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Authors: Monica H. Swahn, Jane B. Palmier, Rogers Kasirye, & Huang Yao 

Abstract: While suicidal behavior is recognized as a growing public health problem world-wide, little is known about the prevalence and risk factors for suicidal behaviors among street and slum youth in Africa, and in Uganda, specifically. The number of youth who live on the streets and in the slums of Kampala appears to be growing rapidly, but their mental health needs have not been documented, which has hampered resource allocation and service implementation. This study of youth, ages 14-24, was conducted in May and June of 2011, to assess the prevalence and correlates of suicidal behavior. Participants (N = 457) were recruited for a 30-minute interviewer-administered survey through eight drop-in centers operated by the Uganda Youth Development Link for youth in need of services. Bivariate and multivariate logistic regression analyses were computed to determine associations between psychosocial correlates and suicide ideation and suicide attempt. Reporting both parents deceased Adj.OR = 2.36; 95% CI: 1.23-4.52), parental neglect due to alcohol use (Adj.OR = 2.09; 95% CI: 1.16-3.77), trading sex for food, shelter or money (Adj.OR = 1.95; 95% CI: 1.09-3.51), sadnesss (Adj.OR = 2.42; 95% CI: 1.20-4.89), loneliness (Adj.OR = 2.67; 95% CI: 1.12-6.40) and expectations of dying prior to age 30 (Adj.OR = 2.54; 95% CI: 1.53-4.23) were significantly associated with suicide ideation in multivariate analyses. Parental neglect due to alcohol use (Adj.OR = 2.04; 95% CI: 1.11-3.76), sadness (Adj.OR = 2.42; 95% CI: 1.30-7.87), and expectations of dying prior to age 30 (Adj.OR = 2.18; 95% CI: 1.25-3.79) were significantly associated with suicide attempt in multivariate analyses. Given the dire circumstances of this vulnerable population, increased services and primary prevention efforts to address the risk factors for suicidal behavior are urgently needed.

Click here to read full study

Authors: Monica H Swahn, Lindsay Gressard, Jane B Palmier, Rogers Kasirye, Catherine Lynch, & Huang Yao.

Introduction: Violence among youth is a major public health issue globally. Despite these concerns, youth violence surveillance and prevention research are either scarce or non-existent, particularly in developing regions, such as sub-Saharan Africa. The purpose of this study is to quantitatively determine the prevalence of violence involving weapons in a convenience sample of service-seeking youth in Kampala. Moreover, the study will seek to determine the overlap between violence victimization and perpetration among these youth and the potentially shared risk factors for these experiences.

Methods: We conducted this study of youth in May and June of 2011 to quantify and describe high-risk behaviors and exposures in a convenience sample (N=457) of urban youth, 14-24 years of age, living on the streets or in the slums and who were participating in a Uganda Youth Development Link drop-in center for disadvantaged street youth. We computed bivariate and multivariate logistic regression analyses to determine associations between psychosocial factors and violence victimization and perpetration.

Results: The overall prevalence of reporting violence victimization involving a weapon was 36%, and violence perpetration with a weapon was 19%. In terms of the overlap between victimization and perpetration, 16.6% of youth (11.6% of boys and 24.1% of girls) reported both. In multivariate analyses, parental neglect due to alcohol use (Adj.OR=2.28;95%CI: 1.12-4.62) and sadness (Adj.OR=4.36 ;95%CI: 1.81-10.53) were the statistically significant correlates of victimization only. Reporting hunger (Adj.OR=2.87 ;95%CI:1.30-6.33), any drunkenness (Adj.OR=2.35 ;95%CI:1.12-4.92) and any drug use (Adj.OR=3.02 ;95%CI:1.16-7.82) were significantly associated with both perpetration and victimization.

Conclusion: The findings underscore the differential experiences associated with victimization and perpetration of violence involving weapons among these vulnerable youth. In particular, reporting hunger, drunkenness and drug use were specifically associated with victimization and perpetration. These are all modifiable risk factors that can be prevented. It is clear that these vulnerable youth are in need of additional services and guidance to ameliorate their adverse childhood experiences, current health risk behaviors and disadvantaged living context.

