Sample Orphanage Summary Report St. Mary’s Children’s Home Dates of Evaluation: March 3-10, 2007 This report is confidential. Only those people authorized by the institution being evaluated are to have access to this report. If you do have permission to read this report you are not authorized to make the report, or any part thereof, available to others without permission. (Since this is a sample report it may be copied at will. Others may use this sample report and this concept to develop similar evaluation projects only if they provide OSSO with a copy of their finished product so that we can share ideas to provide better care for the greatest number of children.) On March 3-10, 2007, at the request of St. Mary’s Children’s Home (SMCH) and the Great Adoption Agency (GAA), Orphanage Support Services Organization (OSSO) performed an evaluation of SMCH. Jan Smith of GAA had committed $10,000 of support to the orphanage pending our evaluation, and then ongoing support after that with a commitment to try to find additional sources of support. We do not like to conduct evaluations where there is not a prospect of support to meet the needs we identify. This is a summary of that evaluation. For more details, or for evaluations of individual children, contact OSSO’s office. EVALUATION TEAM The evaluation team all volunteered their time (except the team leader) and paid their own expenses and the expenses of the evaluation itself. The evaluation itself did not cost SMCH or GAA or anyone besides the evaluation team anything. The team consisted of: OSSO Team Training and Experience Affiliations Home Teresa is a licensed social worker and Team Leader: has participated in many previous Bountiful, UT Teresa Galloway evaluation teams. OSSO Staff email@example.com Jenson family Mom: Elementary school teacher Jenny (mom) Dad: Architect Adoptive family; Mike (dad) Mary: their adopted child from St sponsors of three Mary (12-year-old daughter) Mary’s Children’s Home children in SMCH Boston, MA Occupational therapy student, Independent OSSO Janice Majors previous evaluation team member volunteer Cody, WY Director of Great Julie Smith 20 years working in adoptions Adoptions Seattle, WA Rodriguez family Bob (father) Sponsors of child from Katie (16-year-old daughter) Business man and high school student SMCH Rexburg, ID Bill Dana Pre-Med student U of Oregon Local Team Sister Lorena García Director of SMCH SMCH Loja, Ecuador Sister Cristina López Social worker SMCH Loja, Ecuador Loja Ministry of Child Martín Pérez Social worker Welfare Loja, Ecuador Staff The entire staff of SMCH SMCH Loja, Ecuador THE CHILDREN There are 54 children in the home ranging from two weeks of age to 18 years of age. The average amount of time that the children have lived in the home is six years. There are 23 children under the age of three that live all together in the nursery. There are 28 children over the age of three living in four family-style group homes. There are three severely handicapped children living in a separate room adjacent to the nursery. Nutrition and Growth Screening In an initial evaluation we do not evaluate the actual diet of the children, rather, we do screening for malnutrition of each child. Depending on what is found in the initial evaluation, a more detailed look at nutrition may be recommended for future evaluations. It has been noted that children in institutions are almost universally growth-delayed. The level of that growth delay loosely correlates to the quality of care they have received. This is not a direct correlation, and one must take other factors into account such as the health and conditions the child experienced before entering the institution, as well as underlying medical conditions. The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) both recommend screening children’s nutritional status by measuring their height, weight and head circumference, and then comparing them to standardized norms. While this is not a perfect method, it does help identify children who may need a closer evaluation. Children who are not properly nourished not only do not grow normally, their brains do not develop normally, they have behavior problems, and they get sick more easily. Each child’s height, weight and head circumference was measured. These measurements were done twice for every child. If the two measurements were not in agreement, the child was measured a third time. HEIGHT FOR AGE Children who are unusually short for their age are said to have stunted growth. Stunting usually means that they have suffered from poor nutrition or poor health at some time in the past. Stunting does not necessarily mean children are currently malnourished now but rather that they were at some point. We did nutritional screening on all of the children in the home. The children in the home fell in the following categories for height for age. This excludes the three severely handicapped children who were evaluated separately. Height for Age (or Stunted Growth) (number of children in each category) Unusually Severely Normal Tall for Age Stunted Stunted Range Age TOTAL 0-3 years 2 6 15 23 3.1-5 years 1 2 6 9 5.1-11 years 2 1 5 1 9 11+ years 3 2 5 10 TOTAL 8 11 31 1 51 WEIGHT FOR HEIGHT Children who have low weights compared to their height are said to be wasted. Wasting usually is a consequence of severe acute starvation and/or severe disease. Long-term starvation and/or disease can also cause wasting. The children in the home fell in the following categories for weight for height, excluding children with a known specific, chronic, non-nutrition-related medical diagnosis affecting growth. Weight for Height (or Wasting) (number of children in each category) Length of Time Severely Normal Overweight in the Home Wasted Wasted Weight for Height TOTAL < 3 months 2 0 1 3 3-12 months 2 3 4 9 12-36 months 0 1 8 1 10 36+ months 1 3 24 1 29 TOTAL 5 7 37 2 51 HEAD CIRCUMFERENCE Measuring the circumference of the head is very useful. An unusually small or large head circumference is a sign that there may be something wrong with the development of the brain. If the head circumference is small or large but in proportion to the child’s overall size it likely does not mean anything. Excluding the three severely handicapped children, there were four children with unusually small head circumferences, and zero with unusually large head circumferences. (Two of the