Occupational performance concerns within international orphanage
settings
According to the
UNICEF definition, an orphan is any child under that age of 18 who has lost one
or both parents (UNICEF, 2009). An
estimated eight million children worldwide live in an institutionalized setting
such as an orphanage or children’s home (Csaky, 2009). Unfortunately, almost every occupational performance
area shows greater deficits the longer a child resides in an orphanage (i.e.,
greater than six months) and the earlier a child is placed
in an orphanage (i.e., under two years old)(Beverly, McGuinness, & Blanton,
2008; Ellis, Fisher, & Zaharie, 2004; Wilson, 2008). Better illumination and understanding of these
deficits can guide the roles of occupational therapists within these settings. While current research highlights many
performance area deficits, much research still needs to be conducted in terms
of occupational engagement.
Development of a
child relies heavily upon participation in everyday, meaningful occupations
that are facilitated by support from caregivers, peers, and the community. Studies in orphanages have shown that
children spend between 40-70% of waking hours unengaged in activity; they also
lack adequate caregiver interactions to cultivate effective play experiences
(Daunhauer, Bolton, & Cermak, 2005; Smyke et al., 2007). This is true even when toys and materials are
regularly available to the children. Children
in orphanages spend roughly equal time engaged in activities of daily living (ADLs)
as their age-matched peers; however, attention received from caregivers
generally revolves around mechanical ADL completion (St.Petersburg, 2005;
Tirella et al., 2008).
Inadequate social
support may well serve as the driver of developmental, and consequently
occupational, deficits. Children in
orphanages generally do not have adequate social opportunities, exposures, or
supports required to foster empathy development, which can have negative
implications for social and communication outcomes (Colvert et al., 2008). In fact, as reported by parents who adopted
children from Russia, 62% were labeled with communication disorder; following
instructions and listening effectively were primary concerns (Beverly et al.,
2008). A review article noted toddlers
reared in orphanages displayed deficits in receptive language and vocabulary
skills, while non-verbal communication did not necessarily elicit concern
(Glennen, 2002).
Related to the
social environment, orphanages frequently have poor caregiver-to-child ratios
and highly variable work schedules, straining relationship formation and
consistency of care (St. Petersburg, 2005).
Studies in orphanages have shown that caregivers only participate in
activities with the children around 25%-50% of the time, with interactions
primarily directed at meeting physical needs through task demands and little to
no reciprocating behavior (Daunhauer et al., 2005; Smyke et al., 2007). In general, the caregivers lack emotional
expressiveness, disregard communication opportunities with the child, and avoid
physical contact with the children; staff members may see their role as
“professional” and undermine the value of emotional support (St. Petersburg,
2005; Vashchenko, Easterbrooks, & Miller, 2007). A cyclical relationship can consequently
develop within the orphanage: children do not receive the social support needed
from caregivers (or peers) resulting in decreased social skills, increased
attention problems, and heightened behavioral issues, which in turn impact
their social engagement capabilities, again impacting their social skill
development.
Another facet of
the social environment includes social capital, defined as the establishment of
trustworthy interpersonal relationships with families, social networks,
organizations, social norms, and communities (Coleman, 1988). Stigma
surrounding diseases, poverty, perceived duty of care (e.g. government), family
history, and orphan status (including real or imagined behavioral issues) may
contribute to diminished social capital of orphaned children (Thurman et al.,
2008). Additionally, children in
orphanages may lack the confidence to trust in others amidst the crises they
have experienced in the past, such as familial separation, abandonment, or
abuse.
Psychosocial
issues are one of the most researched areas in orphanages, and studies have
repeatedly demonstrated issues with insecure attachment,
hyperactivity/inattention, behavioral problems, and decreased self-efficacy
(Ellis et al., 2004; Simsek, Erol, Oztop, & Munir, 2007). Orphanage
caregivers reported 27.5% of toddlers as having attention deficit hyperactive
disorder (ADHD); parents
reported an ADHD frequency of 23-42% for orphanage children adopted after
twelve months (Beverly et al., 2008; Ellis et al., 2004; Wiik et al., 2010). Children and adolescents in orphanages
also display a significantly increased risk of both internal (e.g. anxiety and
depression) and external (e.g. conduct and oppositional defiant disorders)
behaviors, with odds ratios of 1.7-3.4 and 2.5-2.9, respectively (Simsek et
al., 2007; Wiik et al., 2010).