Click here to read the full study

Authors: Mary Jane Rotheram-Borus, Marguerita Lightfoot, Rogers Kasirye, & Katherine Desmond

Abstract: In a pilot study, young people in slums in Kampala, Uganda received an HIV prevention program (Street Smart) and were randomized to receive vocational training immediately (Immediate) or four months later (Delayed). Youth were monitored at recruitment, 4 months (85% retention), and 24 months (74% retention). Employment increased dramatically: Only 48% had ever been employed at recruitment, 86% were employed from months 21 to 24 post recruitment. Over two years, decreases were recorded in the number of sexual partners, mental health symptoms, delinquent acts, and drug use; condom use increased. Providing employment in low income countries, in conjunction with HIV prevention, may provide sustained support to young people to prevent HIV acquisition.

Read full study here


Prior research—mostly on the US and Europe—suggests that children who grow up without one or both parents in the household are at risk for a host of negative educational outcomes (Magnuson and L. M. Berger, 2009).  This essay builds on this research to explore whether this finding holds true in all regions of the world.

Key questions:

1. Is family structure associated with children’s educational outcomes, even when other possible factors explaining differences are taken into account (for example, parental education, family wealth, and parental employment)?

2. Is family structure associated with children’s feelings of being connected to their school and their perceptions of how relevant school is for them?

3. Are there important differences in the association between family structure and children’s education between major world regions?

Data Sources: 

This essay draws on original analyses of two international datasets to answer these questions. The first was the 2009 Program for International Student Assessment (PISA), conducted by the Organization for Economic Cooperation and Development (OECD), which was used to examine the effect of family structure on educational outcomes among 15-year-olds in countries that are mostly considered middle- or high-income countries, though some countries in PISA may be considered low income.  The 2000 PISA data were also used to supplement these analyses.The second was from the Demographic and Health Surveys (DHS), which was used to examine the effect of family structure on educational outcomes among similar youth in low-income countries.

Results & Discussion: 

As expected, among high- and middle-income countries, children living with two parents are more likely than are those living with one or no parents to follow a normal progression though school, and to experience higher levels of reading literacy. These results suggest that in many countries, parents serve as an important source of support and resources that can benefit their children’s education, with greater resources coming from two parents. In many European countries, parents’ skills and resources have a strong association with children’s cognitive abilities, and family conditions during childhood (including the number of parents children live with) play a key role in children’s long-term life chances.

However, the results of this study also indicate that the positive effects of living with two parents were much less consistent in low-income countries. There were few differences between children living with one versus two parents in many low income countries once all family and individual background factors were considered, and there was even an advantage to living with a single parent for some educational outcomes in some countries.

There are several potential non-competing explanations for why family structure seems to matter less in low-income countries. It is possible that family structure simply does not matter as much for children’s education in low-income countries where many obstacles to good educational outcomes remain. These obstacles are likely to affect children in all types of families, and include the availability and cost of schools, teacher quality, parental health, children’s health and nutrition, seasonal labor demands, and attitudes toward work and school. Thus, rates of school enrollment and children’s normal progression through school in low-income countries may be much more sensitive to these types of factors than to the number of parents in the household.

Labor migration may also play a role in the relationship between family structure and educational outcomes in low-income countries. When a parent is absent from the household because he or she is sending money home while working in a more economically-advanced area, children may experience less disadvantage from a parent’s absence than may children whose parent was never part of the household or whose parents divorced. Additional income may even place such households at an advantage. For example, in South Africa, households receiving remittances were found to be 50 percent more likely to keep children in school.51 Thus, in low-income countries, incentives for separating the family in order to support it are greater than in high- and middle-income countries. Further exploration of the reasons that children may be living with only one or no parents, and more detail on who is in these households (many children that are not living with their parents may be living with grandparents, for example) will help us understand the processes occurring within these families that may benefit or harm children’s educational attainment and achievement.

Investigators: Mindy E. Scott, Laurie F. DeRose, Laura H. Lippman, and Elizabeth Cook

Read full study here

Child Trends—“a nonprofit, nonpartisan research center that studies children at every stage of development”—that seeks to ameliorate Child wellbeing and outcomes by providing research to individuals, organizations and institutions that create policies and make decisions affecting the lives of children around the world. In January, Child Trends released an inaugural report, “World Family Map Report 2013: Mapping Family Change and Child Well-being Outcomes,” which aims to examine patterns “the health of family life around the globe and to learn more about how family trends affect the well-being of children” in 45, high- and low-income countries from every region in the world. Sponsored by the Annie E. Casey Foundation, Focus Global and the Social Trends Institute, the “World Family Map Report 2013”  analyzes family structures and the “strengths and challenges” they provide in relationship to “educational outcomes for children and youth.” Co-primary investigators, Laura H. Lippman (Senior Program Area Director & Senior Research Scientist at Child Trends) and  W. Bradford Wilcox (director of the National Marriage Project at the University of Virginia) summarize the report’s key findings below:

Children’s lives are influenced by the number of parents and siblings that they live with, as well as by whether their parents are married. The World Family Map reports these key indicators of family structure in this section.