four children with small heads appear to have Fetal Alcohol Syndrome. See the Fetal Alcohol Syndrome Screening section below.) Further evaluation of all four of these children by local physicians is recommended. NUTRITION AND GROWTH OF CHILDREN WITH A KNOWN SPECIFIC, CHRONIC, NON-NUTRITION-RELATED MEDICAL DIAGNOSIS Some medical and genetic conditions affect the normal growth patterns of children so that comparing them to standard growth charts is not useful. The best screening method for determining nutrition levels for these children is the use of skin calipers to determine percent body fat. This method is only fair to average at identifying malnourished children, but with retesting it is very good at monitoring progress of individual children. The following chart summarizes the nutritional information for children with a known specific, chronic, non-nutrition-related medical diagnosis in the home. Body Fat of Children With a Known Specific, Chronic Medical Diagnosis Very Number of Low Low Optimal High Children Body Fat Body Fat Range Body Fat 3 1 2 0 0 All three of the children appear to have low body fat levels, which is common, but not ideal, with severely handicapped children. Many children in orphanages who lack proper attention and love just do not grow, and may suffer from stunting or wasting despite the availability of adequate food. Summary and Recommendations for Nutrition and Growth ***To allow a broader circulation of the report, it is our policy not to include the names of individual children in the Summary Report. For detailed personalized findings and recommendations, see the personal reports for individual children and the “Director’s Recommended Action Checklist.”*** Nineteen of 51 children had some degree of stunting, indicating probable malnutrition or severe illness in the past. Only 12 of 51 children showed wasting, or evidence of current malnutrition or illness, and most of those were in the new arrivals in the orphanage. This suggests that many of the children arrive at the orphanage malnourished or severely ill, but there was very little evidence of ongoing malnutrition in those who had been there more than 12 months. Of the four children that showed evidence of severe wasting, one was recovering from a serious case of pneumonia, and two of the others were newly identified as having Fetal Alcohol Syndrome, which can cause wasting. All three of the severely handicapped children showed low body fat. It is recommended that they be evaluated by local medical professionals to consider options, including the surgical placement of feeding tubes. See their individual reports. It is recommended that all the children be reevaluated in four to eight months. It is also recommended that, with the reevaluation, an overall dietary intake assessment be made for the entire orphanage. See below in the overall recommendations what we suggest for improvement for these children. Individual recommendations are noted in the individual children’s reports and in the Director’s Action Checklist. Developmental Screening Children in orphanages almost always have some developmental delays, however, if they can be provided with a less institutional-like experience, and a more normal family-like environment in the orphanages their development will be better. We conducted a developmental screening on 31 of the 32 of the children 60 months and younger using the “Ages & Stages Questionnaires®” (see http://agesandstages.com). One child was felt to be too ill (recovering from pneumonia) to be evaluated. This method is not a perfect tool for diagnosis but allows us to identify problems that need further investigation. These are the results for all 31 children. Z-scores for Development* (number of children in each category) Delayed Normal Range Ahead Severe Delay Less -3 to -2 -2 to +1 Greater than Developmental Area than -3 Z-score Z-score Z-score +1 Z-score Average 22 of the 23 children in the nursery area Communication 4 12 6 -2.5 Gross Motor 3 10 9 -2.1 Fine Motor 3 12 7 -2.4 Problem -2.7 Solving 5 11 6 Personal-Social 4 8 10 2.2 9 children under 60 months in the family units Communication 2 2 5 -1.9 Gross Motor 1 2 5 1 -1.5 Fine Motor 1 3 5 -1.8 Problem Solving 2 1 6 -1.7 Personal-Social 3 5 1 -1.4 *Z-scores are the number of standard deviations above or below the mean: -1 z-score is about the 15th percentile, a -2 is about the 2nd percentile and -3 is lower than the 1st percentile. Summary and Recommendations for Development ***To allow a broader circulation of the report, it is our policy not to include the names of individual children in the Summary Report. For detailed personalized findings and recommendations, see the personal reports for individual children and the “Director’s Recommended Action Checklist.”*** The children in the nursery, as a group, showed the greatest degree of developmental delay. The children in the family-style units showed less delay, in spite of having previously lived in the nursery as infants, suggesting that in the family-style environment the children seem to develop more normally and even catch up to some extent. We recommend that all the children be reevaluated in four to eight months. See below in the overall recommendations what we suggest for improvement for these children. Individual recommendations are noted in the individual children’s reports and in the Director’s Action Checklist. Behavioral and Emotional Screening To assess the behavioral and emotional status of the children, the “Strengths and Difficulties Questionnaire” (SDQ) was used (see http://www.sdqinfo.com/b1.html). We had workers who knew the children fill out questionnaires. We had at least one worker fill out a questionnaire on all 21 of the children over the age of five (two of these were severely handicapped children). Ten of the children had questionnaires completed on them by two workers. Eleven children only had evaluations filled out on them by one worker. We also had nine of the 10 children (ages 11-17) fill out questionnaires on themselves. These 10 children also had questionnaires filled out on them by workers. So every child had two to three evaluations filled out on them, including those done on themselves. The scores below are a composite of all the evaluations filled out for each child. The SDQ is a screening device which correlates well, but not perfectly, with more in-depth evaluations conducted by