Through our
senses (touch, smell, taste, movement, hearing, sight) we understand the world
around us and are able to adapt to novel situations. Children in, and adopted from, orphanages
recurrently exhibit visual abnormalities, most commonly strabismus, refractive
errors, and visual-perceptual skills (Gronland, Aring, Hellstrom, Landgren
& Stromland, 2004; Shreshtha et al., 2010).
Eastern European institutionalized children displayed significantly
higher sensory scores for modulation of touch, movement, vision, and audition
(Lin, Cermak, Coster, & Miller, 2005; Wilbarger, Gunnar, Schneider, &
Pollack, 2010); this impacts their ability to regulate behavioral and emotional
responses to stimuli. Additionally,
vestibular-proprioceptive, visual form, and space perception discrimination
tasks yielded significantly lower scores in long-term versus short-term
institutionalized children, with implications for decreased motor planning and
coordination (Lin et al., 2005).
Self-stimulatory behaviors, such as body rocking, face guarding, finger
shadowing, and wrist flapping have been observed in children residing in
orphanages (Sweeney & Bascom, 1995).
Unengaged activity or aversion to tactile stimuli tended to prompt body
rocking and face guarding, while
both body rocking and wrist flapping manifested during periods of stress or
anxiety (Sweeney & Bascom, 1995).
Children respond positively
or negatively to their physical environment as a means to adapt to their
surroundings; with each interaction his/her understanding of and functioning in
the environment increases.
Unfortunately, orphanages are notoriously categorized as overcrowded and
understaffed (Groark et al., 2005).
Studies on the developmental effects of crowding demonstrate myriad
consequences, such as social withdrawal, decreased caregiver response to the
child, increased stress, more aggressive behaviors, and poorer IQ scores
(Evans, 2006). Visual stimulation within
orphanages is purportedly low; drab wall colors with few engaging pictures
characterize many orphanage spaces (Yoxall, 2007). Finally, consideration of the cleanliness of
the orphanage environment will influence occupational opportunities for the
children residing there (e.g. “floor time”).
Exposure to environmental toxins must also be considered when evaluating
the physical environment of orphanages.
Of greatest concern to children internationally is the intensified
exposure to lead. One Romanian study
found that children exposed to higher levels of lead displayed symptoms
synonymous with ADHD (Nicolescu et al., 2010). Water contamination due to impurities and
bacteria may also pose a sanitation threat to children residing in orphanages,
especially in developing countries (Waddington, Snilstveit, White, &
Fewtrell 2009).
For all children,
cultural practices and views of parents and caregivers tend to define the
culture of that child; this includes expectations of work and independence,
norms for sleep, engagement in play, perceptions of the term “childhood”, and
views on discipline techniques (Pumariega & Joshi, 2010). While society as a whole might view
orphanages as negative, parents may see orphanages as a source of financial
relief and educational opportunity during times of political uncertainty
(USAID, 2006; Yoxall, 2007). Most
countries have policies protecting the rights of institutionalized children, however,
implementation of those policies is often inadequate or nonexistent (USAID,
2006). Meanwhile the picture still
remains bleak in most orphanages, calling for even greater policy formation,
enforcement, and advocacy that influences children reared in those environments.
Role of occupational therapy in
orphanage settings
Clearly the
orphanage environment significantly impacts the personal, environmental, and
occupational factors of the children residing there. Fortunately, occupational therapists have the
required knowledge, skills, and tools to successfully intervene in orphanages
to impact the functioning of both the children and the caregivers. Depending on the situation or the intended
outcomes, this role comes in various forms: educator, consultant, advocate,
and/or clinician. An in-depth needs
assessment, which evaluates organizational assets and weaknesses, will provide
the necessary information to determine the most appropriate roles for the particular
orphanage. This includes investigation
into current programs, local resources, and cultural practices through
interviews and observations. Service
gaps can then be identified to collaborate with the organization on the
establishment of goals and a program plan to reach those goals.