  • Although two-parent families are becoming less common in many parts of the world, they still constitute a majority of families around the globe. Children under age 18 are more likely to live in two-parent families than in other family forms in asia and the middle east, compared with other regions of the world. Children are more likely to live with one or no parent in the americas, europe, oceania, and sub-saharan africa than in other regions.
  • Extended families (which include parent(s) and kin from outside the nuclear family) also appear to be common in asia, the middle east, south america, and sub-saharan africa, but not in other regions of the world.
  • Marriage rates are declining in many regions. adults are most likely to be married in africa, asia, and the middle east, and are least likely to be married in south america, with europe, north america, and oceania falling in between. Cohabitation (living together without marriage) is more common among couples in europe, north america, oceania, and—especially—in south america.
  • Childbearing rates are declining worldwide. The highest fertility rates are in sub-saharan africa. a woman gives birth to an average of 5.5 children in nigeria—down from close to seven in the 1980s, but still high by world standards. moderate rates of fertility (2.3-3.1) are found in the middle east, and levels of fertility that are sufficient to replace a country’s population in the next generation (about 2.1) are found in the americas and oceania. Below replacement-level fertility is found in east asia and europe.
  • Given the decline in marriage rates, childbearing outside of marriage—or nonmarital childbearing—is increasing in many regions. The highest rates of nonmarital childbearing are found in south america and europe, paralleling increases in cohabitation, with moderate rates found in north america and oceania, varied rates found in sub-saharan africa, and the lowest rates found in asia and the middle east.

* You can also read W. Bradford Wilcox’s editorial, “The Parent Trap: Do two-parent families help children get ahead in life? The surprising answer: not everywhere,” available on Foreign Policy‘s website.

* Learn more about the research Child Trends does by examining their newsletters, including their Winter 2013 newsletter, “The Child Indicator.”


I had seen the SEED School of Washington, D.C. in the documentary, Waiting for Superman, so I knew to expect a culture of high expectations for all in a learning community committed to academic excellence at this residential, public charter school.  Still, I was struck by both the quantitative measures of success shared by Charles Adams, Head of School, and the excitement about and pride in their school evident in the student ambassadors leading our tour.   These kids from disadvantaged backgrounds, living in what has historically been considered one of the lowest performing urban public school systems in the country, were optimistic about their future given the educational opportunity being afforded to them at SEED.

My tour of SEE was part of the Coalition for Residential Education‘s (CORE) Leadership Insitute in Washington, D.C., where I had the opportunity to present some of the Positive Outcomes for Orphans(POFO) findings comparing the wellbeing of orphans and abandoned children in institutional and community-based care settings in five less wealthy nations. A national non-profit organization founded in 1994, CORE supports the development of high-quality residential education programs and schools for youth disadvantaged backgrounds. Attendees included CORE board members and other leaders from a variety of residential institutions around the country, including Milton Hershey School, Baptists Children’s Homes, the SEED School of Maryland, and Crossnore School.

The membership of CORE is diverse, with some organizations serving some students in the child welfare system, while others do not.  Certainly large, ‘institution-like’ residential treatment programs for children with serious behavioral and emotional problems have been found lacking in their ability to meet these children’s needs.   However, my tour of SEED and discussions with CORE’s leadership led me to consider the role of residential schools and programs for children without serious emotional and behavioral problems involved in the child welfare system, whose chance of breaking the cycle of poverty and/or abuse in their families lies in their ability to access excellent education.  Perhaps it’s time we reconsider residential education as an option for some of these children.

About the author: Kristen Sullivan (Ph.D. in Health Behavior and Health Education, University of North Carolina at Chapel Hill) is a Research Scholar at Center for Health Policy and Inequalities Research at Duke University.

