In Russia and Latin America, researchers from the University of Pittsburgh Office of Child Development found that improving the social-emotional development of children in orphanages required interventions and structural changes to promote a more nurturing relationship between caregiver and child. A recent visit to China revealed that orphanages in the nation of 1.3 billion people face a similar challenge of replacing less child-sensitive practices with warmer, more family-like care – as well as a challenge researchers had not experienced elsewhere.

Within the past five years, China has experienced a shift in its primary orphanage population from mostly healthy girls to large and increasing numbers of abandoned children with disabilities whose range of special needs are straining the capacity of the nation’s social welfare institutes to train staff or hire specialized staff to care for them.

This new challenge comes at a time when improving the conditions of orphanages in China is a work in progress whose prospects for success benefit from a number of strengths, including more robust foster care and adoption systems, levels of care that are on the rise, adequate and well-regulated orphanage infrastructure, a deep-rooted value of family and caring, an emphasis on pragmatic and balanced approaches to solving complex problems, political support for improving orphanages and an openness to innovation.

"Despite all of the progress China has made with adoption and foster care, the vast majority of children who get adopted or placed in foster care are those who are either healthy, young or, if they have disabilities, they are mild, correctable disabilities," said Junlei Li, PhD, director of the Office of Child Development (OCD) Division of Applied Research and Evaluation. “Of the children who remain in the orphanages, nearly 90 percent of the children have moderate to severe disabilities.”

The purpose of the fact-finding visit this fall by Dr. Li and OCD Co-Directors Christina Groark, PhD, and Robert McCall, PhD, was to explore whether their experience with orphanages in Russia, Nicaragua and El Salvador could be of help to the government agencies, academics and nongovernmental organizations working to improve orphanage conditions in China.

“We went to see if we might contribute in some way,” Dr. McCall said. “We wanted to learn what their needs are, whether what we’ve learned would be useful in fulfilling those needs, and to meet Chinese specialists and policy makers who might take a lead role in modifying what we’ve learned to fit their situation.”

Research conducted in Russian orphanages found that when conditions were in place to promote and sustain warm, sensitive and responsive relationships between young children and with their adult caregivers, the children’s social-emotional and cognitive development improved.

This research was begun nearly a decade ago as an investigation by OCD and a team of Russian researchers to determine the impact of interventions and structural changes intended to promote family-like care in Soviet-era orphanages in St. Petersburg, which for decades had emphad conformity and discipline over warmth and sensitivity.

Caregivers were trained and encouraged to be more warm, sensitive and responsive in their interactions with the children with the idea of integrating loving care into daily routines, such as feeding, bathing and dressing. They were taught how to position and interact with children in their care who had disabilities. For the first time, primary caregivers were designated and their schedules adjusted to give children some consistency in who was caring for them.

Key structural changes were also made to the way orphanages operated. The groupings of children were made smaller – about half the of previous groups – which enabled caregivers to spend more time with individual children. Similar to families, these groups included children of different ages, as well as children with disabilities, in contrast to the more homogenous groups of the past. And children were allowed to remain in their group for several years.

The results were significant. Children saw fewer, but more consistent caregivers. Caregivers substantially improved their responsiveness and involvement with children. They reported being more satisfied with their work. They also reported that they had gained confidence in their ability to work with and care for children with disabilities.

Children showed significant improvement across all developmental domains. On average, their developmental quotient rose from 52 to 92, which is the largest increase associated with a developmental intervention ever reported in child development research. Their behavioral development also improved. They showed more mature social and emotional behavior than children who did not receive the intervention. They were more engaged with caregivers. Even their physical growth improved.

Children with disabilities made significant developmental gains as well, improving across every domain. Their average developmental quotient increased from 23 to 42. The DQ for more than 25% of these children rose 30 points and 1 in 7 increased their DQ by more than 40 points.

