Introduction
For the purposes of this paper, vulnerable children are those who often have a history of traumatic experiences that range from witnessing parental conflict, to sustaining violent losses, and/or dealing with indescribable physical, sexual and emotional abuse, and neglect. Nearly 180 million children in India (Maitra, Chakrabarti, Bhaskar, Pratap, & Shanthi, Reference Maitra, Chakrabarti, Bhaskar, Pratap and Shanthi2012) fall within the ‘vulnerable’ category, therefore requiring special protection according to the Juvenile Justice (Care and Protection of Children) Amendment Act 2000 (as amended in 2006) (National Institute of Public Cooperation and Child Development, 2012, p. 9) and via the Integrated Child Protection Scheme of the Government of India. These attempts make provisions for the rehabilitation and reintegration of children through sponsorship, foster-care, adoption and after-care, with emphasis an on Child Care Institutions (CCIs) as the last resort. However, due to lack of public awareness and governmental backing, alternative systems are not explored fully, increasing the proliferation of CCIs, many of which are not housed within the purview of Juvenile Justice System regulations.
According to Bruskas (Reference Bruskas2008), children are the most vulnerable group in society as they are dependent on adults, have the least power because of this and, therefore, minimal control over their lives and destinies. In other circumstances, some children are marginalised and neglected more so than their counterparts due to socio-economic, cultural and traumatic circumstances. These children are additionally referred to as children in need of care and protection (CNCP). More often than not, in India, children classified as CNCP find their way into institutionalised settings.
Brief Background: Children in Institutions
According to UNICEF (2010, 2013), many children worldwide lose one or both their parents due to conflict, natural disasters, poverty, disability and HIV/AIDS. Children without parental care are at a highest risk of abuse, exploitation and neglect. In India, large numbers of children end up in institutional care and approximately 80 per cent have at least one living parent. Surprisingly, numerous children are institutionalised with the consent of their parents who might be struggling with poverty or illness, or social stigma as a result of their ethnicity, disability, HIV/AIDS status, or gender (girls specifically). Thus, the children who enter institutionalised settings are those who have been through a multitude of losses and suffered great abuses. They frequently display maladaptive behaviours, with a prominence of attachment disorders (Dowdell & Cavanaugh, Reference Dowdell and Cavanaugh2009; Dozier, Zeanah, Wallin, & Shauffer, Reference Dozier, Zeanah, Wallin and Shauffer2011; The St. Petersburg Orphanage Research Team, 2008). Around the world, institutionalised children suffer from inadequate care and attention and often considerable danger (The St. Petersburg Orphanage Research Team, 2008). According to Morgan (Reference Morgan2004), this can further impair such children socially and emotionally. Most orphanages do not have enough staff, let alone trained staff, to provide children with the affection, attention or stimuli that they need to maintain adequate development (Dozier et al., Reference Dozier, Zeanah, Wallin and Shauffer2011). Furthermore, the World Health Organisation Atlas (2005) highlights the low number of mental health professionals in India, which is troublesome in itself. Lack of funding and their scarcity prevents non-governmental organisations (NGOs) from utilising their services. In order to combat resource obstacles and work with the challenges the children present, Udayan Care was set up to capitalise on existing systems, while also improving them in the process. The next section details exactly how this was carried out.
Structure and Development of the Udayan Care Model
The 13 Udayan Ghars and three Aftercare facilities in and around New Delhi draw on features from both traditional orphanages and the foster family system. The LIFE (Living In Family Environment) strategy provides a loving, family-like setting, and consists of: (1) multiple long-term volunteers as Mentor Parents meeting the childrens’ psychosocial needs; (2) professionals and live-in care staff fulfilling legal obligations; (3) other children in the home as involved siblings; and (4) neighbouring community, teachers and other volunteers, for complete social integration.
Expounding upon this model, lifetime volunteers are recruited by Udayan Care largely by word of mouth. No formal advertising is undertaken. These individuals tend to be men and women passionate about improving the lives of the children at Udayan Care and they are eventually designated Mentor Parents after a series of training sessions in order to facilitate the ‘F’ in the LIFE model, a family. Mentor Parents start out as volunteers, and they commit themselves to raising and attending to the children they are assigned to ‘as if’ they are their own, through building positive relationships and fostering safe attachments with the children. Additionally, they develop links to the children so there is an existing outlet to fulfil other developmental needs, with the ultimate outcome focused on superseding some of the dysfunctional effects known to result from the children's traumatic histories and sustained parental losses. Though we recognise Mentor Parents are not a replacement for the children's biological parents, their existence builds upon foster care models to negotiate parental figures who can provide many of the things not delivered by the children's biological parents and relatives.