Research
demonstrates that a train-the-trainer approach used to educate orphanage staff
yields positive outcomes for children’s cognitive, psychosocial, and behavioral
health (Groark, Muhamedrahimov, Palmov, Nikiforova, & McCall, 2005; Sparling,
Dragomir, Ramey, & Florescu, 2005). Primarily,
the therapist works with the caregivers to determine their specific needs, and
subsequently provides strategies to improve various social and developmental
supports for the children. Building
relationships and establishing cultural competence through information sharing
must occur for this objective to be successful.
Once educational needs are identified, the conduction of weekly meetings
allows for the dissemination of information and demonstration of techniques to
aid in the provision of support from the child’s peers, the community, and the
caregivers. Modeling and feedback
regarding the use (or disuse) of the knowledge and strategies enhances the
follow-through from the weekly meetings (Groark et. al, 2005). Video recording the behaviors of the
caregivers can serve as a useful teaching tool to reflect on both the positive
and negative components of the caregiver-child interactions (Sparling et. al,
2005). Structural changes, such as creating consistent caregiver schedules, in
conjunction with improved caregiver-child interaction demonstrated more
beneficial outcomes than simply influencing caregiver behavior (Groark et al.,
2005; Sparling et al., 2005).
Additionally, depression and anxiety scores of caregivers in a Russian
orphanage substantially decreased following a 4-month “train-the-trainer”
intervention (Sparling et al., 2005).
Occupational
therapy is frequently an unheard of or undeveloped profession outside the U.S. Therefore, advocacy must accompany any
international project. Community-based
collaboration can enhance the perceptions of orphaned children and help
eliminate some of the associated cultural stigmas (Thurman et al., 2008). Not to mention community-based programs tend
to enhance the sustainability and long-term impact of international projects,
as illustrated by AIDS campaigns (Baptiste et al., 2006; Bell et al., 2008). Including the orphaned children in advocacy
movements can further increase their contact with community members as well as
their visibility, with implications for expanding social capital. Involvement in political agendas to
positively influence policies related to institutionalized children, including
funding, laws, and structural regulations, is another powerful method to
improve the life outcomes of orphanage-reared children (USAID, 2006).
Assuming the role
of a consultant is also feasible for occupational therapists wanting to work in
orphanage-settings. A consultant
collaborates with the organization or client in order to problem-solve
solutions to identified problems, but is not directly responsible for the
changes made (AOTA, 2008). In this way the therapist would travel to one or
more orphanages within an area to provide recommendations to the staff
regarding ways to improve environmental conditions, structural organization,
and/or caregiver techniques, as well as briefly discuss methods for that
orphanage to implement those changes.
While this role seems similar to that of an educator, consultants
generally have brief stays at multiple sites, maintain closer follow-up, and
are not responsible for the direct delivery of intervention (AOTA, 2008).
In addition,
occupational therapists can undoubtedly serve as a clinician within orphanages. Occupational therapist should work with the
children in one-on-one or small group sessions to provide culturally sensitive
skilled services that complement or enhance the caregiver supports. Sessions might involve play-based activities,
social-skills training, school-related needs, and/or disability-specific
interventions. In this way children
learn the principles of peer interaction, hone their developmental skills, and
participate in occupations in a safe environment with increased attention. Given the numerous deficits that exist within
orphanage-settings one must use clinical judgment to determine how to maximize
functional outcomes within the given time frame; addressing every deficit of
every child may not be feasible.
Implementation and evaluation
of occupational therapy in an orphanage
Through a
doctoral apprenticeship, the application of occupational therapy within an
orphanage was realized at a private institution for typically-developing
children in a Romanian city. Forty-five
children reside at the orphanage, aged five to twelve years old. The orphanage employs a psychologist, a
social worker, six caregivers, four nuns, two cleaning ladies, five kitchen
staff members, and two maintenance personnel.
With the exception of the two maintenance workers all the staff members
are female. The nuns live at the
orphanage while the other employees commute from the surrounding
communities. Only one of the nuns held a
position similar to that of a caregiver; the others cared for the garden or elders
in the community. Caregivers, educated
at the high-school level, worked seven-hour shifts six days a week, with
between one and four on duty at a given time.
First a needs
assessment was conducted through interviews and observation to ascertain the current
resources, services, and cultural practices.
