The Fair Start Global Project

In project cooperation with the Social and Health Care College, Aarhus, Denmark, the Danish Psychologist Association, the European Psychologist Association, and the European Union, Leonardo Division, EU partner countries, institutional leaders and foster family managers from Crete, Italy, Romania, Spain and Turkey.Intro: This paper describes the development of the open source online caregiver and leader education www.fairstart.net/training and the Third World language versions being developed at www.fairstartglobal.com. The scientific network behind the program, how to use it for staff and foster family group training in attachment based care, examples of application and contact info.

The author’s intention is to transform research in children without parents to organizations (governments, NGOs, local decision makers), by offering global non-profit online education in as many languages as possible. The program today has some 50,000 users and will be available online in 29 languages in 2014.The higher purpose is to set global standards for professional orphan care and support the development of local professional care cultures.

Abbreviations

UN: United Nations. LEA: Leadership Equity Assessment. RAD: reactive attachment disorder. ADHD: attention deficit/ hyperactive disorder. IA: Institutional autism (behaviors similar to autism symptoms due to severe deprivation).

Background –why was the program designed?

The global orphan population amounts to 143,000,000 children being at high risk for deprivation and subsequent developmental delays in physical, personality and social development. Prior to placement this population probably has increased rates of genetic and pregnancy/ birth problems.

Their professional caregivers worldwide often receive little support from their governments, they have a low socio-economic status, and they lack access to education facilities. Institutions often work from outdated care concepts and from organizational principles harmful to child development. The aim of the ongoing project is to develop free science-based internet education programs for orphan institutions and foster families, aimed at improving care for especially young children in public custody.
Methods for program development

Establishing a joint scientist/ decision maker/ practitioner network to design and test free e-learning development programs in local languages in Europe. Recommend common educational standards as requested by the European Union. The program combines basic attachment theory, the influence of stimulation on brain development, social interaction training and group identity formation. The setup is short 2-3 hour workplace learning sessions, combined with practice and leadership development and video production of new participant local practices. Program participation should only require access to the internet and the use of a projector. A two-day training program for trainers is optional.

Results

Results indicate high program efficiency in advancing care-giving practices and organizational development. A two-year European project in 2008-10 involving orphanages and foster care organizations tested the program in five countries (Romania, Italy, Spain, Greece and Turkey), and the program was launched in English, German, Turkish, Spanish, Catalan, Greek and Turkish versions. Furthermore, a second EU project www.transfair-eu.com now spreads program use also in Bulgaria, Russia, Denmark, Poland and Latvia.

Conclusions

Results indicate improved child development and high motivation and involvement from users, indicating the relevance of further developing a global program version, www.fairstartglobal.com , aimed at 3rd World child care professional and foster family education programs.

Background – Children without parental care

The orphan population

According to UN reports 2004 (Children on the Brink) 143,000,000 children – equivalent to the total Russian population – are orphans. Parents are often alive (90%), but have no contact or parental function. The term “orphan” has several definitions: a child permanently bereaved of contact with and care from birth parents despite having living parents. In UN report terminology: one or both parents have died. The first definition is preferred in this text. (NB: only a fraction of orphans live in registered public custody).

In 2003 12.4 million lived in Latin America (stable), 87.6 million children were Asian (numbers decreasing due to increased wealth) while 43.4 million lived in Sub-Saharan Africa (numbers exploding due to AIDS and other events). Even though the percentage of orphan children has decreased in Asia, the absolute number of Asian orphan children is large due to the immense population size. China alone is estimated to have 100,000 orphanages.

Even in “rich” countries like the U.S.A., many children grow up at the bottom of society: 533,000 children were placed in foster care in 2003. Of these 116,000 were ready for adoption, but only 36,000 were in fact adopted, and they were usually below five years of age.

Orphan numbers in the US increased dramatically when crack (a malicious variant of heroine) suddenly flooded the market some years ago, disabling large numbers of parents. In Europe the estimate is 1,500,000 orphans, of which 46,000 children younger than three are placed in public custody. This number is increasing in spite of decreasing birth rates.

To these official statistics, an unknown number of non-registered children can be added. Regarding sex, 64 % of 3rd World orphans are girls, reflecting the low social status of girls in many societies. With respect to age, children are more likely to become orphans with increasing age: only 12 % of world orphans are aged five years or less, whereas 33 % are between six and eleven years, and 55 % are twelve to seventeen years.

