problems reported by students (β = 0.15) and their parents (β = 0.33).

CONCLUSIONS

Our findings suggest a high prevalence of mental health problems using screening tools among secondary school students in Tanzania as well as an association between physical violence by parents and adolescents' mental health problems. Our findings emphasize the need to inform the population at large about the potentially adverse consequences associated with violence against children and adolescents.

CAREGIVER SENSITIVITY AND CONSISTENCY AND CHILDREN'S PRIOR FAMILY EXPERIENCE AS CONTEXTS FOR EARLY DEVELOPMENT WITHIN INSTITUTIONS

The current study addressed whether two institution-wide interventions in St. Petersburg, Russian Federation, that increased caregiver sensitivity (Training Only: TO) or both caregiver sensitivity and consistency (Training plus Structural Changes: T+SC) promoted better socioemotional and cognitive development than did a No Intervention (NoI) institution during the first year of life for children who were placed soon after birth. It also assessed whether having spent less than 9 versus 9 to 36 months with a family prior to institutionalization was related to children's subsequent socioemotional and cognitive development within these three institutions. The Battelle Developmental Inventory (J. Newborg, J.R. Stock, L. Wnek, J. Guidubaldi, & J. Svinicki, 1988) was used to assess the socioemotional and cognitive functioning of children in NoI (n = 95), TO (n = 104), and T+SC (n = 86) at two to three time points during their first 6 to 12 months of residency. Results suggest that improving caregiver sensitivity can improve the cognitive development of infants in the first year of institutionalization whereas improving caregiver consistency in addition to sensitivity is more beneficial for socioemotional development than is sensitivity alone. Similarly, for children in T+SC, longer time with a family prior to institutionalization (consistent caregiver, unknown sensitivity) was associated with better socioemotional, but not cognitive, baseline scores and more rapid cognitive than socioemotional development during institutionalization. These results suggest caregiver sensitivity is more highly related to cognitive development whereas caregiver consistency is more related to socioemotional development in the first years of life.

Violence and maltreatment in Tanzanian families-Findings from a nationally representative sample of secondary school students and their parents

Though the Sustainable Development Goals of the United Nations aim to end all forms of violence against minors, child maltreatment remains a globally prevalent phenomenon. Despite the fact that parents in numerous countries apply violent discipline methods to control children's behavior, little is known about the prevalence of maltreatment and violent discipline in Sub-Saharan Africa. In this study, we examined the prevalence of maltreatment and violent discipline from both the adolescents' and parents' perspectives. In addition, we explored risk factors that could be associated with violent discipline by parents. We administered questionnaires to a nationally representative sample of 700 Tanzanian secondary school students (52% girls, mean age: 14.92 years, SD = 1.02, range: 12-17) and 333 parents or primary guardians (53% females; mean age: of 43.47 years, SD = 9.02, range: 19-71). More than 90% of all students reported exposure to violent discipline by a parent within the past year. Concurrently, more than 80% of parents acknowledged using violent discipline techniques. Using a path model, we found that violent discipline by parents was associated with parental stress. Other risk factors contributed to a higher stress level but were not directly linked to maltreatment. Our findings indicate high levels of violent discipline in Tanzanian families. There is a pressing need to design and implement interventions that prevent children from experiencing violence at home. Reducing parents' stress levels may be a starting point for intervention. Yet, due to the high levels of violent discipline, societal beliefs also need to be considered.

A new look at the supposed risks of early institutional rearing

The main focus is on the assessment of the effects of early institutional care and compares three longitudinal studies from Romania, Greece and Hong Kong/China. The findings have been strikingly contrasting. The review asks if the risks are dependent on whether or not the institutional rearing is accompanied by gross pervasive deprivation (as it was in Romania) and investigates the methodological issues to explore the causal influence of the outcomes. Evidence is considered on changing institutional practices and the benefits of doing so. Comparison is made between institutions with major deprivation and those without global deprivation. A small number of studies are discussed that look at direct comparisons between institutional and community care. The empirical and conceptual implications of the findings are discussed.

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.