Editor’s note: this opinion piece was originally posted on Dr. Alexandra Murray Harrison’s blog, “Supporting Child Caregivers,” and has been re-posted with permission from the author.

Charley Zeanah presented to the group on September 21 and 22. He has been involved in Romania for 14 years. The Romania initiative traces its beginning to a movement started by the 1909 White House Conference on Children that declared its opposition to the institutionalization of dependent and neglected children. Now institutionalization of children whose families cannot take care of them is rare in the U.S., but not in other parts of the world. Romania is a unique story. The research group was invited to study there in the context of a policy debate about what to do with all the children institutionalized by Ceausescu’s government. Under Ceausescu, the official position was that the State could do a better job in raising children than many mothers could, so mothers who were struggling with poverty or other adversities were encouraged to give up their children in the maternity hospital. After several months in the maternity hospital, if the child had no obvious problems, he was transferred to a nursery, where he stayed until 36 months. At that point, if an exam determined him to be normal, the child was sent to a children’s home.

Although there was wide variability in children’s homes, there were some important common features, including many factors working against the establishment of individualized attachment relationships with the caregivers. The children were fed around the table with little or no talking, there was a lot of “free play time” with little support from the caregivers, and aggressive behavior and expressions of distress were often not attended to.  Films of this “free play time” revealed painful images of children rocking and spinning.

The study created a model foster home project in which social workers were trained to work closely with the foster families to facilitate attachment and support the foster parents. Interestingly, one of the main effects of this intervention was an increase in IQ of the children in foster families. Also, these children showed greater expression of positive emotion than the institutionalized children within a few months. When assessment was repeated after 42 months in foster families, a community control group had the best attachment to their caregivers, the foster group had medium results, and the institutionalized group had the worst outcome.  The children in this last group included a high percentage of withdrawn, inhibited kids with Reactive Attachment Disorder. It is interesting to note that the characteristic “indiscriminate” attachment behavior of RAD persisted even after the group in foster care had formed attachments to their foster families.

Later, when psychopathology was assessed at 54 months, 55% of the children living in institutions had diagnosable psychiatric disorders in contrast with 22% of children in the (control) community group. Both foster care and institutionalized groups had higher levels of emotional disorders (such as anxiety and depression) and behavioral disorders (such as ADHD, Oppositional Defiant Disorder, and Conduct Disorder) than the community group.  The improved cognitive outcomes in the foster care children were most significant for children placed in foster care before 24 months. Similar sensitive periods were also found for the development of language, attachment, and indiscriminate behavior. An important finding was that secure attachment at 42 months predicted psychopathological outcome at 54 months. Interestingly, there was a big gender difference, with most of the securely attached children at 42 months being girls and most of the children with psychiatric symptoms at 54 months being boys.

In conclusion, the research group found that children raised in institutions have compromised development across almost all domains, that attachment status moderates many aspects of psychopathology, and that the socio-emotional effect is more profound than the cognitive effect. When you place these children in good foster homes, you get attachment recovery and some – but not all – recovery from psychopathology. The research group strongly recommends intervening in abusive and neglectful caregiving situations as early as possible.  More specifically, they propose removing children from institutions and placing them in foster homes.

I noted that this was a beautiful presentation of a study of monumental importance in child development and child psychiatry. The study demonstrates the power of the caregiving relationship to influence development. I pointed out, though, that the Romanian orphanages represent – as Dr. Zeanah explained – a rather unique and extreme caregiving situation, and that there is a problem in that is that this study of Romanian orphanages is being used by some international agencies to promote a one size fits all approach to the problem and laws such as LEPINA in El Salvador that require immediate reunification of institutionalized children with their biological families, with little or no support for their severely disadvantaged and dysfunctional families in the community.

Ed Tronick quoted the “old literature “– the first edition of Jerome Kagan’s book on child development that included accounts of children raised in institutions after WWII. These children did relatively well. How can we explain that? One possible reason is that there was a commitment to these children because of something terrible, morally bad that had been done, enhancing the caregivers’ desire to do something for them. Dr. Zeanah talked about the meaning of the children to the caregivers. In the case of Romanian orphanages, the society’s negative attitudes towards the Roma, who make up of 30% of children in orphanages, though they comprise only 6-9% of the population, may affect the caregivers’ commitment to the children.