Orphans and children placed outside home probably suffer from organic and genetic deficits more often than others although this area is poorly mapped (see Rygaard: psychopathic children: indicators of organic dysfunction), thus representing a challenge to staffs and foster parents.
The Fair Start e-learning program www.fairstart.net/training

Homepage site, handbook, roles, logistics, sessions design, contents and their theoretical rationale
Homepage and e-learning sites

Readers can use the program, for English please open www.fairstart.net/training and do not click any language flags – you are already in the English version. For all other languages, click the flag desired.

Handbook and professional work roles in the e-learning program

The e-learning site consists of a joint “handbook” (can be printed from the page as PDF) for the institution’s leader (or a foster family manager), and the person appointed by the leader as responsible for conducting staff sessions, the instructor. The instructor is responsible for conducting sessions and supporting staff/ foster families during the curriculum. The instructor can be a motivated and skilled staff member or an external person experienced in learning processes, such as a clinical psychologist or a school or university teacher. In small organizations, the leader/foster family manager may also take the instructor’s role; in large organizations a group of instructors can be in charge of a local staff group.

The handbook describes all joint tasks for leader and instructor, gives advice for ensuring staff motivation and conducting the tutorial sessions, how to use the homepage and digital equipment, and how to secure video recordings or written observations in ethically correct ways. This team design implies new kinds of cooperation since many leaders and staffs are not used to discussing and agreeing on practices. It is much based on supporting the development of dialogue-based leadership.

Logistics

The program is scheduled to be completed in one to two years, depending on local circumstances and care quality prior to program participation. It consists of 15 two-hour sessions performed at the workplace during working hours. Users may also decide to pick a set of sessions especially relevant for their training needs.

Prior to start, the leader applies the questionnaire “Secure Base Scorecard for Leaders”. This scorecard is a modified version of the Leadership Equity Assessment scale, linking product quality, user satisfaction and workplace milieu to the quality of social relations between staff members and relations between leader and staff. Background research by the Gallup Institute (2006) suggests close relations between degrees of efficient organizational performance and twelve aspects of social relations quality among staff/staff and staff/leader.

The scorecard purpose is to enable the leader in assessing the institutions readiness for education and decide three major co-operational improvement goals during the program. Also, the use of LEA in this program is based on the hypothesis that the quality of social relations between staff and children depend much on the quality of work relations between leader and staff and among staffs. If so, improving staff/ leader relations may improve caregiver/ child relations.

Simultaneously, the instructor(s) uses the “Secure Base Scorecard” to assess the qualities of daily child care practices regarding attachment possibilities, physical stimulation, staff/ child relations and social interaction between children. The degree of contact between staff/children and the local environment is also assessed. From this survey, the instructor decides three major goals for improving care practices during the program.

Leader and instructor present their organizational and care practice goals to each other and then present them to staffs in order to create ownership and awareness of focus points. At the end of the program, all parties evaluate progress from the original scorecards and goals by using them once more.

Sessions design
At the site, please click “sessions” and open the first one.

Each session is planned for two hours during work days conducted by the instructor in the workplace, and can be scheduled during extended staff meetings. The first part of a session describes in text and video what science recommends, in the second part of the session staffs and leader agree on how to practice until the next session.

In the second hour planning how to practice concepts is discussed and decided upon by leader, instructor and staff. Role responsibilities for practicing the methods are agreed upon. Practicing the new methods is recorded on video by staffs (the camera in a mobile phone is sufficient) until next session. Each consecutive session starts with an evaluation of success in the practical changes and reflections from work since the last session. The videos made by staff are reflected upon in the group. Any session can be repeated if necessary, and all texts are printable.

Session contents and their theoretical rationale

The content sequence works from ‘inside-out’, meaning that the first session focuses on staff member’s own childhood experiences, parental styles and personal experiences of loss and separation.