professionals. It provides us with two things. First, it supplies us with a list of children who may need further evaluation by a professional. Secondly, it provides us with an overall measure of behavioral and emotional problems of the children in the institution, and allows us to see how those problems change as changes are made in the institution. The results are more accurate if a composite score is obtained by combining the results of multiple questionnaires filled out by different people for each child. The SDQ screens for four problem areas: emotional, conduct, hyperactivity and peer problems. It also gives an overall score which is the total of the four problem areas. In a normal population, about 10% of the children will have a score in the abnormal range, and about 10% will have a score in the borderline range. It also measures positive social behavior and gives a prosocial score, and also provides an impact score which measures how significantly the problem areas impact the life of the child and their environment. The results are summarized below. Strengths and Difficulties Questionnaire (number of children in each category) Developmental Area Abnormal Borderline Normal Emotional Symptoms 2 1 18 Conduct Problems 1 2 18 Hyperactivity 3 3 15 Peer Problems 1 1 19 Total Difficulties 2 3 16 Total number of children with at least one score in the abnormal or borderline range 4 4 13 Prosocial Behavior 0 3 18 Average Impact Score 8 2 N/A Summary and Recommendations for Behavior and Emotion ***To allow a broader circulation of the report, it is our policy not to include the names of individual children in the Summary Report. For detailed personalized findings and recommendations, see the personal reports for individual children and the “Director’s Recommended Action Checklist.”*** The SDQ indicated that approximately 20% of the children were in the abnormal range and 20% were in the borderline range. That is about twice as high as one would expect in a normal population. Two of the eight children in the abnormal or borderline groups were already identified by the orphanage staff as needing help and were receiving professional help by a psychologist. The remaining six should be further evaluated by local professionals. Further analysis of the data indicated that those children who had more recently arrived at the orphanage were more likely to score in the abnormal or borderline range. See below in the overall recommendations what we suggest for improvement for these children. Individual recommendations are noted in the individual children’s reports and in the Director’s Action Checklist. Educational Screening School Status (number of children in each category) 1-2 3-4 5-6 7+ Special At grade Grades Grades Grades Grades Type of school Education level Behind Behind Behind Behind TOTAL Public 3 10 2 2 17 Internal Private 1 1 Independent Study 1 1 2 Not in School 34 TOTAL 4 10 2 2 1 1 54 The most recent report cards (these were for the trimester ending February 27) for the 16 school children not in special education were reviewed. The results are summarized below. Individual reports are given for the four children in special education in their individual evaluations. School Performance of 16 Children not in Special Education (number of children in each category) Most recently available report based on 20-point system: 20=perfect, Class <12 failing Average <8 8.1-12 12.1-14 14.1-16 16.1-18 18.1-20 Math 4 2 5 2 2 1 13.5 Science 2 2 6 4 1 1 14.4 Social Studies 0 1 7 4 4 15.6 Spanish 0 3 5 3 4 1 15 Behavior (if graded) 0 5 3 2 2 3 14.9 Summary and Recommendations for Education ***To allow a broader circulation of the report, it is our policy not to include the names of individual children in the Summary Report. For detailed personalized findings and recommendations, see the personal reports for individual children and the “Director’s Recommended Action Checklist.”*** In talking to the children, as well as the staff, there was general frustration with the fact that most of the children needed more help with their homework, but there was no one on the staff that had time to help on a consistent basis. Some of the older, better students, tried to help the younger children, but they also did not have time to give as much help as was needed. The house “moms” often were too busy or in many cases did not have a solid education themselves. Six children were behind their grade level. With one exception, these children had arrived at the orphanage at an older age with no previous schooling. Two teenage girls had recently arrived at the orphanage with no previous school experience. They were both studying in the orphanage with a formal independent study program, but lacked someone on the staff who could consistently give the help they needed. One child who just turned 18 is an exceptional student and will graduate in June (two months form now). She has been helping the younger children with their homework when she has time and does a very good job. It has been suggested by the orphanage director that this young woman remain living at the orphanage upon graduation and work full-time as a tutor for the younger children. The Great Adoption Agency has agreed to provide the funds to pay her a full-time wage of $150/month to do so. Since the younger children go to school in the morning, and the older children go in the afternoon, she will be able to work a normal work day as a tutor. She will be assisted by one of the nuns who has worked 30 years as a teacher. It is recommended that the children’s grades be reevaluated in eight months to evaluate the results of this plan. Legal Status Screening The social worker who was to help us obtain this information was not available the last two days of the evaluation due to a family emergency. While each child does have an individual file with this information in it, we were not able to review these files. The following information was obtained from the orphanage director’s memory on all of the children. She feels that it is only about 80% accurate. Legal Status (number of children in each category) Questions Yes No Uncertain Does the child have a legal identity? 40 9 5 Is the child in the home by some type of legal authority or court order? 35 19 Does the orphanage have legal custody of the child? 35 10 9 Is the child in protective custody? 