Title: Family reunification
Author: Fred Wulczyn
Abstract: Reunifying children placed in foster care with their birth parents is a primary goal of the child welfare system. Yet, relatively little is known about the reunification process. This article analyzes new data on trends in family reunification and discovers: Although most children still exit foster care through family reunification, exit patterns have changed over the last 8 years. Currently, reunification takes longer to happen, whereas adoptions happen earlier. A child’s age and race are associated with the likelihood that he or she will be reunified. Infants and adolescents are less likely to be reunified than children in other age groups, and African-American children are less likely to be reunified than children of other racial/ethnic backgrounds. Although many children who are reunified exit the system within a relatively short period of time, reunifications often do not succeed. Nearly 30% of children who were reunified in 1990 reentered foster care within 10 years. The principle of family reunification is deeply rooted in American law and tradition, and reunification is likely to continue as the most common way children exit foster care. Thus, greater efforts should be made to ensure that reunifications are safe and lasting. The article closes with a discussion of changes in policy and practice that hold promise for improving the safety and stability of reunified families, such as instituting better measures of state performance, and continuing to provide monitoring and supports for families after a child is returned home.
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Study Title: School support as structural HIV prevention for adolescent orphans in Western Kenya
Context: The HIV/AIDS pandemic has led to illness and early death for millions of adults, and this, in turn, has left many millions of orphans in sub-Saharan Africa. In Kenya, alone, there are more than 2.4 million orphans who are at great risk for school dropout, early sexual debut, and HIV infection. Approaching the fourth decade of the AIDS epidemic, many in the field have called for a paradigm shift in HIV prevention, to address structural, as well as individual-level, factors.
Study Aims: This study examines the impact of school support as a structural intervention, tested among adolescent Luo orphans in Nyanza Province, Kenya. The Luos have the highest HIV prevalence and largest orphan prevalence of all ethnic groups in the country. The study uses a rigorous randomized controlled trial design to test whether school support can retain adolescent orphans in school through the transition to high school, delay sexual debut, and reduce the likelihood of HIV and herpes simplex virus type 2 (HSV-2) infections. Specific aims for the proposed study are: 1) To experimentally test whether providing comprehensive school support to Luo orphaned boys and girls will reduce school dropout, reduce sexual risk behaviors, and prevent HIV/HSV-2 infection; 2) To conduct a process evaluation of the implementation of the program; and 3) To conduct comparative cost effectiveness analyses, specifying the intervention’s cost and return on investment as evidenced by cost per unit improvement in the primary outcomes of school enrollment, delay of sexual debut and prevention of risk behaviors and HIV/HSV-2 infection, as well as by gains in health- related quality of life.
Methods: The design randomizes 24 primary schools to intervention or control condition. All youth in grades 7 and 8 who have lost one or both parents, regardless of cause of death, will be invited to participate; the total number of participants to be recruited into the study is approximately 840 students, 420 in each condition. Youth in intervention schools will receive five years of school support, including tuition, fees, uniforms, and a school-based adult “helper.” Data will comprise annual ACASI surveys, school data (attendance, grades), and HIV/HSV-2 bio-specimens. Analyses will test posited mediators and gender moderation in causal pathways and program effects. Cost effectiveness analyses will add much needed policy-relevant information.
Public Health Relevance: Although millions of children have been orphaned as a result of the AIDS pandemic, few studies have considered the particular vulnerability of young orphaned adolescents for school dropout, risky sexual behaviors, and HIV infection. The Luo people of Nyanza Province have the highest proportion of orphans, highest HIV prevalence, and earliest sexual debut among all ethnic groups in Kenya. This structural intervention trial uses a strong conceptual framework and rigorous experimental design to test whether school support can keep adolescent Luo orphans in school, reduce sexual risk behaviors, and prevent HIV /HSV-2 infection. Process evaluation and cost effectiveness analyses add further relevance for policy development.