Supporting institutional caregivers in a children's home in rural south India

Orphans and other institutionalized children frequently have histories of maltreatment prior to entering institutional care. Better understanding the impact of these maltreatment experiences is essential to meeting the needs of these children. Institutional caregivers are challenged to address the unique and complex needs of these children. A team of child psychiatrists and mental health specialists visited a children's home in south India to provide consultation to the caregivers. The cases of two adolescent girls illustrate two distinct presentations following histories of significant maltreatment and early loss. One of the girls was significantly dysregulated. The other was struggling academically after leaving the home but was better able to regulate her affective states. The team recommended supporting the children's existing defensive structures and allowing them to speak about any past traumas on their own terms without being pushed to do so. The team also considered the self-regulating function of the cultural practices in which the children engaged and encouraged them to continue these activities.

Child violence experiences in institutionalised/orphanage care

Institutions are not necessarily good environments for children. In the face of challenges such as HIV, Ebola, poverty, conflict and disaster the numbers have grown rather than reduced. Some countries have closed institutions down -driven by findings that cognitive developmental delay is associated with institutional care. Yet insight into abuse and violence within institutionalised settings is neglected. Maltreatment -violence and abuse -may be an issue. This systematic review series addresses violence and abuse experiences in institutionalised care, exploring firstly the frequency of abuse/violence in institutions, secondly any interventions to reduce such violence or abuse and thirdly the perpetrators of such violence or abuse. The final systematic review updates the findings on cognitive delay associated with institutionalised care. With a violence lens, cognitive delay may well be considered under the umbrella of neglect. Maltreatment and abuse may be a driver of cognitive delay. The keyword search covered several electronic databases and studies were included for data abstraction if they met adequacy criteria. Eight studies were identified on the prevalence of abuse in institutions and a further three studies reported on interventions. Only one study was identified documenting peer on peer violence in institutions. Sixty-six studies were identified examining cognitive development for institutionalised children. All but two of these record cognitive deficits associated with institutionalisation. Only two asked about violence or abuse which was found to be higher in institutionalised children. Overall the abuse experiences of children in institutions are poorly recorded, and in one study violence was associated with high suicidal attempts. The major intervention pathway for ameliorating cognitive challenge seems to be placement out of the institutions which shows benefits and redresses some cognitive outcomes - yet not a total panacea. The single study providing training and monitoring of harsh punishment and maltreatment showed immediate and decided reductions. This data suggest, despite the paucity of studies, violence and abuse, by commission or omission is prevalent in institutions, has an effect on child well-being and is amenable to intervention. Simple training or more complex structures to place children within conducive alternative environments (or to avoid institutionalised placements in the first place) seem to be the main pathway of intervention.

Culturally sensitive adaptation of the concept of relational communication therapy as a support to language development: An exploratory study in collaboration with a Tanzanian orphanage

BACKGROUND

Orphans and other vulnerable children (OVC) who grow up in institutional care often show communication and language problems. The caregivers lack training, and there are few language didactics programmes aimed at supporting communication and language development in OVC in institutional care in Tanzania.

OBJECTIVES

The purpose of the study was to adapt the German concept of relational communication therapy (RCT) as a support to language development in a Tanzanian early childhood education context in a culturally sensitive way. Following the adaptation of the concept, a training programme for Tanzanian caregiver students was developed to compare their competencies in language didactics before and after training.

METHODS

A convergent mixed methods design was used to examine changes following training in 12 participating caregiver students in a Tanzanian orphanage. The competencies in relational language didactics were assessed by a self-developed test and video recordings before and after intervention. Based on the results, we drew conclusions regarding necessary modifications to the training modules and to the concept of RCT.

RESULTS

The relational didactics competencies of the caregiver students improved significantly following their training. A detailed analysis of the four training modules showed that the improvement in relational didactics competencies varied depending on the topic and the teacher.

CONCLUSION

The results provide essential hints for the professionalisation of caregivers and for using the concept of RCT for OVC in institutional care in Tanzania. Training programmes and concepts should not just be transferred across different cultures, disciplines and settings; they must be adapted to the specific cultural setting.

Maltreatment and Mental Health Outcomes among Ultra-Poor Children in Burkina Faso: A Latent Class Analysis

Objectives

Research about the mental health of children in Francophone West Africa is scarce. This paper examines the relationships between adverse childhood experiences, including exposure to violence and exploitation, and mental health outcomes among children living in ultra-poverty in rural Burkina Faso.