15 39 Summary and Recommendations for Legal Status ***To allow a broader circulation of the report, it is our policy not to include the names of individual children in the Summary Report. For detailed personalized findings and recommendations, see the personal reports for individual children and the “Director’s Recommended Action Checklist.”*** As mentioned, the above information is not very reliable. The staff, including the social worker, is aware of a great deal of work that must be done to clarify the children’s legal status. In some cases, children have been placed in the home on an urgent basis, and no one has taken the time to clarify the situation or prepare the needed paper work. There is currently funding for only four hours of the social worker’s time per week. It is our recommendation that funding be found by the GAA to pay for a full-time social worker. It is estimated by the staff and the current social worker that the backlog of work will require at least one year if the social worker can work full- time. It is estimated that to keep current from that point, once the backlog is completed, will require at least 20 hours a week of the social worker’s time. This is considered very high priority. Family Status Screening We believe that every child has a right to live in a permanent, loving, supportive family. When such a placement cannot be made with a birth family or an adoptive family, a permanent alternative, as much like a real family as possible, should be sought. The following information was obtained from the orphanage social worker who was reviewing records as we asked her questions on each child. Family Status (number of children in each category) Questions Yes No Comments Does the child have known family? 41 13 10 have been well assessed; If the child has known family, has the family been many others have had a partial assessed for possible reinsertion? 10 31 assessment How many children are progressing toward reinsertion? 5 5 If the child does not have known family, has an adequate search for the family been made? 8 5 Are the children legally available for adoption for for most of the children these which reinsertion into their birth family is unlikely? 8 7 issues are not clear How many children are assigned to a prospective adoptive family? 2 Do the children in the orphanage live in permanent, reasonably sized, well-supported, family-style groups? 28 26 Summary and Recommendations for Family Status ***To allow a broader circulation of the report, it is our policy not to include the names of individual children in the Summary Report. For detailed personalized findings and recommendations, see the personal reports for individual children and the “Director’s Recommended Action Checklist.”*** Of the 54 children, only seven are progressing well toward permanent reinsertion or adoption. Six more are awaiting adoptive families. The remaining 41 children are in an uncertain category because their situation has not been adequately evaluated. This is primarily due to the fact that the social worker is only available four hours a week. As discussed above, this is a crucial problem. We suggest that a full-time social worker be found immediately. See above in the legal status recommendations. Only 28 of the children live in a family-style environment while the rest live in a large nursery. See below in the overall recommendations what we suggest for improvement for these children. Individual recommendations are noted in the individual children’s reports and in the Director’s Action Checklist. Health, Medical and Dental Screening Of the 54 children in the orphanage, zero had records showing a visit to a medical practitioner for routine health maintenance in the last year (we define routine health maintenance as a visit when the child is not sick but just seen to review progress and screen for problems). Fifty had never seen a practitioner for routine health maintenance. Two had records of a dental evaluation in the last year. Forty-eight had never seen a dentist. It was noted that there was not an effective method of recording medical histories on the children. While the staff seemed to have some knowledge of the health histories of the children, there was not written record for most of them. Summary and Recommendations for Health, Medical and Dental It is our recommendation that each child should have a routine medical exam by a physician. It was felt that a local pediatrician that the orphanage uses regularly would be willing to do so for a fee of about $3/per child per visit which should cover supplies and labs if needed. While this cost is small, it should be anticipated that these routine exams may lead to further testing and treatment that may be more expensive. We also recommend that at least all the school-age children should be seen by a dentist. It is not clear how much this may cost, but the orphanage director was going to try to find out. A simple form for recording the children’s medical history was suggested, and a copy of this form was left with the orphanage director. Immunizations The national ministry of health recommends the following immunization schedule for all children: - BCG within 24 hours of birth - Pentevalente (Diptheria, whooping cough, tetanus, Hepatitis B and Hemophilus) and polio are to be given at two, four & six months - Measles, Mumps and Rubella are given at one year of age - Diphtheria, whooping cough and tetanus at 18 months of age - Diphtheria and Tetanus at six years of age Only 10 of all of the children had records showing they were current on their immunizations. Twenty-two more were slightly behind or were missing less than half of the immunizations they should have received. Of the remaining 22 children, fifteen of them entered the orphanage after the age when most immunizations are given, and none of these 15 children had records of having been immunized before they entered the orphanage, nor had they been given any missed immunizations. Summary and Recommendations for Immunizations It is our recommendation that children who have no record of immunization should be immunized, with the approval of a local pediatrician, for all missing immunizations. A list of children and the immunizations needed was given to the director of the orphanage. Vision Screening A Snellen Chart was used to test the distance vision of 20 children over the age of five. We found five children who had worse than 20/40 vision. The level at which