Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, October 14, 2015

Orphanages, Foster Families, and Culture Wars

A struggle over the right way to care for unparented children has been shaping for a number of years now. The difficulties of doing good outcome research on this issue are such that evidence tends to be overborne by values, opening the door to confirmation biases. The current arguments in Russia about orphanages, and the encouragement by some parties of a movement toward foster-family care for all unparented children, are examples of a confusion between systematic evidence and values as reasons for making practical decisions.

Child-care institutions have existed in some form back to at least the Middle Ages, when monasteries accepted children as oblates, cared for them, educated them, and reared them to be part of the monastic group. Often, but not always, orphanages were run by religious or other charitable groups. During the Great Depression in the United States, institutional care was common, not only for genuine orphans, but for children whose parents could not afford to care for them at home. Although some institutions involved cruel experiences for the children, others did excellent jobs and were remembered with pleasure by their graduates. During the 1994 Congressional upheaval in the U.S., Newt Gingrich (I never thought I’d be quoting him!) referred to those successful orphanages and suggested that they might do a better job than foster families do.

But today we have people in a range of countries speaking loudly against institutional care for children and advocating family care systems. How did this shift come about? The initial push came from the revelations about the horrible Ceausescu-era Romanian orphanages. This information became public in 1996, following the death of Ceausescu, when news sources published extremely disturbing photographs of malnourished young children tied to cribs and groups of older children naked.  The term “orphanage” quickly took on a powerful negative coloring when people identified highly inappropriate practices as equivalent to all institutional care for children.

A few years after the Romanian revelations, several researchers became interested in the outcomes for children who were adopted from Romanian orphanages. The English-Romanian Adoptees project, directed in part by Michael Rutter , followed these children into young adulthood and found that on the whole their development was quite satisfactory. An American research group, the Bucharest Early Intervention Project, headed by Charles Zeanah, began in about 2000 to conduct an investigation that would compare young children randomly assigned to remain in the orphanage to others randomly assigned to foster families. Zeanah and the rest of the BEIP group reported later that the fostered children showed better development than those who stayed in the orphanage, and that therefore family care had a better effect on development than institutional care did. This conclusion, repeated in several professional journals, in the magazine Science, and in the publication Zero to Three, as well as in popular news sources, has had a strong influence and has been used to support the argument that foster care or adoption are demonstrably better methods for unparented children than institutional care.

However, as I have pointed out in this blog and in letters published in Science and Zero to Three, the design of the BEIP studies does not permit the conclusion that has been publicized. The Romanian foster families received special training and funding, as well as access to frequent consultation with child development experts. The orphanage staff received none of these, nor were they helped to provide more consistent staff assignments that would allow infants and toddlers to be with a few familiar caregivers. The comparison was thus between the best possible foster care and poor institutional care, so the outcome was not surprising. Indeed, it would be interesting to know what would have happened if the institutional staff had been specially trained, paid more, and had consultants available to them, while the foster families were left to get along as best as they could--  that would have been a meaningful test of the advantages of foster care per se over institutional care.

As I have also pointed out on this blog, there is important research that contradicts the BEIP conclusions. That work, by Kathryn Whetten, was a nonrandomized study of children in low- and middle-income countries that compared development of fostered children with that of children in institutions and did not find an advantage for foster care. Whetten’s work has received much less attention than the BEIP work, presumably because her design was nonrandomized, whereas the BEIP involved random assignment to groups—but the fact is that randomization is used to attempt to isolate a variable, and the remainder of the BEIP design did not successfully isolate the variable of type of care, instead conflating type of care with availability of training and resources. In my opinion, the two studies are about equal in appropriateness of design and outcome validity.

A new study in which Whetten was involved is also relevant to the comparison of institutional and family care. This study (and my thanks to Yulia Massino for calling my attention to it!) is by Christine Gray et al., “Prevalence and incidence of traumatic experiences among orphans in institutional and family-based settings in 5 low- and middle-income countries: A longitudinal study” (http://www.gshpjournal.org/content/3/3/395.abstract). The researchers looked at physical and sexual abuse experiences among children in institutions and in foster care, and found no more such experiences in institution-reared children than in those cared for by foster families.

