Category: Measures and Evaluations

Article Title: A Caregiver-Child Social/Emotional and Relationship Rating Scale (CCSERRS)

Authors: Robert B. McCall, Christina J. Groark, and Larry Fish


This paper reports the construction and pilot reliability, validity, and psychometric properties of a new caregiver-child rating scale that emphasizes caregiver-child social-emotional interactions and relationships. While the scale was developed and studied in the context of orphanages for young children, it potentially could be used in non-residential early care and education settings as well as for parent-child interactions in the home. The intent was to assess a few dimensions that comprehensively cover the range of caregiver-child social-emotional interactions and relationships but could be administered in a relatively short period of time in a variety of situations and would not require extensive coder training, manuals, or materials. Results showed that the scale can be reliably administered even using observation periods as short as five minutes, reliability was replicated over seven different coders working in three different orphanages, and ratings of caregivers were similar across different types of caregiving activities (i.e., feeding, dressing/bathing, free play) and for caregivers attending to children birth to 4 and 4 to 8 yrs. of age. In the orphanage context, factor analyses showed the scale primarily reflects caregiver-child mutual engagement and relationship with subordinate components of caregiver punitiveness and caregiver- vs. child-directed behaviors and intrusiveness.

Early social/emotional relationship experiences, especially warm, caring, sensitive, and responsive interactions between adults and their infants and young children, are crucial contributors to promoting attachment (e.g., DeWolff & van IJzendoorn, 1997van IJzendoorn & Sagi, 1999), which in turn is associated with longer-term positive child outcomes in social and mental development (e.g.,Aviezer, Sagi, Resnick, & Gini, 2002Landry, Smith, & Swank, 2006;Landry, Smith, Miller-Loncar, & Swank, 1997Landry, Smith, Swank, & Miller-Loncar, 2000Steelman, Assel, Swank, Smith, & Landry, 2002). Social/emotional relationship experiences have also been associated with the quality of early care and education environments, early childhood developmental gains, and longer-term educational success (e.g., Edwards & Raikes, 2002Kontos, Howes, Shinn, & Galinsky, 1995).

Conversely, insecure attachment, especially disorganized attachment, is related to increased later problem behaviors, including externalizing behaviors in males and other social, behavior control, crime, and mental health problems, more so in high-risk children and those who continue to experience insensitive parenting and/or child care (e.g., Carlson, 1998Fonagy et al., 1997;Greenberg, 1999Lyons-Ruth, Alpern, & Repacholi, 1993Rothbaum & Weisz, 1994Shaw, Owens, Vondra, Keenan, & Winslow, 1997).

More specifically, institutional rearing environments for young children tend to provide quite minimal social/emotional relationship experiences (e.g., St. Petersburg-USA Orphanage Research Team, 20052008Rosas & McCall, 2008), and perhaps as a partial consequence of this deprivation such children tend to be substantially underdeveloped and have higher rates of behavioral problems even after being adopted into advantaged families (Blizzard, 1990Gunnar, 2001Johnson, 2000MacLean, 2003St. Petersburg-USA Orphanage Research Team, 20052008). Further, interventions that emphasize improved early social/emotional relationship experiences in orphanages (St. Petersburg-USA Orphanage Research Team, 2008Zeanah, Smyke, & Koga, 2003), provide high-quality foster care instead of institutionalization (Nelson, Zeanah, Fox, Marshall, Smyke, & Guthrie, 2007), or promote responsiveness in parents towards their own infants (Landry et al., 2006) have produced improvements in children’s development in several domains.

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Study Title: International adoption: Implications for early intervention

Authors: Johnson DE, Dole K

Abstract: A total of 56 children adopted from Eastern Europe and the former Soviet Union were evaluated in 2 international adoption clinics. Preadoptive medical records were available for 47 of these children. Results: “Children had 1 month of linear growth lag for every five months in an orphanage. Developmental delays were also common (gross motor delays in 70% of children, fine motor in 82%, language in 59%, and social-emotional in 53%). Overall, children fell behind 1 month of linear growth for each 3.4 months in the orphanage. All children in this study lived in institutional care, either orphanages or hospitals. Avg. age was 28.3 months.

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Authors: Karen O’Donnell, Robert Murphy, Jan Ostermann, Max Masnick, Rachel A. Whetten, Elisabeth Madden, Nathan M. Thielman, Kathryn Whetten

10461Abstract: Assessment of children’s learning and performance in low and middle income countries has been critiqued as lacking a gold standard, an appropriate norm reference group, and demonstrated applicability of assessment tasks to the context. This study was designed to examine the performance of three nonverbal and one adapted verbal measure of children’s problem solving, memory, motivation, and attention across five culturally diverse sites. The goal was to evaluate the tests as indicators of individual differences affected by life events and care circumstances for vulnerable children. We conclude that the measures can be successfully employed with fidelity in non-standard settings in LMICs, and are associated with child age and educational experience across the settings. The tests can be useful in evaluating variability in vulnerable child outcomes.

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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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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.

Policy Implications:

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)


Study Title: Child Status Index (CSI)

Context: In past, programs for orphaned and vulnerable children (OVC) have been evaluated by reporting the numbers of children and the services that they received (outputs.) To measure more appropriately the needs of OVC and the effectiveness of the support these programs provide (outcomes), the President’s Emergency Plan for AIDS Relief (PEPFAR) requested a tool to assess vulnerabilities, needs, and outcomes of OVC. To fill this gap, the Child Status Index was developed to provide a framework for identifying a child’s needs, creating service plans, and assessing intervention outcomes.

Study aims: As it is currently designed, the Child Status Index provides an assessment strategy that addresses the areas of a child’s life that are most indicative of the child’s relative well-being or vulnerability in low- and middle-income countries (LMIC). The CSI was developed based on twelve child centered factors, including food security, growth and nutrition, abuse and exploitation, legal protection, wellness, healthcare services, emotional health, social behavior, performance, and education. These factors are rated on a high inference scale following interviews and specific observations in a home/community visit. Each factor is rated as “good”, “fair,”, “bad”, and “very bad” relative to local norms by community volunteers who work for local organizations and who may have varying degrees of literacy.

Methods: The development of the CSI involved a community participatory process that included community workers, OVC caregivers, and village leaders in Kenya and Tanzania. To derive the domains and the factors that comprise the CSI, researchers conducted a series of informal discussions with community workers, guardians, and other service providers in Kenya and Tanzania. The CSI was then successfully tested to ensure its reliability and validity, and it has been utilized in trials in other countries, such as Ethiopia, Rwanda, India and Cambodia to raise ongoing feedback about its applicability.

Policy Implications:

  • CSI results can be used for targeting children with needs and factors in which those needs appear, not by aggregating total scores, but rather by developing algorithms at a community level, such as: any score in the “very bad” range or more than a pre-specified number of scores in the “bad” range, and so forth. The targeting strategies are developed by community organizations depending on their funding priorities and resources.
  • The CSI is often used in case management for child and households cared for by community based organizations.
  • CSI information, when aggregated by factor, can inform program planning for identified organizations in a defined setting.
  • The CSI can help identify benefits children receive from services, preferably used in conjunction with other outcome measures.

Principal Investigator: Karen O’Donnell (Duke University)



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 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.

Policy Implications:

  1. 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)