glasses are generally felt to improve the quality of life is 20/40 or 20/50 vision. One child had 20/100 vision but had glasses that improve his vision to 20/30. None of the other children had glasses. One child had 20/40 vision, two were in the 20/60 range, and one had 20/80 vision. This type of notation compares how a normal person sees (the bottom number) to how the person tested sees (the top number). So someone with 20/100 vision can see things as well at 20 feet as a normal person can see at 100 feet. Formal screening was not done on the younger children, but the workers all seemed confident that all of the younger children could see. Summary and Recommendations for Vision The four children with vision 20/40 or worse should see a local professional to be evaluated for glasses. Their names and recommendation are on the Director’s Action Sheet with our recommendation. Hearing Screening All the children four and older were screened using a handheld pure tone hearing screener at four different frequencies. All the children under the age of four were screened to see if they turned toward or were startled by loud noises. One 10-year-old child had difficulty hearing the highest frequency pure tone. Summary and Recommendations for Hearing The child with the questionable hearing should be seen by a local professional and evaluated. Fetal Alcohol Syndrome (FAS) Screening We use the four-digit code method for diagnosing Fetal Alcohol Syndrome (FAS) (see http://depts.washington.edu/fasdpn/htmls/4-digit-code.htm). There are four basic elements common to children with FAS. 1. Growth delay 2. Evidence of abnormal brain development or impaired intellect or behavior 3. Facial features typical of FAS 4. Prenatal exposure to alcohol The first two are common in institutionalized children because of conditions in the orphanage, regardless of exposure to alcohol in the womb. A history related to the fourth area (prenatal exposure to alcohol) is often not available. For this reason we screen these children only for full- blown FAS and partial FAS and do not try to determine if they have one of the many more subtle fetal alcohol related diagnoses. All children with full-blown FAS, and those with partial FAS, share certain distinct facial features: small eyes, thin upper lip and a smooth philtrum. With appropriate training and good photos to compare, it is not difficult to identify children with these features. All children with FAS have these features, and probably 80%-90% of children with these features have FAS or partial FAS. All of the children in the orphanage were evaluated for the presence or absence of the facial features of FAS. Four children were identified as having possible facial features of FAS. Close- up facial photos were taken of these four children. These photos, together with the growth measurements and the developmental, behavioral and educational information on each child, were then sent to a physician with training in diagnosing FAS. The photos were analyzed using a computer program for detecting FAS facial features, and the other information was also reviewed. Based on that review, two children were felt not to truly have the facial features of FAS. The other two children were both felt to have the facial features to a severe degree. Both were not only small, according to standard norms, they were among the smallest for their age in the orphanage. Thus, both met the criteria for growth deficiency. One was also one of the most delayed in development in the orphanage, and the other was already enrolled in special education in school, so both qualify as having brain function impairment. The birth mother of one was a known alcoholic, and nothing is known of the prenatal history of the other. While it is possible to over-diagnose FAS in an orphanage setting, we feel that these two children clearly have the evidence to support this diagnosis. Summary and Recommendations for FAS We recommend that these children be further evaluated by a local physician for other abnormalities that can be associated with FAS (details given in Director’s Action Sheet). Unfortunately there is no curative treatment for FAS. We do recommend that, if available, they be given therapy or special educational assistance to help minimize the negative impact of FAS. THE ORPHANAGE STAFF Staff Overview Hours per week Own Direct Median Lives children Total hours Ongoing child-contact years on on come to Title/Job per week * training hours * job Salary site orphanage Administration Director 60+ 7 yes 3 ? Yes No Assistant 60+ 10 yes 5 ? Yes No Professionals Social worker 4 1 Yes 4 ? No No Psychologist 2 2 Yes 1 ? No No Doctor None ? No No Nurse None ? No No Non-childcare support, i.e. cooks, maintenance, cleaning, etc. Cook 60 50 No 10 ? No No Laundry 40 6 No 8 ? No No Childcare workers 3 children live with 2 7 Full-time 700 700 No 2 ? 4 Yes moms 4 part-time 82 82 No 2 ? No No *Each house is staffed by a “mom” who works six 24-hour shifts a week. In general, their childcare duties are limited to about a 15-hour period of time per day. Their time worked was calculated as 15 hours/day. The Director and the Assistant live onsite and are both nuns from the Dominicana order. They generally rotate every six years. The 23 healthy children in the nursery and the three handicapped children are cared for during the day by two full-time employees that work six 11-hour shifts. There is one night worker that works six 13-hour shifts. These three workers are replaced one day a week by two part-time employees. During meal times they are assisted by the cook, laundress, the Director or the Assistant Director. The older children, especially the girls, do much of the housecleaning and help out a great deal with the laundry and the cooking. Worker to Child Ratio Screening In the family-style houses, the ratio of adult caretakers per child is one hired “mom” for seven children. However, for most of the day, many of the children are at school, so that leaves a much better ratio—in some cases 1:3. This allows some very close interaction. In the Nursery, the ratio of workers to children is much higher, 1:13 for most of the day. During these times the workers are often busy making bottles, changing diapers or changing or feeding individual children. The children spend almost all of the day in their individual cribs, because it is not practical for the workers to supervise