Gray et al. concluded that “understanding the specific context, and elements contributing to potential harm and benefits in both family-based and institutional care, are essential to promoting the best interest of the child.” This comment should be related to recent ideas in clinical psychology, where professionals are beginning to recognize that there are adverse events in psychology just as there are in medicine, and that these should be investigated, recognized, and reported along with  demonstrated benefits.

Decisions about best practice need to take unwanted events into account as well as considering the level of evidence supporting a practice. Yet, as we see in the Russian disagreements about orphanages and about adoption, as well as in the American movement from reuniting families at all costs some years ago, to the current concern about putting child safety first, many such decisions are driven by value considerations other than the best interest of the child, and adverse events are not mentioned. An egregious example would be the push for multiple adoptions by fundamentalist Christians in the U.S., as described by Kathryn Joyce in The child catchers.

As Gray and her co-authors imply, one size does not fit all unparented children. When anyone suggests that there is a single best care approach, we should ask what value considerations are guiding this claim. Culture wars are not a way to provide the best outcomes for children, who are likely to experience “collateral damage”.

   

25 comments:

  1. Some years ago, two Colorado legislator who had been orphans themselves tried to establish state-run orphanages, but unfortunately their bill did not succeed.

    Now the trend appears to be for county DHSs in this state to hand over their entire foster program to religious organizations, some of which have been associated with highly authoritarian parenting methods.

    Accountability and transparency is essential for guarding the best interest of the child, and for that reason, I would think that state-run orphanages would be the more reasonable choice.

    States should also not allow religious indoctrination of foster children for whom they are ultimately responsible.

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    1. This brings up some interesting questions about religious education. Certainly I agree with you that "faith-based" programs are inclined to push their particular version of faith.

      Public schools in the U.S. are not supposed to teach religion and most often do not even teach about religion. When I was teaching history of psychology, a course that requires some understanding of the religious concepts that underlay some psychological systems (e.g., a dualism of body and mind), college students were shocked and seemed to feel that nothing about religion should ever be mentioned in public. So, indoctrination aside, should foster children not have opportunities to learn about religious beliefs and to understand their roles, both positive and negative, in many people's lives?

      This seems to me to be a difficult problem whether in a state-run institution or in foster care. Adoption agencies used to attempt to place babies born to Catholic mothers with Catholic adoptive families, etc.-- I have no idea whether these efforts are still made, although it appears that "Christian" agencies want all babies to go to "Christian" parents.

      Just noodling here!

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  2. The content of the child in the Russian orphanage is much more expensive for the state than financial grants for foster families. In addition adolescence is the most difficult to control these children. 16 year-old
    Russian orphans tend to leave the orphanage and go to live in a student dormitory. The State pays them cash grants and student scholarships. But teens do not know how to properly use the money. During this period, the most common crashes and children fall under the influence of crime. It is necessary to improve the work of these young people (socialization and adaptation to independent life. It is expensive and requires a cash outlay. It is much easier to arrange child in a family and make a complaint to the guardians or adoptive parents. Russia chose this the easiest and cheapest way to go. Again, the emphasis is on two-core (patience and endurance) of the Russian people. People have to stand and show good results. Of course, they survive .... because they are accustomed to overload. However, sometimes very sad that the government chooses to ignore the results of successful work of children's homes. The inspectors sometimes do not even want see the personal files of successful students. They do not want to hear that children successfully complete college and Universities. Even the fact that children successfully create a family .... not impressive. EXPENSIVE! and this is the main argument. They do not say it does not talk about it but it's obvious.
    We hear that all the kids want to have a family. The family is the natural and most appropriate way to discipline children. I agree with that .... but in Russia there is almost no middle class. Rich people do not often adopt orphans. The main flow of Russian adopters are people with low incomes. Often, a child in an orphanage has better living conditions than in the Russian foster family. We must help foster families .... but probably will be as usual. Families will raise these children alone at the cost of enormous efforts and patience. I have no doubt that the vast majority of foster families cope with this task, and even maybe the result will be better than that of children's homes. Everything depends on the will and belief in success. Where there is a sincere interest in the fate of the children and love for children ... will always be a lot of good results. It does not depend on where the child lives ... in an orphanage or in a foster family.
    After World War II, some families to adopt more than 10 children. It was a very ednye family but the children grew successful because it was available for free education and a strong government support for these children.
    Experience education of orphans is .... means families will survive and perform well ....... (((
    Many children foster family (Kirov Region)
    http://www.gtrk-vyatka.ru/uploads/posts/2015-03/1425992488_vbp_priemnaya-semiya_-0-00-44-237.jpg