Principal Investigator: Hyunsan Cho (Pacific Institute for Research and Evaluation)
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Study Title: A family-based economic empowerment model for orphaned children in Uganda
Study Aims: The overall goal of this R34 is to further develop and examine a family economic empowerment intervention, called SUUBI-MAKA, that creates economic opportunities for families in Uganda who are caring for children orphaned due to the AIDS pandemic, and to lay the groundwork for an R01. The study has two specific aims: (1) To conduct formative work in order to understand children and families’ ability and interest in participating in a family-level economic empowerment intervention focused on savings and family income generation, and their response to this family-focused economic empowerment approach alongside additional intervention components, including savings for youth education and adult mentorship. (2) Based on formative data (Aim #1), to adapt the intervention and examine issues related to feasibility and preliminary outcome on a small scale in order to prepare for a larger study. The intervention, SUUBI-MAKA, uses a novel approach by focusing on economic empowerment of families caring for children orphaned due to AIDS. The intervention has three key components: (1) it promotes family-level income generating projects (micro-enterprises) which we believe will enhance economic stability, reduce poverty, and enhance protective family processes for youth orphaned by AIDS. (2) It promotes monetary savings for educational opportunities for AIDS-orphaned children. (3) It provides an adult mentor to children.
Methods: The intervention will be evaluated via a two-group randomized trial. The two groups are: SUUBI-MAKA or Usual care for orphaned children. The participating children will be nested within 20 primary schools that will be randomly assigned such that all children from a particular school receive the same intervention. There will be three assessment points: baseline (pre-test), 12-month, and 24-month post-intervention. The effectiveness of SUUBI-MAKA will be compared with the Usual care on: children’ educational experience, psychosocial development, sexual risk taking, and mental health, caregiver’s attitudes and capacities, and family and caregiving relationships.
Principal Investigator: Fred Ssewamala (Columbia University)
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Study Title: Cognitive and Psychosocial Benefit of caregiver training for Ugandan HIV children
Context: 110,000 Ugandan HIV children and 1 million non-infected AIDS orphans will have poor or inconsistent caregiving because one or both parents are ill or dead from AIDS (UNAIDS 2006). Consequently, the cognitive and social development of these children may be stunted in early childhood, and eventually they will perform more poorly in school. Mediational intervention for sensitizing caregivers (MISC) has a structured curriculum and training program to teach HIV mothers/caregivers the skills for enhancing their child’s cognitive and social development in the home each day. This is done by teaching mothers/caregivers how to focus a child’s attention, excite a child’s interest, expand her cognitive awareness, encourage her sense of competence, and regulate behavior during play, feeding, bathing and working.
Study Aims: To adapt MISC to the Ugandan context and demonstrate its effectiveness for enhancing the cognitive and social development of HIV children and orphans, we will use a four-part protocol for evaluating parent training programs: context evaluation, input evaluation, process evaluation, and product evaluation (CIPP Model of Evaluation). Study Aim 1 is the context evaluation of MISC through the use of focus groups of local community leaders, teachers, and caregivers, partnering with us to adapt MISC to the Ugandan context. Study Aim 2 involves the input evaluation of appropriateness and acceptability of MISC training for the caregivers and household through interviews and training compliance. Study Aim 3 is the process evaluation of the fidelity of intervention though home observation and evaluation of HOME quality, and videotape evaluation of caregiving interactions between mother/caregiver and child, as well as changes in the caregivers own attitudes and approach throughout the year-long training period. Study Aim 4 evaluates the product or benefit of the MISC training; in terms of the child’s gains on the Mullen Scales of Early Learning, the Early Childhood Vigilance Test (ECVT) of attention, the Color-Object Association Test (COAT) for memory, and the Child Behavior Checklist (CBCL) for psychosocial adjustment.
Methods: Mothers/caregivers of half of 120 HIV-infected and 120 non-infected preschool AIDS orphans in Kayunga District, Uganda, will be assigned to monthly home-based MISC training for one year. The remaining children and caregivers will continue to receive the regular monthly home health care visits. MISC for both the HIV infected and non-infected orphans will lead to greater gains on the Mullen learning, ECVT attention, and COAT memory scores compared to non- intervention children. These gains will be mediated by improved scores on monthly videotaped caregiving samples evaluated for MISC features, HOME scale quality of home environment, and child/caregiver quality interactions (CCQI) scores from home-based observations. These gains will be moderated by clinical stability of the HIV children.