Methods

This paper utilizes baseline data collected from 360 children ages 10–15 and 360 of their mothers recruited from twelve impoverished villages in the Nord Region of Burkina, located near the Sahel Desert and affected by extreme food insecurity. We used a Latent Class Analysis to identify underlying patterns of maltreatment. Further, the relationships between latent classes and mental health outcomes were tested using mixed effected regression models adjusted for clustering within villages.

Results

About 15% of the children in the study scored above the clinical cut-off for depression, 17.8% for posttraumatic stress disorder (PTSD), and 6.4% for low self-esteem. The study identified five distinct sub-groups (or classes) of children based on their exposure to adverse childhood experiences. Children with the highest exposure to violence at home, at work and in the community (Abused and Exploited class) and children not attending school and working for other households, often away from their families (External Laborer class), demonstrated highest symptoms of depression and trauma. Despite living in adverse conditions and working to assist families, the study also identified a class of children who were not exposed to any violence at home or at work (Healthy and Non-abused class). Children in this class demonstrated significantly higher self-esteem (b = 0.92, SE = 0.45, p<0.05) and lower symptoms of trauma (b = -3.90, SE = 1.52, p<0.05).

Conclusions

This study offers insight into the psychological well-being of children in the context of ultra-poverty in Burkina Faso and associated context-specific adverse childhood experiences. Identifying specific sub-groups of children with increased exposure to life stressors has implications for program developers. Study findings indicate a further need to explore the mental health consequences of traumatic experiences within the context of ultra-poverty and to develop integrated economic and psychosocial interventions that prevent or mitigate childhood adversities linked with the family-level poverty and violence in the family.

Harsh discipline relates to internalizing problems and cognitive functioning: findings from a cross-sectional study with school children in Tanzania

BACKGROUND

Child maltreatment poses a risk to children and adolescents' mental health and may also affect cognitive functioning. Also harsh discipline has been frequently associated with mental health problems. However, within societies in which harsh disciplinary methods are culturally normed and highly prevalent less is known about the association between harsh punishment, mental health problems, and cognitive functioning.

METHODS

In a cross-sectional study, we conducted structured clinical interviews with a sample of Tanzanian primary school students assessing exposure to harsh discipline (Maltreatment and Abuse Chronology of Exposure), internalizing problems (Strength and Difficulties Questionnaire, Children's Depression Inventory), and working memory (Corsi Blocktapping Task). School performance was measured by using the exam grades in 4 core subjects. The 409 children (52% boys) had a mean age of 10.5 years (range: 6 - 15).

RESULTS

Using structural equation modeling, a strong relationship was found between harsh discipline and internalizing problems (β = .47), which were related to lower working memory capacity (β = -.17) and school performance (β = -.17).

CONCLUSIONS

The present study suggests that harsh discipline is closely linked to children's internalizing mental health problems, which are in turn associated with lower cognitive functioning and school performance. Given the high rates of harsh discipline experienced by children in East African homes and elsewhere, the findings of the present study emphasize the need to inform the population at large about the potentially adverse consequences associated with harsh discipline.

Associations among child abuse, mental health, and epigenetic modifications in the proopiomelanocortin gene (POMC): A study with children in Tanzania

Child abuse is associated with a number of emotional and behavioral problems. Nevertheless, it has been argued that these adverse consequences may not hold for societies in which many of the specific acts of abuse are culturally normed. Epigenetic modifications in the genes of the hypothalamus-pituitary-adrenal axis may provide a potential mechanism translating abuse into altered gene expression, which subsequently results in behavioral changes. Our investigation took place in Tanzania, a society in which many forms of abuse are commonly employed as disciplinary methods. We included 35 children with high exposure and compared them to 25 children with low exposure. Extreme group comparisons revealed that children with high exposure reported more mental health problems. Child abuse was associated with differential methylation in the proopiomelanocortin gene (POMC), measured both in saliva and in blood. Hierarchical clustering based on the methylation of the POMC gene found two distinct clusters. These corresponded with children's self-reported abuse, with two-thirds of the children allocated into their respective group. Our results emphasize the consequences of child abuse based on both molecular and behavioral grounds, providing further evidence that acts of abuse affect children, even when culturally acceptable. Furthermore, on a molecular level, our findings strengthen the credibility of children's self-reports.