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    1. Why is the institution more expensive than foster care-- is it simply that foster families are poor (financially)?

      Thanks for the comments about the middle class. This is an interesting point.

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  3. Because for the normal development of the child in an orphanage needs a staff of skilled staff (doctors, psychologists, nurses, teachers, speech therapists, massage therapists, music director, a specialist in the development of logical thinking, metodis on educational work, etc.) also needs to be support staff (cleaners , laundress, cook, caretaker, janitor, security guard .........).
    Besides teaching aids for the development of children, children's furniture, children's clothing, toys .......... food, bedding .......
    public utilities expenses .......... excursions and holidays for children.
    Organization of summer recreation for children (summer camps ), etc. and aphids. Simply give adopters small cash grants and regularly check these families and to require reports and results.
    Children should always go to different music or sports clubs. Children need to sing, dance, and take part in various sports competitions ....... Children should be ........ They must be grow successful and other options are not considered .....
    https://www.youtube.com/watch?v=-irAoS5XNDQ

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  4. foster home .https://www.youtube.com/watch?v=mi2j7-dGFvA

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  5. You seem to be saying that the payments to foster families don't allow for all the services that are provided in the orphanage. That would account for the difference in cost-- and, as the saying goes in English, "you get what you pay for."

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  6. For adopted children, these services are free. For example a child from foster family can attend music school for free, but the child of an ordinary family does not have such privileges. Just kindergarten, summer camp or speech therapy services are free .... for foster children.

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    1. I am wondering whether we are having a linguistic confusion here. In English/American usage, adoption and fostering are two different things. An adopted child is entirely the responsibility of the adoptive parents, although if the child has handicapping conditions there may be financial subsidies. A foster child lives with a family who are paid to care for the child and do not have sole responsibility or authority for the child. Does Russia have the same two possibilities?

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    2. Um... What? When I was in foster care I did not have music lessons, sports, or any other kind of extra curricular activity because I was told by foster parents and case worker that it was not in the budget. Youth programs that offered scholarships or pricereductions hadwaiting lists so long I would have been grown before I got on them. Nice try though...

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    3. I think Mihail is talking about how things would ideally be done in Russia. We seem to have some translation problems at times.

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    4. I wrote about the Moscow foster families. In Moscow, all after-school educational, musical and sports clubs for children are free for foster children. But there can be problems. For example dance studio has 8 budget places (Free), but wanting to do more. Then we have to look for another studio which is further away from the home or less prestigious. Of course Moscow is not an indicator. Moscow Russia's richest city. But statistics Voronezh. Voronezh is srednestatesticheskim Russian city.
      Help from social services, organizations, institutions dealing with guardianship and custody, foster families, is the majority (94%) households, 6% contribution will be paid (this category of respondents refers to the proportion of foster parents, who themselves solve problems and do not ask for help).
      Families provides various forms of social assistance. All families were assisted social teacher. Most of the families received medical assistance (94%), a lawyer (98%) and psychological (82%). Financial assistance was provided to 41% of families.
      Total income 9% of foster families below the poverty line, 25% of households believe they нуждаются assistance; 52% of households believe that any help is needed child but the is not the parents. More than half (55%), foster children attend any clubs, clubs and so on. N .; Among the groups and sections frequented adopted children: dance studio, sports clubs, school theater, art studio, vocal studio, chorus, music school.
      Most (68%), foster children attend hobby groups for free, the remaining 32% - for a fee.
      However, kindergarten, school, medical care, summer camps are free for all foster children.