Implications: Establishing the feasibility and effectiveness of MISC caregiving training will provide a strategic and sustainable means of cognitive enhancement for millions of HIV-affected children in resource-poor settings. Beyond the direct neurodevelopmental impact of pediatric HIV infection, the public health burden of HIV disease for tens of millions of HIV orphans globally is monumental when considering how it further compromises quality of home environment and caregiving for children already impoverished. In the African context, home-based caregiver training interventions to enhance the developmental milieu of HIV-affected children may be the single most developmentally strategic, culturally relevant, and resource sustainable means of buffering them from this impact of HIV disease. More broadly, caregiver training interventions may also enhance the cognitive ability and psychosocial adjustment of all children at risk from poverty and other public health challenges to the second of the UN Millennium Development Goals, which is to ensure that all children are able to complete primary schooling.
Principal Investigator: Michael Joseph Boivin (Michigan State University)
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Study Title: Trauma-Focused Cognitive Behavioral Therapy for Adjudicated Youth in Residential Treatment
Context: Adjudicated youth have high rates of trauma exposure and Stress Disorder (PTSD) which place them at increased risk for future offending and incarceration. Few of these youth receive evidence-based developmentally appropriate PTSD treatment.
Study Aims: Adjudicated youth have high rates of trauma exposure and Posttraumatic Stress Disorder (PTSD) but most have never received effective treatment. The purpose of this study is to test two alternative methods for training therapists to deliver an evidence- based trauma treatment to adjudicated youth with PTSD symptoms during residential treatment and therefore decrease their risk of future offending and incarceration
Methods: This study proposes to evaluate two alternative strategies for training therapists to deliver a proven youth trauma treatment, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to adjudicated youth in ten juvenile justice RTF programs in New England. All RTF programs will receive organizational readiness consisting of 1) novel integrated trauma training for RTF staff (direct care milieu staff, teachers and administrators) about trauma impact and how to support TF-CBT implementation in the RTF; and 2) PTSD assessment training for therapists. Randomization will then occur within each RTF program at the therapist level, to one of two TF-CBT delivery strategies: 1) Web-based TF-CBT Delivery (“W”) in which therapists will receive web-based training and web-based consultation via the TF-CBTWeb and TF-CBTConsult distance learning programs; or 2) W+ Live (“W+L”) in which therapists will receive W+ face-to-face 2-day expert TF-CBT training and ongoing twice monthly expert phone consultation and training to TF-CBT fidelity standards via audiotape rating. The study’s central hypothesis is that W+L will lead to superior outcomes. However, based on cost- effectiveness analyses, W may be acceptable. The study will evaluate the differences in outcomes between the two strategies in terms of the following hypotheses: 1) fidelity: W+L strategy will lead to greater treatment fidelity and to youth receiving greater RTF staff support in TF-CBT delivery than W; several mechanisms are proposed for these differences; 2) improved youth outcomes: W+L will lead to greater improvement in youth PTSD and depressive symptoms than W; and 3) broad and sustained TF-CBT uptake: more youth will receive TF-CBT from W+L than from W therapists; 4) cost effectiveness: W may be acceptable due to cost effectiveness analyses.
Principal Investigator: Judith Cohen (Allegheny General Hospital)
Title: Depressive symptoms in youth heads of household in Rwanda – Correlates and implications for intervention
Authors: Neil Boris, Lisanne Brown, Tonya Thurman, Janet Rice, Leslie Snider, Joseph Ntaganira, Laetitia Nyirazinyoye
Abstract: Objective: To examine the level of depressive symptoms and their predictors in youth from one region of Rwanda who function as heads of household (ie, those responsible for caring for other children) and care for younger orphans. Design: Cross-sectional survey Setting: Four adjoining districts in Gigonkoro, an impoverished rural province in southwestern Rwanda. Participants: Trained interviewers met with the eldest member of each household (n=539) in which a youth 24 years old or younger was caring for 1 child or more. Main Exposure: Serving as a youth head of household. Main Outcome Measures: Rates and severity of depressive symptoms using the Center for Epidemiologic Studies Depression scale; measures of grief, adult support, social marginalization, and sociodemographic factors using scales developed for this study. Results: Of the 539 youth heads of household, 77% were subsistence farmers and only 7% had attended school for 6 years or more. Almost half (44%) reported eating only 1 meal a day in the last week, and 80% rated their health as fair or