Not by bread alone': impact of a structured 90-minute play session on development of children in an orphanage

Effects of Play in an Upright Position on Intra-Individual Variability of Gross Motor and Language Development in Institutionalized Infants

(1) Objective: To investigate the effects of play in an upright position on intra-individual variability and to examine the relationship between the variability of gross motor and language development in institutionalized infants aged six to ten months. (2) Methods: Thirty infants were conveniently enrolled in either the experimental or control groups. The Alberta Infant Motor Scale (AIMS) and the Communication and Symbolic Behavior Scales Developmental Profile (CSBS-DP) Infant/Toddler Checklist were tested pre and post each monthly intervention for three months. Sixteen infants in the experimental group received an additional program of 45 min play in an upright position three times a week for a 3-month period. (3) Results: There were significant between-group differences in intra-individual variability of the AIMS percentiles (p-value = 0.042). In addition, there was a significant difference in the intra-individual variability of the language percentile between groups (p-value = 0.009). The intra-individual variability of gross motor development was significantly correlated (r_s = 0.541; p = 0.03) with language development. (4) Conclusions: Play in an upright position could be applied to improve intra-individual variability in gross motor and language development percentiles in institutionalized infants.

Development of children adopted to the United States following a social-emotional intervention in St. Petersburg (Russian Federation) institutions

This study is a post-adoption follow-up of a social-emotional intervention in St. Petersburg, Russian Federation Baby Homes (BHs). Children previously resided in BHs and received Care as Usual (CAU, N=220), Training Only (TO, N=94), or Training plus Structural Changes (T+SC, N=45). This study examined intervention effects 0-6.5 years post-adoption to the USA, at age 9 months to 7 years old. Adoptive parents completed questionnaires on their child's social and behavioral development. Intervention graduates had better attachment security, less indiscriminate friendliness, and fewer behavior problems than CAU graduates. Children who had longer exposure to intervention conditions had better attachment security, but poorer executive function, externalizing and internalizing problems, and competence. Thus, although post-institutionalized children were generally functioning in the normal range in early childhood and effect sizes were small, a social-emotional intervention in institutions is associated with modest benefits to attachment and behavior problems and apparent decrements to executive function.

Early Neurodevelopmental Outcome of Very Low Birthweight Neonates with Culture-positive Blood Stream Infection: A Prospective Cohort Study

Aim

Our study aimed to evaluate the early neurodevelopmental outcomes of very low birthweight (VLBW) neonates with culture-proven sepsis compared with VLBW neonates without sepsis.

Materials and methods

Our study included 80 VLBW neonates with blood culture-proven sepsis and 80 VLBW neonates without sepsis. For each neonate with sepsis, a control neonate of matching gender and gestational age was selected. We evaluated weight, length, and head circumference and conducted Hammersmith neonatal neurological examinations for each participant. We also conducted Developmental Assessment Screening II and vision and hearing impairment screening during a follow-up evaluation.

Results

We noted a developmental delay in 11 (23.4%) neonates with sepsis and two (3%) without sepsis at six months of age. The median developmental quotient, motor quotient, and mental quotients were significantly lower in the neonates with sepsis compared to those without sepsis.

Conclusions

Our findings suggest that sepsis significantly affects mortality and neurodevelopmental outcomes at six months in VLBW neonates. Therefore, preventive measures for sepsis in VLBW neonates is crucial, and those with culture-positive sepsis will require close monitoring and follow-up evaluations.

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.