free play time with all of their other duties. During meal times, three times a day, other workers (the nuns, the cook or the laundress) come in to help out. There are often five or occasionally six people assisting at meal times, raising the ratio to 1:4 or 1:5 for these brief periods. As mentioned above, the social worker is not there near enough to accomplish the many tasks needed from her. The same is true of the psychologist. The administrative staff also seems overwhelmed by the amount they need to do. Retention There seems to be pretty good retention in the nursery with the three main employees having worked there, two, seven and 18 years. In the family-style houses however, the situation is different. The four full-time “moms” have worked six months, eight months, two years and four years. In talking to the staff it seems that about half of the “moms” change almost every year. That means that half of the children have a new parental figure every year. This can be very disruptive. The two moms that have been there the longest both have at least one of their own children living with them. We did not talk to the employees about job satisfaction and concerns, but from past experience it is very difficult to find caring dedicated women willing to work six 24-hour shifts a week. Allowing single women to stay in the home with their children often improves retention but often leads to a two-tier type of childcare in the home where the caretakers own children get better care than the others. Summary and Recommendations for Worker to Child Ratio The orphanage seems understaffed in almost every area. The most crucial need is for more childcare workers in the nursery, to provide stimulation, supervision and nurturing to the infants. There is also a great need to improve the retention rate of workers in the family-style houses. The social worker should be increased to full-time at least for a year. Assistance of speech and developmental specialists would be helpful, as would physical and occupational therapy for the handicapped children. Some ongoing training in childcare and parenting would be useful for the childcare workers. See the general recommendations below for a suggested overall strategy and goal. It is also recommended that on a future evaluation in four to eight months that the feelings and challenges of the workers be looked at, as well as salary levels. The evaluation team leader did not feel comfortable asking salary information this trip. But knowing information about salaries would help guide us in making recommendations. Policies, Practices and Finances The team leader did not feel comfortable asking detailed questions about the policies, practices and finances. Information in these areas also helps us see the overall picture and make better recommendations. More information should be obtained in these areas in the future. We would like to make the following overall general recommendations. * The system of bookkeeping should be transparent and have some type of internal and external oversight or auditing. * Often orphanages provide food, clothing, childcare services, or other unofficial types of compensation for employees since they are often unable to provide competitive salaries. This is potentially problematic but sometimes needed. When these types of compensation are given it should be clearly defined, recorded and limited, and done in an open manner. *There should be clearly defined and effective policies and procedures for screening, monitoring and dealing with past or ongoing child abuse for all employees, including the director. *There should also be plans in place for emergencies and natural disasters. VOLUNTEERS There are three volunteers that work at the orphanage on a consistent basis: a woman and her adult daughter that come every Sunday afternoon for about two hours and read books to the children, and an elderly woman that comes most Friday mornings to hold babies and feed them. There are a number of short-term volunteers and several inconsistent long-term volunteers that come to help out in the orphanage. The Director estimated that these volunteers average about four hours a week, although some weeks no one comes, and the week before Christmas there are many. They have from time to time had international volunteers who would come and serve daily for a period of months. Summary and Recommendations for Volunteers We shared some specific suggestions on how to encourage local and international volunteers. FACILITIES The orphanage is located in an urban area in an old but relatively safe neighborhood. It consists of a three-story building with two three-bedroom apartments on each floor. Each apartment is approximately 900 square feet. One of the ground floor apartments has been converted for use as an administrative area with offices. One of the apartments on the third floor has been converted into a nursery. The other four apartments are used to house the four family-style groups. There is an adjacent apartment that houses four nuns. The Director and Assistant Director live there as well as two other nuns that work outside the orphanage in a nearby hospital. Attached to the nuns’ housing is a large kitchen where food for everyone is prepared (but eaten in the individual apartments). There is a small grassy play area in front and a laundry area and cement basketball court in back. It is surrounded by a three-meter wall with barbed wire at the top (see the attached sketch of the layout with pictures). Security and Safety Screening The facilities appeared well constructed and seemed to provide adequate protection from the elements. The gate is always locked, and no one is admitted without proper approval. The walls, while not impenetrable, provide at least as much security as other homes and businesses in the area. There were some safety concerns about some of the playground equipment that were discussed with the staff. Some second and third floor windows opened too wide and did not have adequate locks. In fact, a child fell from a third floor window two months ago and was seriously injured. These should be fixed. The railing systems on the stairs are not adequate to keep small children from falling. Play Area Screening While there seemed to be a lack of quality toys and play equipment in good repair, there was adequate space for play. Water Screening Each apartment and kitchen have hot and