poor. The mean score on the Center for Epidemiologic Studies Depression scale was 24.4, exceeding the most conservative published cutoff score for adolescents. Multivariate analysis revealed that reports of depressive symptoms that exceeded the clinical cutoff were associated with having 3 basic household assets or fewer, such as a mattress and a spare set of clothes (odds ratio [OR], 1.69; 95% confidence inter-vat [CI], 1.06-2.70), eating less than 1 meal per day (OR, 1.68; 95% CI, 1.092.60), reporting fair health (OR, 1.32; 95% CI, 0.762.29) or poor health (OR, 2.33; 95% CI, 1.17-4.64), endorsing high levels of grief (OR, 2.67; 95% CI, 1.734.13), having at least 1 parent die in the genocide as opposed to all other causes of parental death (OR, 1.83; 95% CI, 1.10-3.04), and not having a close friend (OR, 1.91; 95% CI, 1.1.7-3.1.2). There was an interaction between marginalization from the community and alcohol use; youth who were highly marginalized and did not drink alcohol were more than 3 times more likely to report symptoms of depression (OR, 3.07-1 95% CI, 1.73-5.42). When models were constructed by grouping theoretically related variables into blocks and controlling for other blocks, the emotional status block of variables (grief and marginalization) accounted for the most variance in depressive symptoms. Conclusions: Orphaned youth who head households in rural Rwanda face many challenges and report high rates of depressive symptoms. Interventions designed to go beyond improving food security and increasing household assets may be needed to reduce social isolation of youth heads of household. The effect of head-of-household depressive symptoms on other children living in youth-headed households is unknown.
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Title: Malawi Orphans and Vulnerable Children Evaluation (MOVE)
Context: Between 700,000 and 1.2 million children in Malawi have been orphaned by AIDS, and many others are vulnerable. The Funders’ Collaborative for Children (FCFC), a novel collaboration between 4 independent funding organizations, is funding an intervention that aims to establish a collaborative, replicable, and sustainable model of prevention, treatment, and care which will result in a “system of care” better able to support children and their families than the currently fragmented organization of agencies and groups. The program is implemented in Salima District, Malawi, by Family Health International (FHI) in collaboration with XXX implementing partner organizations. Duke University and Malawi’s College of Medicine were contracted to jointly evaluate the effectiveness of the 5-year program. MOVE assesses the impact of the intervention on child outcomes in four domains: health; education; social welfare; and nutrition and livelihood.
Study Aims: The FCFC intervention aims to improve the lives of 65 percent of vulnerable children in Salima District in terms of their education, health, livelihood, and social welfare. Researchers at Duke University and the College of Medicine will determine if the Funder’s Collaborative for Children achieved its objective.
Methods: The effectiveness of this intervention model is evaluated using qualitative and quantitative monitoring and evaluation methods. Repeated cross-sectional cluster surveys with a total of 1,260 vulnerable children and their caregivers assess district-level intervention coverage and changes in outcomes over time. Repeat assessments with 200 of these children, half in intervention areas and half in non-intervention areas seek to attribute changes to the program. Twice-annual surveys with implementing partners assess changes in scale and scope of service delivery.
This evaluation will determine if the FCFC intervention is effective in improving the wellbeing of orphans and other vulnerable children in Salima District, Malawi. If the evaluation demonstrates that the intervention is effective, it will help funders and national policymakers design more integrated and more effective care systems for orphans and vulnerable children.
Investigators: Karen O’Donnell (Duke University) Jan Ostermann (Duke University), Eric Umar (College of Medicine, Malawi), Kathryn Whetten (Duke University), Sara Legrand (Duke University)
Funding Source: Funders’ Collaborative for Children (Children’s Investment Fund Foundation, Comic Relief, Elton John AIDS Foundation and the Diana Princess of Wales Memorial Fund)
Contact: [email protected]
Study Title: Cambodia Orphan Project Evaluation
Context: Save the Children Australia has established support services for more than 9,500 children in Cambodia, providing food, health services, educational support, shelter, psychosocial counseling and livelihood training to orphans in need. A unique feature of this program, funded by the Elton John AIDS Foundation, is that services are delivered through monks living in pagodas. Our role is to evaluate the effectiveness of this program.
Study Aims: This study evaluates the monk-led intervention by comparing orphans receiving their services with orphans not receiving any care and orphans who participated in the Positive Outcomes for Orphans study (POFO – see pofostudy.org for more information).