The Effect of a Social-Emotional Intervention on the Development of Preterm Infants in Institutions

This study examined the effect of a social-emotional intervention implemented in one St. Petersburg (Russian Federation) institution (called a Baby Home, BH) on the general behavioral development of preterm children (gestational ages of 30-36 weeks) during their first two years of life. The intervention consisted of training caregivers and implementing structural changes to create a more family-like environment. The study included preterm (N = 56) and full-term (N = 93) children from one BH that implemented the intervention and from another BH with no intervention. Children were assessed at 3, 6, 9, 12, 18 and 24 months of age with the Battelle Development Inventory (LINC Associates, 1988). The results showed that the intervention positively influenced the general behavioral development of BH preterm children throughout their first two years of life compared to preterms from the no-intervention BH. Also, results indicated that the intervention effect was developmentally similar for preterm and for full-term children, but preterm children consistently scored lower than full-terms during their first two years living in the BH. In general, our research emphasizes the crucial role of warm, sensitive, and responsive interactions with a constant and emotionally available caregiver for healthy child development for both term and preterm children.

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.

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.

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.

The importance of early experiences for neuro-affective development

This chapter considers the functional utility of the prolonged period of immaturity in human brain development. Development of the amygdala and its connections with the prefrontal cortex is used as an example system for discussing the special role of sensitive periods in shaping neural functional architecture. The argument is made that neural immaturity during childhood may be important and confer a longer period of neuroplasticity, which can increase learning from the environment.

Infant Movement Motivation Questionnaire: development of a measure evaluating infant characteristics relating to motor development in the first year of life

This paper highlights the development and testing of the Infant Movement Motivation Questionnaire (IMMQ), an instrument designed to evaluate qualities of infant characteristics that relate specifically to early motor development. The measurement development process included three phases: item generation, pilot testing and evaluation of acceptability and feasibility for parents and exploratory factor analysis. The resultant 27-item questionnaire is designed for completion by parents and contains four factors including Activity, Exploration, Motivation and Adaptability. Overall, the internal consistency of the IMMQ is 0.89 (Cronbach's alpha), with test-retest reliability measured at 0.92 (ICC, with 95% CI 0.83-0.96). Further work could be done to strengthen the individual factors; however it is adequate for use in its full form. The IMMQ can be used for clinical or research purposes, as well as an educational tool for parents.

Systems, strategies, and interventions for sustainable long-term care and protection of children with a history of living outside of family care

OBJECTIVES

This article reviews the available evidence regarding the efficacy, effectiveness, ethics, and sustainability of approaches to strengthen systems to care for and protect children living outside family care in low- and middle-income countries.

METHOD

For trafficked children, children of and on the street, children of conflict/disaster, and institutionalized children, a systems framework approach was used to organize the topic of sustainable approaches in low- and middle-income countries and addresses the following: legislation, policies, and regulations; system structures and functions (formal and informal); and continuum of care and services. The article draws on the findings of a focal group convened by the U.S. Government Evidence Summit: Protecting Children Outside of Family Care (December 12-13, 2011, Washington, DC), tasked with reviewing the literature on systems, strategies, and interventions for sustainable long-term care and protection of children with a history of living outside of family care in low- and middle-income country contexts. The specific methodology for the review is described in the commentary paper (Higgs, Zlidar, & Balster, 2012) that accompanies these papers.

RESULTS

For the most part, the evidence base in support of sustainable long-term care for the populations of interest is relatively weak, with some stronger but unreplicated studies. Some populations have been studied more thoroughly than others, and there are many gaps. Most of the existing studies identify population characteristics, needs, and consequences of a lack of systemic services to promote family-like care. There is some evidence of the effectiveness of laws and policies, as well as some evidence of service effectiveness, in improving outcomes for children outside of family care.

CONCLUSIONS

Despite the weaknesses and gaps of the existing research, there is a foundation of research for going forward, which should focus on developing and implementing systems for these most vulnerable children. The evidence reviewed indicates that child protection systems should aim for appropriate, permanent family care (including reunification, adoption, kinship care, or kafalah) for children in order to secure the best environment for a child's developmental prospects. Evidence also suggests that the quality and duration of care, including both permanent family care and alternative care, are important regardless of setting. The diversity of political, socioeconomic, historical, regional, community, and cultural contexts in which child protection systems operate need to be taken into account during programming and research design.

What are the most effective early response strategies and interventions to assess and address the immediate needs of children outside of family care?