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  7. Yes. Perhaps there was confusion. Adopted children have no benefits. They are equal to the native children. Foster family - is a form of placement of children left without parents. Foster children are not equated to the legal rights to biological relatives. The government gives certain benefits to adoptive parents, whose purpose - to help foster care in the maintenance, upbringing and education of the child.
    Typically, between adoptive parents and the child welfare authorities is a contract of paid services, which are detailed payouts and put benefits.
    For each child in a foster family paid a monthly allowance - for food, clothing and footwear, toys, educational materials and art books.
    Приёмные families receiving benefits include priority right to receive vouchers to sanatoriums and rest homes.
    Foster parents are required to keep records of all funds spent on children and to give a report on the spending of these funds in the guardianship and custody.
    Children who are placed with foster families, retain the right to social benefits and compensation, put it as orphans and to receive free apartments after they reach adulthood.
    I hope now the interpreter translated correctly :)

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  8. The state is not going to eliminate all the children's homes. But embarked on reducing kollichestva orphanages. Will profile (Specialty) children's homes (sports, military, music). Also will continue to operate children's homes for orphans with developmental problems. Also will continue to run boarding schools for children with health problems and boarding schools for children from low-income families. Recent years have revealed a lot of cadet schools - boarding. There's a big competition and selection but the children - orphans and children from foster families have significant incentives to enroll in these schools.

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  9. Jean, I want to ask ................ phenomena described hospitalism Rene Spitz in 1945. Hospitalism can be observed not only in the length of hospital stay, but also at home. Erased hospitalism symptoms manifest where education and child care takes place in the partial absence of the mother or if not enough attention and dislike mother for her child.
    Hospitalism may occur if the mother-child emotional contact is not adjusted, there is proximity; but there is detachment, ignorance of the needs, interests and abilities of the child. This social deprivation in the family - also displays hospitalism. Hospitalism can occur in adults, too .... if a long stay in the hospital, and the lack of communication and proper care.
    Is it not seems to be the theory of the trilogy "Attachment and loss» (Attachment and Loss) (1969-1982).?
    What is the difference?

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    1. Dear Mihail-- I think it was a mistake for Spitz to use the term "hospitalism". As you point out, these problems can occur under many circumstances. But the babies he studied were old enough to have formed attachments to their mothers, and when the mothers went to prison, the babies were cared for in a hospital. They did not have individual caregivers and had little opportunity to make new attachments, and they did not eat well or play or sleep well under these circumstances. Spitz thought of the hospital itself as the cause of the trouble, but really the problem was probably the lack of individual attention and comforting by familiar caregivers. That was what Bowlby discussed in his trilogy. Does this help you see the difference?

      By the way, I should point out that so-called "boarder babies", who are taken care of for months after their birth in hospitals because there is no family to take them, have very different reactions from what Spitz described. They are physically healthy and friendly, but because they have little extended contact with caregivers, they tend not to develop skills for more than very brief social interactions.

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  10. Maybe John Romanian orphanages during the reign of Ceausescu children .....
    suffered mostly from a lack of attention from the medical staff? Maybe the reason for severe mental retardation of children not in the absence of the mother or permanently nurse but anti-human conditions in which these children?

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    1. Yes, I think a real lack of attention was probably the main cause. Even proper feeding of young babies takes a lot of patience and individual care, and they probably did not get this. But it is easier for caregivers to do a good job when they know a baby well, and that is probably why an assigned or permanent caregiver is beneficial-- the baby actually gets better care from a person who is familiar with him or her, as well as benefiting from a chance to become attached to someone.

      However, I do want to point out that for some of these children, mental retardation or other problem conditions were the reason they were placed in the orphanage to begin with. Their problems may have been worsened by their treatment, but they were not entirely caused by it.

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  11. Jean. Yes . I understood .
    Thank you for the explanation!