Methods: Over a three year period researchers are collecting quantitative and qualitative data from 200 orphans and caregivers in Siem Reap and Prey Veng who are receiving services and a total of 100 orphans and caregivers not receiving services in Siem Reap and Prey Veng to account for regional differences in care.
- If the monk-led intervention is shown to be effective, it will provide a model of care for children who are orphaned or abandoned in the region.
M-Principal Investigators: Sarah LeGrand (Duke University), Vanroth Vann (Homeland, Cambodia), Kathryn Whetten (Duke University)
Investigator: Jan Ostermann (Duke University)
Contact: [email protected]
Study Title: Positive Outcomes for Orphans (POFO): Longitudinal study of orphaned and abandoned children (OAC) from ages 6-12 to ages 15-21 living in 6 diverse settings
Context: International policymakers are struggling to find solutions for the estimated 153 million children worldwide who have had at least one parent die, largely due to high mortality rates from conditions such as malaria, tuberculosis, HIV/AIDS and pregnancy complications. Millions more do not know the whereabouts of their parents. In light of the large presence of orphaned and abandoned children, especially in low- and middle-income countries continued research is needed that allows policy makers and providers to understand and develop locally feasible and appropriate ways to care for the children.
Study Aims: Positive Outcomes for Orphans (POFO) is longitudinal study conducted in five countries over a period of 9-10 years thanks to 2 consecutive National Institutes of Child Health and Development (NICHD) funded studies. OAC were ages 6-12 at baseline and will be ages 15-21 at the conclusion of the study. This unique population-based study is the only one of its kind that follows orphaned and abandoned children (OAC) for up to 9 years in culturally and structurally diverse settings allowing for a glimpse into what current care options are and the effects of that care and other life events over time on: health, cognition, emotion, educational attainment, labor force participation (including forced labor), sexual risk taking, marital patterns and community engagement.
Methods: OAC ages 6-12 and living in family settings were recruited from six diverse study areas in five countries: Addis Ababa (Ethiopia), Bungoma District (Kenya), Kilimanjaro Region (Tanzania), Battambang District (Cambodia), and Hyderabad and Nagaland (India) (N=1480). The sampling strategy involved the selection of 50 sampling areas (‘‘clusters’’) at each site and five OAC from each cluster. From comprehensive lists of residential facilities in study area, 83 facilities were randomly selected for including in the study with 1,357 OAC then randomly selected from lists of children of the appropriate age from each facility. Baseline assessments were collected for children and caregivers being in May 2006: enrollment continued for 22 months. OAC were defined as children who had at least one parent die or who were abandoned by both parents. In households with multiple eligible children, one child was selected as the child whose first name started with the earliest letter in the alphabet. Interviews with children’s self-identified primary caregivers were conducted in their respective native language in the child’s residence. Six-month follow-up assessments were conducted in 5 of the 6 study sites and 12-months follow-up assessments in all sites. Interview windows for follow-up assessments were open from one month prior to two months after the scheduled follow-up date.
- The study seeks to determine which environmental characteristics (e.g. home, community, culture, social networks, etc.) promote positive and negative outcomes for OAC as they transition through to young adulthood. With this knowledge, more appropriate local, national and international policies can be created for this age group and appropriate care options can be more actively supported.
- The study will seek to examine how personal factors, including life events, (e.g. number of potentially traumatic events experienced, emotional health, and cognitive development) affect orphans and identify potential interventions that could improve outcomes for the adult lives of orphans.
Principal Investigator: Kathryn Whetten (Duke University)
Investigators: Bernard Agala (Duke University), Cyrilla Amanya (ACE Africa, Kenya), Misganaw Eticha (SVO Ethiopia), Amy Hobbie (Duke University), Dafrosa Itemba (TAWREF, Tanzania), Rachel Manongi (KCMC, Tanzania), Lynne Messer (Duke University), (KCMC, Tanzania), Karen O’Donnell (Duke University), Jan Ostermann (Duke University), Brian Pence (Duke University), Nathan Thielman (Duke University), Vanroth Vann (Homeland, Cambodia), Augustine Wasonga (ACE Africa, Kenya), Rachel Whetten (Duke University)
Contact Information: [email protected]