(Template for Orphanage Summary Report ) by TGuiliani

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									                                     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

    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                         tgallo_1@yahoo.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.

    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)
                                  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

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

                             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

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.

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
                       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
           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

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
     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.
The national ministry of health recommends the following immunization schedule for all
- 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

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
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

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

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
                                                  Direct                           Median                      Lives        children
                       Total hours                     Ongoing
                                              child-contact                        years on                     on          come to
      Title/Job         per week *                     training
                                                 hours *                             job          Salary        site       orphanage
   Director            60+            7               yes                          3             ?             Yes        No
   Assistant           60+            10              yes                          5             ?             Yes        No
   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.

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.

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.

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

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

Below is a summary of the water testing.

                                Summary of Water Testing
                                                               (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

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

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

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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