OBJECTIVES

Children outside of family care face increased risk of threats to their well-being, have lower educational achievement, and experience adverse developmental outcomes. While it is generally accepted that early response and intervention is critical to reducing the risk of harm for children who have been separated from their families, it is not always clear what the most effective early response strategies are for assessing and addressing their immediate needs. The purpose of this review was to identify evidence-based early response strategies and interventions for improving the outcomes of children outside of family care, including children of and on the street, institutionalized children, trafficked children, children affected by conflict and disaster, and who are exploited for their labor.

METHODS

A multi-phased, systematic evidence review was conducted on peer-reviewed and gray literature, which yielded a total of 101 documents that met the inclusion criteria and were reviewed.

RESULTS

Overall there is a weak evidence base regarding assessment and early response interventions for children living outside of family care. Few studies included careful outcome measures or comparison groups. Although few proven interventions emerged, the review identified several promising early interventions and approaches. In emergency settings, family tracing and reunification is a highly effective response in regard to separated children, whereas placing children in institutional care is problematic, with the possible exception of time-limited placements of formerly recruited children in interim care centers. Livelihood supports are promising in regard to preventing and responding to children living outside family care. Other promising interventions include psychosocial support, including the use of traditional cleansing rituals as appropriate, educational supports such as Child Friendly Spaces, the maintenance of family connectedness for children of or on the streets, the use of community-based approaches that aid social integration, and approaches that enable meaningful child participation. A recurrent theme was that to be effective, all assessments and interventions must fit the context.

CONCLUSION

A strong need exists for strengthening the evidence base regarding the effectiveness of early assessments and responses to children living outside family care and for using the evidence to guide operational policy and practice. Recommendations regarding policy, practices, and research emerged from the review process.

Supporting language and cognitive development of infants and young children living in children's homes in Turkey

AIM

The purpose of the present study was to improve language and cognitive development of infant and young children residing in institutional settings in Turkey.

METHOD

In Study I, there were 12 children with a mean age of 35 months in the intervention group and 12 children with a mean age of 36 months in the control group.

RESULTS

When both groups' pre-test post-test general development t scores and cognitive and language sub-domain developmental gaps were compared, neither the time nor the time by group interactions were significant. Nevertheless, both groups' developmental gap appeared to decline. In Study II, children were recruited from the same institution and randomly assigned to the intervention and control groups. Results indicated that infants and children who were in the intervention group showed a decline in the language and cognitive development gaps, whereas the control group children's developmental gaps were increased.

CONCLUSIONS

It can be concluded that by increasing the quality of care in children's homes infants' and young children's development can be enhanced.

Risk and developmental heterogeneity in previously institutionalized children

This article presents an overview of the developmental outcomes of children adopted from institutional care. The author describes how institutional care is a risk factor for typical human development and describes the areas of development, both behavioral and neurobiological, that are most vulnerable to this risk. Also described is variation in outcome and resilience, where some children thrive despite exposure to adverse rearing conditions. The author concludes with an emphasis on heterogeneity in outcome, describing how the risk associated with institutional care is not a deterministic factor but rather an influential one.

The effect of institutionalization on psychomotor development of preschool aged children

Development can be altered by several factors which can either facilitate or obstruct development. The aim of the current study was the examination and the detection of differences in the developmental profiles of preschool aged children living in conventional institution facilities (N=28), in SOS villages (N=20) and in natural family environment (N=48). The psychomotor development of the 96 children, aged 4-6 years old, was assessed using the six scales of the Griffiths Test No II. Two-way analysis of variance designs showed that family reared children had better performance in all scales of the Griffiths test compared with children of the other two groups and that children living in a SOS village had better scores on all domains of development examined compared to children living in a conventional institution (p<.05). The findings reinforce the need to transform institution environments into more supportive ones for the most benefit of children's development and mental health.