Global research, practice, and policy issues on the care of infants and young children at risk: the articles in context

This Special Issue includes articles that contribute to (a) the global research base pertaining to the development of infants and toddlers at risk, primarily those who are institutionalized in lower resource countries; (b) interventions in institutions and to promote family alternatives to institutionalization; and (c) attempts to create modern child welfare systems emphasizing family care in entire states and countries. This introduction places these articles into the broader contexts of the literature in these three domains of interest. Across the world, urbanization, migration, armed conflict, epidemics, and famine disrupt families. Add poverty, abuse, neglect, and parental incapacity due to substance abuse and mental health problems, and the result is millions of children without parental care who come under governmental responsibility, often to be reared in institutions, and at risk for long-term developmental deficiencies and problems. Over the last 2 decades and especially recently, national and international governments and nongovernment organizations have increased efforts to help such children, especially those in low-resource countries. Two types of efforts have been made: one to improve the quality of care provided by institutions and the other to minimize the use of institutions and promote family residential care alternatives. The latter effort includes preventing family separations in the first place, reunification of children with birth families, and developing systems of kinship care, foster care, and adoption. This Special Issue of IMHJ is devoted to reports pertaining to issues in the research knowledge base, program practices, and countrywide policies for infants and young children at risk. We attempt in this introduction to place these reports in the broader context of this field, identify their unique contributions, and highlight lessons learned that can contribute to improved care practices and better child welfare systems.

Improving care quality and preventing maltreatment in institutional care - a feasibility study with caregivers

Institutionalized children in low-income countries often face maltreatment and inadequate caregiving. In addition to prior traumatization and other childhood adversities in the family of origin, abuse and neglect in institutional care are linked to various mental health problems. By providing a manualized training workshop for caregivers, we aimed at improving care quality and preventing maltreatment in institutional care. In Study 1, 29 participating caregivers rated feasibility and efficacy of the training immediately before, directly after, and 3 months following the training workshop. The results showed high demand, good feasibility, high motivation, and acceptance of caregivers. They reported improvements in caregiver–child relationships, as well as in the children’s behavior. Study 2 assessed exposure to maltreatment and the mental health of 28 orphans living in one institution in which all caregivers had been trained. The children were interviewed 20 months before, 1 month before, and 3 months after the training. Children reported a decrease in physical maltreatment and assessments showed a decrease in mental health problems. Our approach seems feasible under challenging circumstances and provides first hints for its efficacy. These promising findings call for further studies testing the efficacy and sustainability of this maltreatment prevention approach.

Neglect and perceived stigmatization impact psychological distress of orphans in Tanzania

BACKGROUND

Research has shown that orphans in sub-Saharan Africa are at increased risk for mental health problems. Exposure to maltreatment and HIV/AIDS-related stigmatization are related to orphans' psychological distress. Yet, researchers stress the need for more research in low-income countries to identify which factors of being an orphan may lead to psychological distress.

OBJECTIVES

The present study aims to systematically investigate orphans' experiences of maltreatment and stigmatization to identify factors that relate to their psychological distress.

METHODS

In total, 89 Tanzanian children who had lost at least one parent were compared to 89 matched non-orphans (mean age: 11 years; 51% boys). We measured exposure to maltreatment and perceived stigmatization as an orphan. Mental health was assessed using the Strengths and Difficulties Questionnaire, the Children's Depression Inventory, the UCLA PTSD Index for Children, and the Reactive-Proactive Questionnaire.

RESULTS

Orphans reported significantly more experiences of neglect, but not of abuse. A group comparison revealed more depressive symptoms, posttraumatic stress symptoms, and aggressive behavior among orphans. Neglect, abuse, and stigmatization correlated with orphans' internalizing and externalizing problems, yet only neglect and stigmatization were related to orphans' depression severity. Perceived stigmatization moderated the relationship between neglect and depression.

CONCLUSIONS

Our findings suggest that orphans in Tanzania are at increased risk of experiencing neglect. Maltreatment and perceived stigmatization may play a role in orphans' psychological distress. Culturally appropriate and evidence-based interventions may help to prevent maltreatment and stigmatization of orphans.