Exploring the Role of Occupational Therapy in Orphanage Settings

Here is a paper I wrote that briefly justifies the presence of occupational therapists in orphanages, as well as reflects on the experience at Casa Sperantei.

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.