This is in order to let staff open up and understand the reactions of placed and traumatized children by recognizing separation reactions from their own lives. Also to understand that professional care-giver style stems from personal experience and is not only something to externally ‘learn’, rather something to become aware of and reflect on. This step is based on the attachment theory assumption that reflections on early experiences of attachment and loss can modify insecure care giver styles and promote secure attachment behavior (Dozier 1999, Bates 2004).
Present attachment research applies a transmission model of attachment patterns from parent to child, where the care-giver’s behavior reflects personal attachment concepts and causes the child to produce similar concepts and responsive behaviors (Berlin 2005). Attachment research has established a clear link between attachment patterns formed during the first years of parent/ child interactions and child behavior and development outcome. Based on Dozier and Juffer, basic attachment theory and secure care giver style is described and demonstrated in the following sessions, and the two professional aspects of practical care work combined with relations work is established.

In the sessions “The Hospital Model” and “Insecure attachment patterns in children placed outside home” the negative effects of depriving environments for brain development and social interaction behavior are demonstrated. Elements describe insecure attachment behaviors in children and relevant professional responses. Being able to respond to insecure behaviors is important since it is a challenging task to work with children where many have been exposed to aberrant parenting, maltreatment, abuse and deprivation. A considerable part of children (especially children older than 12 months prior to placement) can be expected to have developed abnormal responses to care. Training in this respect is inspired by Dozier (2002 a & b, 2004, 2006) Juffer (2008, 2009) and this author (Rygaard 2006).

One effect of deprivation seems to be lowered levels of brain activity, which probably account also for growth and brain development problems (Chugani 2001, Marshall 2004). In “Care giver style and brain development in babies and toddlers”, physical stimulation practices are demonstrated such as using hammocks or cradles instead of fixed beds, taking up children and interacting while feeding, giving baby massage, using the floor for group stimulation practices and interaction. This section relies on results from Zeanah (2002, 2005), Rutter (1998,1999), Hoksbergen and Rijk (2008) (Smyke 2002) and others concerning the effects of early deprivation.

Having concluded these sessions, staffs, leader and instructor evaluate half-way program progress and discuss cooperation adjustments and improvements.

In the following sessions more demanding organizational changes and issues are addressed. The “Secure Base Model” principles for group care is demonstrated and thoroughly discussed between staffs and leader. Work plans and schedules are negotiated and revised in order to provide small social units where children have continuous caregivers during the daytime for long periods, and the caregiver group becomes responsible for the development of social relations in a specific group of children. Restructuring work plans for relations continuity is opposed to many legal and other regulations where work shifts cause the children to experience random and superficial care giver contacts (one known factor in RAD development). The basic objective is to offer all children one adult with whom they can have a long-term relation and a peer group to give them a sense of belonging (Gauthier 2004, Vorria 2006 a & b).

In sessions 10-12 staffs plan activities for supporting children’s personal and group identity development, use practices for organizing long term peer relations, identify common learning problems following early deprivation and traumas, and suggest activities for supporting learning faculties and school performance preparation in daily activities. Breaking down social and physical barriers between placement and local society, and giving the children a social identity outside the institution completes the section on social development methods. Helping children to become active and visible members of local society is a means of facilitating integration after institutionalization. This section is inspired by group development psychologists and philosophers such as Kurt Lewin (1943), Foucault (1995), the London Tavistock tradition, William Schutz’ group development theory (1963), and others. The purpose is to inspire the organization to move from institutional orphanage/hospital concepts to open minded social institutions offering opportunities for positive social identity development and participation in society life.

In the two final sessions the participants repeat Scorecard evaluations for comparison with the original scorecards and first videos produced, assess results and plan for further development. Designs are suggested for the formation of extending professional local networks for care-givers and leaders in order to minimize eventual isolation and shame issues. This networking process is important since isolated social units have a higher frequency of sexual abuse and violence than units tending to interact much with other groups (Rygaard 1999).

Basic assumptions for orphan care-giver education projects

Having worked for 25 years as a psychologist, educator and researcher specialized in deprivation and attachment problems in orphans, adoptees and juvenile delinquents, the author wrote a book on the subject (Severe Attachment Disorder in Childhood), leading to visits to universities, orphanages and foster families globally 2005 – 2006. This overview produced some basic assumptions concerning the requisites for effective education programs for care-givers:

– The most important age span for effective intervention is from birth to age three. Many funded programs incorporate children from school age and up, but the most important neurological, personal and social foundations for later life depend on pregnancy and birth impacts and care quality during pre-school age. Interventions should target the preschool age span, as does the “Zero to three” (Graham 2003) and a number other intervention programs. The relevance of targeting this age span is well documented in deprivation literature.
– While cultural differences play a major role in child development and upbringing practices, there are many universal traits in early child care as demonstrated by Bowlby, Ainsworth and child neurology development studies. Programs should emphasize early care-giver attachment behavior competences, physical stimulation competences and social relations training competences.
– The target group for improving child care is front staffs and their daily managers in orphanages and foster families. These professional groups are often underpaid, have low socio-economic status and little access to professional education concerning care for babies and toddlers. Institutions and families are often isolated from society in general. Programs must support the formation of professional self-esteem, identity and practice, and if possible increase care-giver status in society.
– The trend in placement strategies favours foster families (Browne 2006, Johnson 2006). Since Rutter published studies comparing outcomes of institutionalization with adoption into families for Romanian children, this country has moved 90 % of institutionalized children into foster families (NAPCR 2006). While Rutter’s general conclusion – children thrive much better in foster families – is well documented, two problems remain unresolved: what to do with the large number of children who are and will be in institutions in the future in many countries, and how to educate and manage care quality in foster families that live spread over the country.
Romania now struggles to cope with the latter problems. Periods of drug flooding and sudden migration also tend to overwhelm social systems, forcing the use of institutional placement through lack of foster families as seen in the US when crack was introduced. Foster and adoptive families also experience major problems in containing children with severe handicaps, brain injury, RAD, ADHD and IA (O’Connor 1999, Rutter 1999). A program must embrace both institution and foster family care settings.
– Programs should not be limited to specific geographic areas, ideologies, institutions or periods. Many intervention and research programs start due to dramatic media exposure causing their instigation, but scientists and the public often lose interest after a while. Countless numbers of official and NGO organizations work without much coordination. However, the orphan problem seems to persist in time and space and requires a general long-term persisting intervention strategy.
– In many countries scientists, decision-makers and practitioners live in separate sub-cultural groups, a circumstance preventing the transmission of researched child care knowledge into daily practices. Developing an orphanage or a foster family unit’s modus operandi is not only an educational, but also a delicate cultural, religious, political and organizational challenge. An intervention program must equally involve the three groups in cooperation.
– Furthermore, a program should not ‘teach the ignorant’ in a top-down design, but involve participants, create resource awareness, and inspire users to design their own local models of improvements in child care, based on common principles for quality care. Participants should be co-developers of local program versions and organizational designs in order to secure the sense of ownership and self-development processes.
– Program participation must not stress user budgets more than absolutely necessary and should be free and highly accessible. This calls for quality rather than quantity improvements in daily practices, and e-learning versions on the internet in for local language versions. Since many child care staffs are unfamiliar with texts (some are illiterate), the video demonstrations of practices are essential. Programs should be practical, simple and hands-on, requiring that participants learn at the workplace and immediately start practicing and designing recommended elements. Producing videos for supervision and reflection further enhance implementation.
Using Denmark as a project base has some advantages: a small insignificant country is unlikely to be suspected of imperialistic intentions by users. Also, Denmark experienced massive migration of mothers into the workforce in the 1960s, which has created a large professional community producing knowledge in the field of baby and child care in institutional settings, day care and foster family management. A number of Danish child development and organizational leadership professionals have generously contributed to the program presented below.

A problem in designing early life professional care-giving is that most attachment research focuses on family or adoptive family settings, whereas minor attention has been given to professional settings where babies and toddlers are reared in groups by non-relatives, although this is the case for many children using public institutions or day care, children placed outside home, kibbutz children (Sagi -Schwartz 2005) and other group constructions. And – as pointed out by Groark, McCall and others (2005) – the exact qualities and variables of orphanage (and foster family) environments and their respective impacts on child development have not been described, isolated, and related to specific outcomes. This lends some uncertainty to terms such as ‘quality care’ and ‘positive interventions’. Practices recommended should therefore be based on a survey of orphan intervention research.

Orphan research has mainly been triggered by developmental problems in children adopted from orphanages, and recent studies of Eastern Europe orphanages following the decline of communist regimes.

Agents in the project – the project organization of FairStart

The basic assumptions mentioned were presented in 2006 to the Danish Psychologist Association, the Social and Health Care College in Aarhus (experienced in training staffs via e-media) and the Danish State Adoption Council. This resulted in the formation of a project group applying for an EU Leonardo Division grant of 200,000 Euro for a project period 2008-10. The grant purpose is based on a seven-step plan to develop, test and recommend future standards for educating people working in the EU with young children placed outside home. Partner countries testing the program design are Romania, Spain, Italy, Turkey and Crete. Swiss and Austrian partners from educating organizations contribute to program development and quality norm development.