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  12. Ok .So far, scientists have not invented a miracle cure for orphans ..... we will use what we have to raise children.
    Mariinskii Opera House. The new program of the festival "Step Forward!" for orphanages in St. Petersburg (October. 2015)
    https://www.youtube.com/watch?v=OeuGAL5B3vM

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  13. There are already plenty of alternatives to family-based foster care in the U.S. that operate, essentially, as orphanages. These are called "residential treatment centers," and they end up housing many of the difficult-to-place foster children in the country.

    Do they do anything more than housing at these RTCs? Well, they are supposed to be a higher level of care for children in the foster care system with severe social, emotional, and/or behavioral difficulties, and the treatment they provide is often called "milieu therapy." It is largely worthless.

    So, essentially, the RTCs are housing, and the resident population tends to be somewhat stable -- less so than boarding school, but children tend to stay for about 2 years.

    However, the care is costly, and the turnover in staff is huge. The RTCs are staffed round the clock, utilizing three shifts of under-trained and under-paid workers, who at best use the job as the first step in the ladder of a child welfare career. Given weekends, sick/personal days, and vacations -- the usual for a U.S. worker -- resident children are cared for by a large number of adults on an ever-changing schedule that they cannot predict.

    Add in the restrictions that a group home enforces on children's lives -- no peers allowed in the group home, little to no "community time" without staff supervision, "recreational activities" that often consist of riding along while other resident children are driven to doctor's appointments or birthfamily visits (due to limitations in staffing), and facilities that are unfriendly and bleak in the way of many institutions that have a revolving door of inhabitants.

    The peer influence tends to be atrocious, with children developing more dysfunctional ways of behaving from watching each other (and having little to no influence by peers outside the institution), and learning new criminal and self-injurious behaviors through example or rumor (institutional "traditions").

    This is likely going to be what children in U.S. surrogate care will experience if more congregate care is established for children who cannot be raised in their birth families. What would be better, of course, is something along the lines of public-funded but fabulous K-12 boarding schools, with tender residential counselors, stable resident populations of thriving and maturing children, and vegetable gardens growing in the backyard. Not going to happen.

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  14. Foster families, while not ideal, especially given the tremendous stigma that drives away many "normal" families from the endeavor, can provide children with a childhood in a "least restrictive setting," to borrow a term from special needs education law. Even disregarding all the potential benefits from growing up in a family, as opposed to an institution, experiencing childhood without a wall of institutionalization between oneself and one's social, emotional, and cultural development seems fairly important.

    If we provided foster families with respite providers and daycare, trained and experienced therapists (instead of case managers), more adequate payments and/or housing subsidies, intensive treatment support rather than pull-the-plug approaches when children experience difficulties, and respect for the efforts of fostering (rather than culture-wide vilification), we'd have much better results for foster care, I believe.

    The foster care system, as it stands, is broken, without a doubt. But rather than amusing ourselves with fantasies of utopian alternatives, let's fix what isn't working within the current system of surrogate care. We know that some children will need a second family because their first one is inadequate to raise them: let's work harder at insuring that the "second" family does not become the 37th before that child ages out of the foster care system into an adulthood of terrible outcomes. The most dangerous aspect of being raised in foster care is the wandering, I think. Or, as they call it in the business, "lack of permanency." Along with specifying a least restrictive setting for foster children, I would insist on a least mobile (or transitory) experience.

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    1. Thanks so much for these constructive comments. Sorry for the delay in posting-- I was not where I could easily get at the Internet, last week.

      I think the stigma you mention is one of the most important issues in causing families and communities to turn away from children who need non-parental care. That stigma is constantly reinforced by journalistic repetitions of the "bad seed" or "RAD" type, as recently seen in the 20/20 approach to discussing an Arkansas adoption case in which children were "rehomed" with a person who raped one of them. The trailer for that program, http://abcnews.go.com/2020/video/rad-explaining-reactive-attachment-disorder-34667787, "teaches" viewers some serious misconceptions about children who are adopted or fostered.

      I strongly agree with your suggestions about repairing the system, and would add that a good system would have a full range of services as they are needed by children of different ages and backgrounds-- no single program, however Utopian, can do the job.

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