cold water. The water is from the city and there is a large cistern (that was not inspected) that stores water in case the city supply is temporarily out of service. The water was tested for chlorine, nitrate, nitrite and lead levels. Water samples were also incubated and tested for coliform, and E. coli bacteria. If coliforms are present that means that the water supply is contaminated; if E. coli is found that means it is contaminated with feces or sewage. Below is a summary of the water testing. Summary of Water Testing Lead (less than Source Chlorine Nitrate Nitrite 15ppb) coliform E. coli Nursery none ok ok ok present absent Nursery 2nd test ok ok ok ok absent absent Kitchen ok ok ok ok absent absent House 1 ok ok ok ok absent absent house 2 ok ok ok ok absent absent Summary and Recommendations for Water It would appear, like many water sources, that while often the water from the city is acceptable it can be contaminated from time to time. We recommend that no one drink the water from the tap unless it is boiled. That is their stated practice; however, we did see some of the older children drinking directly from the tap. Lead Screening Lead is present in many old paints, in some plumbing and in many other common items. Low level lead poisoning is very common in orphanages and in the general public. It can cause anemia, liver problems, growth retardation, lower IQ and behavior problems. We tested hundreds of potential sources of lead poisoning throughout the orphanage using LeadCheck vials (http://www.leadcheck.com/). We tested all toys, paints, cribs in the nursery, and most of the painted surfaces within reach of children. We tested the water as outlined above. We tested all painted toys. We failed to test the playground equipment. Results: We found significant lead levels in the paint of some of the toys, including two sets of handmade blocks. We found lead in the paint of several children’s chairs and two small play tables. These items were immediately removed with the recommendation that they be destroyed. Summary and Recommendations for Lead We recommended the destruction of the items we found that had lead. We recommend with the next evaluation testing of all painted toys, all cribs and any newly painted items or surfaces. OVERALL RECOMMENDATIONS A detailed list of specific recommendations with suggested priority rankings and, where possible, estimated costs were given to the Director of the orphanage and to Jan Smith, the Director of Great Adoption Agency. This report included a few relatively inexpensive “Priority 1” items (immediate threats to life), and about 100 items rated “Priority 2” which we strongly felt needed to be taken care of right away. There were also many other “Priority 3 and 4” items that we feel are important but not urgent. We feel that there are more “Priority 2” types of problems than there are currently enough resources to meet. We will discuss some of these in the next paragraphs. They all have to deal with the same basic issue: every child deserves to live in a loving, supportive, permanent family setting. We feel these are very urgent issues as research has shown that every day a child remains in an institutional-type environment represents lost development, lost opportunities to learn and reach their potential, lost hope and fewer options for permanent placement. Many of these losses can never be regained. Thus, returning children to prepared and supportive original families, seeking early adoption, or providing good, permanent, substitute families is a high priority. Full-time Social Worker Many, if not most, of the children in the home have the potential to either be safely returned to their original families or placed in adoptive homes. Most of the children are not progressing toward either of these goals, and the biggest reason is both require a great deal of investigation, assessment and planning by a social worker. The current budget for a social worker only allows for four hours a week. We feel that a social worker is needed 40 hours a week. This alone will find permanent solutions for many of these children. The older a child becomes, the harder it is to find an adoptive family for them, so time is crucial. The salary for a full-time social worker is approximately $280-$350/month. Restructuring of the Orphanage to Put Every Child into a Family- style Home We and others have found that children do better in every aspect of their lives when they are in a family-like environment. The closer that environment is to a real family the better. The data from our evaluation of SMCH supports that concept. The children in the large institutional-type nursery seem to be doing worse in almost every area than the children that are in the family-style homes. And even though the children from the nursery start developing more normally and even catch up to some extent once they’re moved to the family-style homes, there will still be long- lasting effects and even possibly life-long repercussions. While there is always more than one possible solution to a problem, and realizing that we are in no position to decide, we recommend that three new family-style homes be created, and that all the children currently in the nursery, as well as the handicapped children, be divided among the (now total of seven) family-style homes. Seven Family-style Homes To accomplish this, the apartments that currently house the nursery and the administrative offices will need to be turned back into family-style housing. We also recommend building a new building that will house one wheelchair-accessible family-style apartment on the main floor and administrative offices on the second floor. The cost to restore the two apartments to family-style homes should be relatively small. According to estimates of two local architects the cost of constructing a new building in Ecuador is about $25/square foot. The building should be about 1,600-1,800 square feet. So a rough estimate of $40,000-$45,000 is the cost of construction. Staffing the Homes Although we were not told the salaries of the staff, it is likely that the three full-time employees working in the nursery make as much money for their six 11-hour shifts as the full-time employees in the houses do for their six 24-hour shifts, if you do not count the free room and board they receive. If you were to staff the new houses the same way as the current houses