Today the project group consists of a Danish project management group including the author, the EU country partners and their affiliated child institution and foster family leaders, a media production group, a quality norm group and local focus groups.

Institutional and foster family leaders have participated in a 4 + 2 day training in Denmark and have subsequently worked with program introduction in their respective organizations, giving valuable feedback on designs. At the same time the EU partners work to expand and disseminate the program politically and scientifically in their countries. In a concluding conference in September 2010, participants agreed on project recommendations for EU educational standards for professionals attending orphans and children placed in public custody.

Results

Participant’s evaluation and future developments

Participants report from testing sessions a high degree of staff engagement and find the material to be comprehensive and useful and improving the understanding of theory and tasks in professional role performance. The program elements are described as versatile and some have been used in public kindergartens and youth facilities. Some institution leaders report problems in maintaining new practices and a tendency to return to former routines. However, no institutions or foster family managers have yet completed more than three sessions. The project group and partners have applied for a second project to assess effects and diversify programs.

Examples from feedback:

Bulgaria: “This training session taught us to organize our work and to create an environment where we do not run around for the work and together with the children feel comfortable.”

Turkey: “This made us much more professional. We became a big family with our kids. The staff was like invisible before.”

Indonesia : “Babies’ reluctance for leaving us was causing stress on us. It was so difficult to stay positive while performing tiring work during their constant crying in order to be hugged. In this training, I noticed that this was our fault. As we changed, they started to be able to stay away from us and play and even to feel happy with this situation.”

Further scientific networking

The author is currently cooperating with researchers Robert McCall and Christine Groark from the Child Office unit at Pittsburgh University. This has spurred the preparation of a special issue of Infant Mental Health Journal and researchers from many countries are describing how their research is passed on to political systems and practical education/ intervention programs. The Danish Society for Intercultural Psychology is cooperating about program use, and pedagogue students have been trained in Denmark before their practice period in Third World countries. Negotiations have been undertaken to create an international master in pedagogic organizational development in cooperation between the author, VIAUniversity Denmark and a number of universities.
The program is now recognized and spread by the European Psychologist Association, the Danish Psychologist Association, the Adoption Board under the Danish Ministry of Welfare, and the following researchers have contributed to the further development of the program: Dr. René Hoksbergen & Katharina Rijk Un. of Tilburg & University of Utrecht the Netherlands, Faculty of Adoption studies. Pr. Rukhsana Kausar, Un. Of Punjab, Lahore. Charles Zeanah of Tulane University, U.S.A. (who conducted the Bucharest Intervention Study when moving children from ‘hospital’ orphanages to foster care families), Kamikado Kazuhiro Un. Of Nagano Japan, C. Hamilton-Giachritsis, Psychology at Birmingham Un., Robert McCall & Christine Groark, University of Pittsburgh, Office of Child Development. Mary Dozier, Delaware Un. (foster family attachment studies and training), Annika Melinder, Child Psychology Department, Un. of Oslo. Sheyla Blumen, Psychology Dpt. Of Universidad Pontifica Catolica in Lima, Peru, Jorge Barudy and Maryorie Dantagnan from Spain/ Chile (children exposed to violence), Michael Rutter group, Femmie Juffer, van Ijzendoorn, Dr. Ed Tronick, Boston, & many others.
Practical applications are: The program is now used in 12 EU countries by various child care organizations and government agencies. In the Third World, the program is used by Adoption Center Denmark for training orphanage staffs. In Indonesia a local language version is now government standard for all staffs in the 8000 Indonesian orphanages. The Spanish version of the program has been applied in Santiago de Chile and Peru.

Contact information

Readers interested in using the program can contact the author at npr@attachment.dk . Info video and other materials are available at www.fairstartgobal.com . At request, readers can be added to the newsletter list. For author CV and book, please see www.attachment-disorder.net .

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Niels Peter Rygaard is a clinical psychologist, private practitioner and program author in Denmark.

This article was first published in: Child and Youth Care Practice Vol 24 Issue 3 fall 2011, and thanks are due for permission to reprint.

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