The primary identified concern included the social-behavioral issues of
the children residing there, such as aggression, lack of empathy, poor
self-efficacy, and rule-breaking, to name a few. Many of these issues were hypothesized to be
related to the inadequate social and emotional support provided by the
caregivers and other staff members. In
response, a 12-week train-the-trainer program was established to provide
information, strategies and techniques, and to problem solve through various
scenarios. Topics consisted of
behavioral management strategies (e.g. time-out, positive attention),
psychological concerns (e.g. depression, anxiety), adolescent development (e.g.
occupational changes, support required), stress management techniques (e.g.
progressive muscle relaxation, mental imagery), and sensory integration basics
(e.g. ideas to address different sensory needs of different children). These meetings encouraged open discussion,
asking specific questions, and exchanging feedback regarding the application of
techniques. At the end of each session
“take-home” points emphasized the most important, practical information for the
caregivers.
In conjunction
with the train-the-trainer program, some of the children participated in small
group activities twice a week (when the children were not on vacation or
engaged with volunteer groups) that focused on empathy development and positive
peer engagement. Activities included
cooperative games with a parachute, team scavenger hunts, encouragement cards,
and a neighborhood trash clean-up. Selected
children—those with the highest Child Behavior Checklist (CBCL) externalizing
behavior scores-- participated in anger management sessions based on the Alert
program principles. These principles
consist of increasing awareness of inappropriate behaviors, learning strategies
to address the behaviors, and recognizing when to implement the behaviors. Puppet shows, role plays, anger-thermometers,
and social stories supplemented the brief discussions. Finally, children who assented received
weekly one-on-one time with the occupational therapy student for forty-five
minutes. This time allowed the child to
escape the group atmosphere, make independent decisions, explore individual
interests, enhance creativity, learn computer skill basics, and/or engage in
games.
Evaluation of the
programs involved the inclusion of multiple data collection approaches. Process evaluation was monitored through
tracking program attendance and gaining subjective feedback from the caregivers;
impact evaluation included monitoring changes in scores on a caregiver knowledge
survey; outcome evaluation relied on Child Behavior Checklist (CBCL 6-18;
Achenbach & Rescorla, 2001) changes.
Good validity and reliability have been established for the CBCL
assessment in numerous international settings; the survey was available in a
Romanian translation (Achenbach & Rescorla, 2001). Impact data were
collected on the first and last days of the caregiver training sessions. Caregivers completed the CBCL 6-18 (for the
children they most frequently interacted with) at the onset of the programs and
one-month after their conclusion.
While this experience
demonstrated the feasibility and relevance of occupational therapists working
in orphanage settings (especially as an educator and clinician), the realities
of creating a controlled environment in which to effectively measure the impact
and outcomes of community-based interventions warrant examination. For example, some of the children vacationed
with volunteers in Italy for several weeks, some went to summer camp for a
week, volunteer groups also ran various programs for the children, some of the
surveys were completed by different caregivers pre-post, and the time between
survey administration was only three months.
The use of both quantitative and qualitative measures can provide a
means in which to balance the sundry uncontrollable aspects within an
international setting with useful data collection; this is true of both the
impact and outcome evaluations. Video
monitoring with an observational checklist regarding the caregivers’ use of the
strategies could have been employed to give insight into how well their
increased knowledge actually translated into increased utilization. A focus group with the children before and
after the program could have yielded introspection on their perceived changes. When dealing with a small sample size, the use
of qualitative data become even more important.
Factor analysis of the quantitative data should be performed in order to
consider the major confounds within the data set. With all this, it is easy to see that performing
an international project in an orphanage requires thorough consideration of
evaluative components.
Conclusion
As outlined in
the available research, children in orphanages experience deficits in almost
every area of performance, including social-behavioral, communication, sensory,
and psychological; all of which impact their ability to engage in occupations
(e.g. Beverly et. al, 2008; Ellis et. al, 2004; Daunhauer et al., 2005). Occupational therapists are equipped with the
skill set to have a positive impact on both the advancement of the field and
the occupational performance of clients served through international projects,
especially in orphanage-like settings. While
the role of occupational therapists in orphanages has not been fully realized,
the advancement of the profession should consider international intervention
programs to benefit children in their occupational engagement and performance.