are staffed, there would be no increase in salary cost. The three nursery employees would become the three full-time moms in the houses, working six 24-hour shifts. While we feel this may be better than the current situation, we feel it is not the best. There is a high turnover rate in the house moms. Every time a house mom is replaced, the primary caretaker for all those children is replaced, causing a great deal of emotional trauma to the children. Adding infants and toddlers into the homes increases the work load for the workers. The younger children require more time day and night and do not go to school. It has been our experience that it is easier to find workers willing to work shifts, even long ones, but go home every day than to find someone to work six 24-hour shifts a week, even if they sleep most of the night during their shift. They also are less likely to quit. That is also seen in the data we collected at SMCH. The workers working six 11-hour shifts average nine years on the job. Those working six 24-hour shifts average less than two years. Currently there are seven full-time and four part-time childcare workers. We suggest increasing to 16 full-time workers. Each house would have two full-time “moms.” They each would either work half of every day (i.e. 12-hour shifts) or each work every other day for 24 hours. Our experience is that workers prefer to work every other day for 24 hours. Most will get to sleep most nights. The two extra full-time moms would rotate among all the houses to give the other moms breaks. The workers tend to like this rotation because they sleep most of the nights when they work but are getting paid for a full 24 hours. They average three 24-hour shifts a week, thus getting paid for 72 hours (as much as six 12-hour shifts) but have four days off a week. They can have a personal life outside of work, which is hard to do working six 24-hour shifts. Because of this, it is easier to find caring dedicated workers. Most caring responsible women do have a personal life or personal commitments making six 24-hour shifts only a consideration if they are desperate. This system is good for the children. The workers tend to be less burned out and can give more to the kids. The children have two primary caretakers with an additional two that fill in a couple times a month, and the workers are likely to be longer-term. But even if one quits, it is less disruptive because they still have one of their two full-time caretakers, and the replacement mom is likely to be one of the substitutes that is already familiar to them. There is an obvious additional cost of having 16 full-time workers instead of seven full-time and four part-time workers. We estimate this will be an additional $1,500/month, or about $30 per child. Stopgap measures: The above plan will take time to finance and carry out. In the meantime, we suggest more daytime workers in the existing nursery to play with, interact with and talk to the children. They should spend hours every day outside their cribs climbing, playing, exploring, etc. There is a need for toddler play equipment and educational toys. We also suggest immediate increased staff in the houses, including a tutor and someone to give the moms more time off. Sources of Increased Funding There are many organizations and individuals that are willing to help abandoned children. Two of the biggest obstacles to receiving help are vision and trust. Donors want to see the vision of what their money can do. Is it needed? Is it going to make a difference? They also need to trust that their money is really being used to meet that vision. We can help with both of these obstacles. By doing regular evaluations every six months, we are, in essence, taking a snapshot of the needs so people can hold, touch, read and understand what the need is. The recommendations that we offer to the snapshot of those needs, or alternative solutions offered by the orphanage, become a vision of how things can be different. In repeat evaluations we are taking another snapshot, so we have a “before” and “after” quantifiable, documented look at the progress, or lack thereof, and trust is developed. Trust is a two-way street. As an orphanage begins to trust our evaluations, our motives and the results we may link them to, they become more trusting and open to us. As a result, we can more clearly document their integrity and purpose to their donors, who are likely to respond with continued or increased support. The GAA has already committed to $10,000 to help immediately, and ongoing support of an unspecified amount. Other adoption agencies that have placed children from SMCH are possible sources of support. Most adoption agencies have a desire to help but often lack the vision of what could be done and the trust that their funds would help it be done. These agencies can also help provide a link to adoptive families that are often very eager to help the orphanage or orphanages in the country where there child was adopted, provided the obstacles of vision and trust can be overcome. ORAI (Orphan Resource Alliance International) is a new organization that networks with individuals, companies and nonprofit organizations seeking to help orphans and helps match them with orphanages and other organizations that need support. A Sponsorship Program which finds individual sponsors for individual children can be very effective. As part of this evaluation we have compiled specific information on each child. An individual report can easily be prepared for each child which is perfect for reporting to sponsors how their child is doing. Effectively run sponsorship programs can provide long-term regular donors. OSSO can help advise on the best way to create a sponsorship program. Local businesses, individuals and government. There is often too little support locally for orphanages. Armed with solid evidence that shows specific needs, orphanages can often find better support locally. Orphanages are often reluctant to be open about the needs of the children to the local community. They sometimes feel if the children’s needs are not met it reflects badly on the orphanage staff. With specific evidence, like that presented in this report, it often can be shown that the needs of the children are not due to failings of the staff but rather a clear result of inadequate support.
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