Dr. Zeahah said that their group is interested in individual differences in response to institutionalization among the children. He noted that there may be a relationship between certain genotypes and indiscriminate behavior. They are looking at alleles that are very sensitive to experience and those that seem impervious. In that case, if you have the impervious alleles you fare well no matter what the environment and if you have the sensitive alleles you may struggle in an average expectable environment. Readers of the blog will recognize the “orchids versus dandelions” metaphor.

Apropos these last comments, I had a number of thoughts. First, I would underscore the importance of the meaning of the child to the caregivers. For example, a religious or spiritual mission to minister to children in need may allow caregivers to see the child as deserving of loving care and to recognize the unique value of each child, while also sustaining the caregiver through the frustrations and disappointments involved in their tasks. For example, the message that each child is precious to Jesus – no matter what he looks like or how much he achieves – is a powerful message indeed.  It is also important to remember the orchids and dandelions story. This story emphasizes the individual characteristics of each child, including the ability – innate or acquired – to take in the good in their environment and make it part of themselves. These thoughts remind us of the complexity of development and of how important it is to continue to search for a repertoire of solutions so that we can find a unique approach to each unique challenge.


Kagan, J. (1962). From Birth to Maturity, John Wiley and Sons, Inc.

Nelson, C.A., Zeanah, C.H., Fox, N.A., Marshall, P.J., Smyke, A.T., Guthrie, D. (2007). Cognitive recovery in socially deprived young children: The Bucharest early intervention project. Science, 318:1937-1940.

Nelson, C.A., Furtado, E.A., Fox, N.A., Zeanah, C.H., The deprived human brain: Developmental deficits among institutionalized Romanian children – and later improvements – strengthen the case for individualized care (2009). American Scientist, 97:222-229.

Whetten, K., J. Ostermann, R.A. Whetten, B.W. Pence, K. O’Donnell, L.C. Messer, N.M. Thielman, The Positive Outcomes for Orphans (POFO) Research Team. “A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6-12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations.” PLoS ONE. 4(12):e8169. 2009.
About the author
Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School, at the Cambridge Health Alliance, and on the Core Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston.

Click here to view the FAO’s policy brief, “Protecting Africa’s future: Livelihood-based social protection for orphans and vulnerable children (OVC) in east and southern Africa”

Here is a summary from the brief:

Despite the existence of noteworthy policy and investment in programmes aimed at responding to these children’s needs, too many programmes remain ill-equipped to cater for their needs in a sustainable and cost-effective way. This is partly as a result of gaps in OVC social protection policy and legislation.

Here are four recommendations offered by the FAO’s brief:

  • “Drafting stand alone social protection policies to fill these gaps.”
  • “Strengthening existing policy frameworks.”
  • “Livelihoods based social protection which refers to initiatives aimed at reducing vulnerability and providing social transfers to the poor.”
  • “Protecting the vulnerable against livelihood risks and enhancing the social status of the marginalised.”


Miracle Mountain: A Hidden Sanctuary for Children is a poignant, beautiful, and powerful video portrait of The Crossnore School, a self-proclaimed “modern-day orphanage” in a remote corner of the North Carolina mountains. The school takes in children from preschool to high school with numerous disadvantages caused by their dysfunctional biological families and by their multiple placements in the dysfunctional foster-care system. The school has one overriding goal, “to give children their childhoods back.” It seeks to produce miracles through the restoration of hope and healing by a staff with a sense of mission and unrivaled grounds and facilities.

The film (which lasts only a little more than seven minutes) is necessarily focused on one self-proclaimed “modern-day orphanage,” revealing the heart and soul of the school’s guiding childcare philosophy founded on common sense, as laid out by its head Phyllis Crain who succumbed to her eleven-year battle with cancer this past summer.  However, the film has a larger message that extends beyond the Crossnore campus.  To critics of orphanages who say, “well, children’s homes might might have worked in bygone eras, but they can’t work today,” the documentary short on Crossnore says loud and clear, “It can be done today, and is being done  in grand style.”

The video portrait was filmed and directed by James Pham (independent of The Crossnore School).

For more information, go to

Click here to watch Miracle Mountain.

This blog post was written by Richard McKenzie, the Walter B. Gerken Professor Emeritus of Enterprise and Society at The Paul Merage School of Business at the University of California, Irvine. Dr. McKenzie is also a member of the OVC Wellbeing Advisory Board and an alumnus of Barium Springs Home for Children where he grew up in the 1950s.

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