One important lesson from the study was the importance of making structural changes to the orphanage. “We believe that for training to work there has to be follow up and supervision,” Dr. Groark said. “But we learned from our experiences in Russia that training and follow-up alone doesn’t work as well as when you make structural changes, such as changing staffing patterns so children are cared for by the same set of caregivers to provide stability.”

The study reported that although children’s development improved in orphanages where only training was provided, the gains were much lower than those experienced by children in orphanages where training was supported by structural changes that offered caregivers better opportunities to practice what they were taught.

Such findings not only have implications for orphanages in nations engaged in improving their conditions, but also for early childhood policy and practices in the United States, where training for teachers, social workers and others who work with young children is increasingly emphad, but making key structural changes to the environments in which they work is not.

In recent years, China has been looking at ways to create settings within its orphanages that promote more child-sensitive, family-like care.

Orphanages in China generally have adequate infrastructure, staffing and funding. Steady progress is being made in the nation’s adoption and foster care systems as alternatives to the placement of children in orphanages, including children with mild disabilities.

Traditional care in these orphanages, however, differs from family-like care in several important ways. Orphanages, for example, tend to group children by age and segregate those with disabilities in separate wards. Assigning primary or permanent caregivers to groups of children is uncommon. Instead, children are cared for by different caregivers who change shift to shift, year to year. These caregivers, who often have little time to devote to individual children, typically perform their duties with little talking and one-on-one or face-to-face interactions.

And reform is made more challenging by the dramatic increase in the proportion of children with disabilities who now reside in China’s orphanages. The recent surge in this population has come about for several reasons. There are, for example, few resources available to parents to help them care for a child with disabilities at home. The lack of high-quality prenatal care and birthing procedures also contribute the rising number of infants with disabilities, evidenced by a rising number of children with cerebral palsy, a condition often triggered by preventable trauma to the brain sustained during birth. And China’s rule limiting family to one child still creates a climate in which families favor keeping the most “viable” infant. Previously, the rule led to an increase of girls being placed in orphanages as a result of families preferring to have their only child be a male. When the rule was relaxed to allow families to adopt a second child, the number of abandoned girls declined, but the percentage of children with disabilities in the orphanages increased.

Several innovative efforts are underway in China to create more family-like care within the orphanages. Some, for example, have implemented supplemental programs, such as separate activity rooms where children are given a few hours of individual attention from trained nannies. Such supplemental programs serves only a limited number of children in each orphanage and requires ongoing foreign investment to pay for the additional staff. They do not create the level of structural change the Russia study found to be an essential to producing significant developmental gains among children.

The visit by OCD researchers this fall succeeded in gaining a working knowledge of the needs of orphanages in China, the efforts to improve conditions within the orphanages, and the key players in government, academia and elsewhere who are involved in promoting change.

They found that nearly all Chinese stakeholders accept the research evidence that family-like care leads to better outcomes for children, including children with disabilities. OCD researchers were asked to write an article on that topic for a government journal that is required reading for civil affairs government personnel and others who work with young children. OCD is also exploring the possibility of collaborating with Half the Sky Foundation, a nongovernmental agency working in China that provides supplemental programs to orphanages. The talks to date have focused on developing a tool to assess the quality of care in orphanages, including caregiver-child interactions and relationships, and on piloting the kinds of structural changes in orphanages OCD found were critical to achieving more nurturing care-giver-child relationships in Russia and Latin America.

OCD researchers learned there is wide agreement in China that the nation does not lack ideas, commitment to family-like care or small-scale experiments intended to promote family-like care in orphanages. What the nation needs most, they were told, is a systematic effort to examine small-scale demonstrations that exist, understand what works and what doesn’t, and develop effective strategies for bringing the best practices up to scale. If OCD were to have a role in a Chinese-directed collaboration, one possibility would be to help nurture the existing orphanage experiments toward broader implementation.

Perhaps most important, OCD researchers wanted to gauge whether there is an openness and readiness in China for collaboratively creating family-like settings in orphanages to improve the development of children with disabilities, which can involve difficult decisions and hard work. “That was our big question,” said Dr. Li. “And the answer was, Yes.”