Response to Last Post

Anna Koons contacted me via email after my last post about Kathryn Whetten’s research. She asked if she could respond to my post, but wanted to do so in a kind and graceful way. These conversations can get easily heated and ugly so I really appreciated her gentleness in her disagreement and invited her to guest post on the blog.

“Anna is a research project coordinator for multiple international studies with the Duke University Center for Health Policy & Inequalities Research. The projects include a supplement project of Positive Outcomes for Orphans (POFO) and “Pamoja Tunaweza”, an RCT looking at the effect of Trauma-focused Cognitive Behavioral Therapy with orphans in sub-saharan Africa. She received her BA from Wheaton College (IL), and is currently pursuing her graduate degree at the University of Texas LBJ School of Public Affairs.”

First, I would just like to say a huge thank you to Megan, for being so gracious as to allow me to respond to your post. I hope that as we continue in respectful dialog about these topics we will continue toward truth, since I think we all believe these children deserve our best work!

In my response, I would like to:

  • Correct a few factual inaccuracies about POFO in Megan’s post.
  • Challenge the widespread opinion that this study privileges institutions over family care settings.
  • Complicate the idea that ‘every child deserves a loving family’:
    • This is a beautiful goal that I share: every child should have a loving, supportive family. (Isn’t this true of all brokenness in the world – we’d fix it all completely if we could!)
    • The difference between our personal ideal and policy objectives is that this compelling belief that ‘every child deserves a family’ can end up becoming the focus and goal in and of itself; it can create a black-and-white, one-size-fits-all situation in practice, where it puts an ideal ahead of actual real kids’ needs in complex situations.

As a member of the study team, here are some details about the project:

The Positive Outcomes for Orphans (POFO) study has been following children for more than 3 years – It started when they were 6-12, and now is in the 8th year of following them. POFO hasn’t yet been able to follow many children aging out due to their younger ages (also some places and families have kept them beyond age 18), but it has followed children who are moving out of institutions, and out of families as well – POFO will follow them wherever they are living, regardless of where they started out.

Our team is in complete agreement that the aging out stage is critical, and is eager to look into that with these children! We are actually waiting to hear back about another round of funding to continue following the children into young adulthood and their early 20’s. The struggles and successes they experience as they become a part of society on their own would be a really important part of this project, and it is possible that it could result in different outcomes than we have seen so far – ah the scientific process! Information about how these children fare in respect to their peers will be so important in how policies are created, and we aren’t yet sure what we will find, so we hope we are able to continue.

As far as the primary means of collecting information, surveys have always been conducted with the children themselves, as well as with the caregivers. Self-report surveys have been used in these settings before (the study team can provide more info if needed but it is available online). Interviewers are from the study areas and are trained in impartiality and to try to have as private an interview as possible with each person (as is allowable within culturally and situational appropriate standards), to give them a safe space to speak. As is pointed out by Megan in her post, it is always true that any study using self-reporting can be biased, but our partner organizations at each site do not provide study participants in either families or orphanages support based on how questions are answered; this is discussed together when participants agree to become a part of the study, and periodically after that, as is worked out with our ethical review boards. And practically speaking, even if that didn’t convince them they wouldn’t somehow maybe get ‘something more’ out of it, as participants been interviewed for so many years now, we hope this bias has been eliminated as much as is reasonably possible.

In scope, the study is deeply interested in much more than the physical health of the children; there is a whole team of faculty involved with different areas of expertise, including child psychologists. POFO has looked at many factors including emotional health, cognition, and attachment. Trauma has been a large portion of our focus and has resulted in some really important findings – such as that boys are just as at risk as girls for abuse. At this point, the team hasn’t found significant results around attachment (meaning statistically significant, not ‘important’). There is a publication looking specifically at the children’s psychosocial wellbeing.

It is true that this study included mainly children who were entering these various types of group care later than age two – however, it is worth noting that 95% of all children who are orphaned or separated/abandoned in low and middle income countries are over the age of 5. It is critical that policies created only from infant and toddler data are not applied to the much larger group of children in need of quality family-like care that can be provided in a family home or a group home setting. It is these older children who are also much more likely to end up on the street or taken for household labor (or worse) if alternatives are not provided.

As far as outside support, one of the initial surprising findings from the study was that a majority of group homes were small, grass-roots places that grew up out of the communities and were not receiving foreign funding. The study has tracked all the financial and other types of support that families and group homes/institutions are receiving. So to say that orphanages and group homes in the study were receiving “thousands of dollars of interventions” or are “fancy” compared to other community families in the study is not accurate. In fact, “fancy” foreign-run institutions that weren’t considered reasonably replicable models in their communities were not included in the study for exactly that reason. If anyone is interested in the sampling (method of including study participants), I’m happy to provide more detail.

When Megan states that this work points to empowering families, she is right! Dr. Whetten does want to support families, and she doesn’t want kids to unnecessarily end up in orphanages. As Dr. Whetten said in a recent lecture “I receive emails saying ‘you want to put all the kids in institutions,’ and that is not true. I want to support families, I want to keep kids from going into institutions, I want to protect boys and girls, and we need to have a menu of options – but it’s not that I think that care in one place or the other is better, it’s the caregiving that happens in either place.”

And as is stated in one of the recent POFO publications, “These studies and ours should not be interpreted to mean that institutions are the preferred living environment for children, but rather that a family-based setting is not guaranteed to be a better place for a child to live. It is likely that the quality of care provided within a setting, whether that setting be family-based or institution-based, makes the difference in child wellbeing outcomes.”

It is also crucial to note that this doesn’t mean that all orphanages and all families are basically the same – so certainly not all children are thriving in institutions. The same journal article points out that “…In other words, there are substantial numbers of children in institutions and family settings doing relatively well and poorly both cross-sectionally and over time, which underscores the need to decipher the microcosm of quality of care issues within each setting.” This means that kids are doing really well, and really poorly in different settings. So, simply being a family or being an orphanage doesn’t automatically award a place a “gold star” for being a good situation for a child.

As a more personal conclusion, I’d like to finish with these thoughts:

We would absolutely love for each of these children to be welcomed into a loving and supportive family. That should be the priority goal for children for whom it is attainable, even if it is expensive or difficult to achieve. At the same time, the issues getting children to that place are big and endemic, and there must be a spectrum of solutions so that the needs and setting of a particular child can drive the solution for them. Family preservation, adoption, and foster care are unquestionably part of that spectrum – and they need further support and growth in so many settings, including our own country! But as numbers of homeless and street kids are rising worldwide and we see in our own country that only biological parents, domestic adoption, family-like care, or foster care alone can’t best meet the needs of every child, the case for a full spectrum of options is evident. Another consideration is that changing and unstable situations can be very traumatic for a child, and so many of these children are going through multiple changes and traumas, which introduces different needs and concerns. Let’s not let the children who are likely to fall through the cracks of what is best for most children not be able to have a good option.

We hope our work can be perceived as less polarizing. Hopefully it can be used to state the importance of excellence in care we provide to children in any setting, and to strengthen the work being done to support families and caregivers. We think it fits together well with Dr. Nelson’s work in Bucharest, for example, in communicating the importance of the quality of care given to all children. We need to support caregivers and family units, however they may have come together, to give kids the best situation for them that we can.


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