Practice Parameter for psychodynamic psychotherapy with children

This Practice Parameter describes the principles of psychodynamic psychotherapy with children and is based on clinical consensus and available research evidence. It presents guidelines for the practice of child psychodynamic psychotherapy, including indications and contraindications, the setting, verbal and interactive (play) techniques, work with the parents, and criteria for termination.

Against the odds: psychomotor development of children under 2 years in a Sudanese orphanage

Providing abandoned children the necessary medical and psychological care as possible after their institutionalization may minimize developmental delays. We describe psychomotor development in infants admitted to an orphanage in Khartoum, Sudan, assessed at admission and over an 18-month follow-up. Psychological state and psychomotor quotients were determined using a simplified Neonatal Behavior Assessment Scale (NBAS), the Brunet-Lezine and Alarm distress baby (ADBB) scale. From May-September 2005, 151 children were evaluated 2, 4, 9, 12 and 18 months after inclusion. At admission, ~15% of children ≤1 month had a regulation impairment according to the NBAS, and 33.8% presented a distress state (ADBB score >5). More than 85% (129/151) recovered normal psychomotor development. The results of the program reinforce the importance of early detection of psychological disorders followed by rapid implementation of psychological case management to improve the development of young children in similar institutions and circumstances.

Childhood adversity, mental ill-health and aggressive behavior in an African orphanage: Changes in response to trauma-focused therapy and the implementation of a new instructional system

BACKGROUND

The number of orphans in Sub-Saharan Africa is constantly rising. While it is known that family or community care is preferable over institutional care of African orphans, little is known about the quality of care in orphanages and possibilities of improvement. STUDY 1:

METHODS

Exposure to traumatic stress, experiences of violence in the home, school and orphanage, as well as mental ill-health and aggression of 38 children (mean age of M = 8.64 years) living in an orphanage in rural Tanzania were assessed at two time points. The severity of post-traumatic stress disorder symptoms (PTSD), depressive symptoms, and internalizing and externalizing problems were used as indicators of mental ill-health.

RESULTS

Violence experienced in the orphanage correlated more strongly with all indicators of mental ill-health than violence in the former home, school or neighborhood at time point 1. Additionally, violence experienced in the orphanage had a positive relationship with the aggressive behavior of the children at time point 2. STUDY 2:

METHODS

With the help of the pre-post assessment of Study 1, the implementation of a new instructional system and psychotherapeutic treatment (KIDNET) for trauma-related illness were evaluated.

RESULTS

In response to both, a change in the instructional system and psychotherapeutic treatment of PTSD, a massive decline in experienced violence and in the severity of PTSD-symptoms was found, whereas depressive symptoms and internalizing and externalizing problems exhibited little change.

CONCLUSIONS

These studies show that violence, especially in the orphanage, can severely contribute to mental ill-health in orphans and that mental health can be improved by implementing a new instructional system and psychotherapeutic treatment in an orphanage. Moreover, the results indicate that the experience of violence in an orphanage also plays a crucial role in aggressive behavior of the orphans.

Community-based interventions to optimize early childhood development in low resource settings

OBJECTIVE

Interventions targeting the early childhood period (0 to 3 years) help to improve neuro-cognitive functioning throughout life. Some of the more low cost, low resource-intensive community practices for this age-group are play, reading, music and tactile stimulation. This research was conducted to summarize the evidence regarding the effectiveness of such strategies on child development, with particular focus on techniques that may be transferable to developing countries and to children at risk of developing secondary impairments.

STUDY DESIGN

PubMed, PsycInfo, Embase, ERIC, CINAHL and Cochrane were searched for studies involving the above strategies for early intervention. Reference lists of these studies were scanned and other studies were incorporated based on snow-balling.

RESULT

Overall, 76 articles corresponding to 53 studies, 24 of which were randomized controlled trials, were identified. Sixteen of those studies were from low- and middle-income countries. Play and reading were the two commonest interventions and showed positive impact on intellectual development of the child. Music was evaluated primarily in intensive care settings. Kangaroo Mother Care, and to a lesser extent massage, also showed beneficial effects. Improvement in parent-child interaction was common to all the interventions.

CONCLUSION

Play and reading were effective interventions for early childhood interventions in low- and middle-income countries. More research is needed to judge the effectiveness of music. Kangaroo Mother Care is effective for low birth weight babies in resource poor settings, but further research is needed in community settings. Massage is useful, but needs more rigorous research prior to being advocated for community-level interventions.

Intervenção psicomotora em crianças de nível socioeconômico baixo

Visou-se identificar o perfil psicomotor de crianças de baixo nível socioeconômico e verificar o efeito nelas de um programa de intervenção psicomotora. Participaram do estudo seis crianças do sexo masculino, na faixa de 10 a 12 anos (11,5±0,92). Os participantes foram avaliados utilizando-se uma bateria psicomotora que avalia sete fatores psicomotores: tonicidade, equilibração, lateralização, noção do corpo, estruturação espaço-temporal, praxia global e fina; de acordo com o desempenho da criança, os fatores são pontuados de 1 a 4; o escore 1 refere-se ao perfil apráxico, 2 ao dispráxico, 3 ao eupráxico e 4 ao hiperpráxico. Com base nas dificuldades detectadas foi elaborado um programa de intervenção psicomotora, aplicado durante três meses, em 16 sessões de uma hora de duração, duas vezes por semana. Ao término da intervenção os participantes foram reavaliados. Pela avaliação inicial, o perfil dos participantes foi predominantemente eupráxico nos fatores equilibração, lateralização, noção do corpo, praxia global e praxia fina; nos fatores tonicidade e estruturação espaço-temporal o perfil foi predominantemente dispráxico. Após o programa de intervenção houve aumento estatisticamente significativo (p<0.05) na pontuação nos fatores tonicidade, equilibração, estruturação espaço-temporal, praxia global e praxia fina, sugerindo que o programa de intervenção psicomotora aplicado beneficiou o desempenho psicomotor de crianças de baixo nível socioeconômico.

Not by bread alone project: a 2-year follow-up report

BACKGROUND

We have previously reported the developmental gains achieved, after introducing a simple programme of structured play to stimulate children in an orphanage. It was envisaged that the caregivers could continue the programme. However, the enthusiasm of the caregivers waned over the year the programme was entrusted to them. After 1 year, a full time play therapist was recruited to rejuvenate the play programme.

METHODS

Children's development was assessed using the Indian adaptation of the Bayley Scales of Infant Development. The first assessment was done when the play therapist joined. Subsequently, three-monthly assessments were done and the scores achieved were recorded.

RESULTS

The initial mean motor and mental scores, when the play therapist joined, were 66.14 and 56.95, respectively (similar to the pre-intervention scores of the pilot study reported in an earlier paper). The scores improved to 81.84 and 78.25 within 3 months of restarting the play programme.

CONCLUSION

The schedule of the 'Not by Bread Alone' project can accelerate the motor and mental development of children in orphanages. However, it requires a highly motivated and dedicated person to sustain this programme over long periods.

Multisensory intervention improves physical growth and illness rates in Korean orphaned newborn infants

The purpose of this study was to evaluate the effectiveness of a multisensory intervention on the physical growth and health of Korean orphaned infants. Fifty-eight full-term infants were randomly assigned to a control (n = 28) or an experimental (n = 30) group within 14 days postbirth. In addition to receiving the routine orphanage care, infants in the experimental group received 15 min of auditory (female voice), tactile (massage), and visual (eye-to-eye contact) stimulation twice a day, 5 days a week, for 4 weeks. Compared to the control group, the experimental group had gained significantly more weight and had larger increases in length and head circumference after the 4-week intervention period and at 6 months of age. In addition, the experimental group had significantly fewer illnesses and clinic visits. These data demonstrate that multisensory intervention in conjunction with human/social contact may be effective in facilitating growth for newborn infants placed in orphanages.