Challenges
Regardless of the idealism and positive intentions in this model, the orphanage faces myriad challenges with which we constantly grapple. Foremost among them in the initial stages is gaining the trust of the children. Considering that their attachment history is formed and cemented in the context of abandonment, neglect and abuses that exacerbate existing vulnerabilities and result in other mental health phenomena, gaining trust is a gargantuan task. Often the initial goal is to address the immediate crisis needs of the children in a sensitive, timely and informed manner, but as mentioned above, availability of expertise to provide trauma-informed care, and funds with which to recruit that expertise are sorely limited. Therefore, Udayan Care has done its utmost to provide a stable-enough environment and foundation to help counterbalance these systemic challenges. By adopting a Group Foster Care Model of only 10–12 children housed in each home, the children are provided with a home that creates the experience of a stable foster family rather than an institution. Sharing the joys and pains of growing up, Mentor Parents form strong family bonds and are integral to gaining trust of the children within each home. Furthermore, Mentor Parents are encouraged to foster a stable milieu by developing a sense of trust, bonding, and security in the children, thus ensuring a non-threatening, non-judgmental, non-violent, loving, caring and sharing environment. One of the most important ways they do this is by being available for the children in the long term. Unlike other staff, who may move in and out of Udayan Care for monetary and/or professional reasons, Mentor Parents are strictly volunteers who want to give of themselves to the children in the long term and are least likely to leave. Mentor Parents tend to hail from more educated backgrounds, ranging from ages 35 to 75, and are also parents and grandparents who are not compensated monetarily for their work. This increases the altruistic nature of their involvement with Udayan Care. The longest remaining Mentor Parent after the Managing Trustee has been at Udayan for 15 of the 18 years of its existence.
One of the more ongoing challenges with the children, after the initial crisis intervention and creation of a stable environment, includes increasing their functional life-skill behaviours. This ranges from the basics of personal hygiene to disciplined and acceptable behaviour, developing and nurturing interests and talents, to pursuing academic excellence that will help them in the future. Commonly, many of the children are first-generation learners who may have limited to non-existent foundational academic skills, such as being unable to read or write. We not only seek to improve and provide these skills, but we also consistently combat the stigma that accompanies such children and the inherent outlook of the local communities who may consider them delinquents or a bad influence on their own children. As with all things already mentioned in this paper, these tasks are further complicated by the many different ways in which trauma-related behaviours present in children.
We have attempted to tackle the aforementioned by including the local community in the operation of the homes and drawing support from their members for the children. In order to accomplish this we strategically placed the homes in the midst of middle-class neighbourhoods. Since LIFE-modelled Udayan Ghars have an open-door policy (children and visitors can come and go as they please), it is found that the neighbouring communities also take ownership of the well-being of children, and the children, in turn, do not feel isolated, thereby aiding speedy assimilation and integration of the children into society. For example, if one of the children is seen with a stranger or in an unsafe situation, members of the community feel empowered to report on the well-being of the child or intervene to make sure they are safe. On a lighter note, the children often play with their peers in the neighbourhood and attend fairs and community events with them. As such, LIFE-modelled Udayan Ghars become catalysts in changing the community's negative perception of such children, thereby helping the children to further develop their confidence and aspirations. In the beginning of a child's stay at Udayan Care they may not interact immediately with the community, but as they become acclimatised and more stable, we slowly integrate them into the community and they are gradually accepted and guided into interactions with other children. Similarly, individuals and corporates from India and abroad see and hear about the ways in which we have integrated the Ghars into the community and join hands through volunteering and helping the children with goal-setting and achievement. Annually, we have approximately 800 volunteers from India and abroad who help with crafts, dances, or any activities and guidance that the children may need at a given time. This helps to feed the life of the orphanage and continues to bring new opportunities into the children's lives.
Another challenge Udayan Care faces daily is the ongoing development of a team of mentors, professionals and care staff who can work cohesively in a structured and planned manner, with each child at the centre. As detailed, having experts support our staff development is extremely important. Expert support is a further method through which our staff can learn to deliver trauma-informed care. Since professional counsellors and psychologists were not immediately available, capacity-building programmes for the mentors, social workers and care staff were initially developed by Dr Deepak Gupta, an honorary child and adolescent psychiatrist and psychotherapist, and Dr Monisha Nayar-Akhtar (residing in the USA), who agreed to come on board, both volunteering great amounts of their time. Together they train the staff and mentors to develop their skills in understanding children's mental health issues and how to address them programmatically. To keep the entire team on the same page, weekly meetings are held with the social workers of all the homes, under the supervision of Dr Gupta. In addition to his home visits to meet with the entire carer group and children, Skype consultations are undertaken once a month with Dr Nayar-Akhtar. Monthly capacity-building workshops are held for sharing knowledge and issues, thereby increasing staff awareness of possible issues and sensitisation to, and early detection of, children with psychological problems. The programme also involves group and individual sessions/workshops for children. There are also pharmacological interventions for children with severe emotional and behavioural problems, which are administered and evaluated by Dr Gupta. Approximately 8–10 per cent of the children are medicated at any given time, with diagnoses ranging from attention deficit hyperactivity disorder (ADHD) to mood disorders and severe conduct problems. The appropriateness of medications and dosing is constantly monitored by Dr Gupta to ensure that proper standards of care are being met, in conjunction with psychotherapy and group sessions provided to the children.
As indicated, trauma-informed care is the greatest need in maintaining successful and stable homes. Through Dr Gupta and Nayar-Akhtar's work with us, we continually hammer at the challenge of moving children away from their past being debilitating, to existing, instead, as one of their lived experiences. We do this by continuing to encourage positivity, growth and opportunities for expression in their lives, which are so integral to the development of a child. We expose them to different arts, sports, life-skills workshops and more, enabling a more holistic, child-centred development. Furthermore, we address the educational needs mentioned earlier by linking and lobbying with many of the best schools and institutions to afford our children the opportunity to increase resiliency, see a future to which they aspire and, overall, to achieve their potential. Quarterly academic and care plans are developed, with special attention to their psychological capacities; and ongoing consultations with mentors, social workers, teachers and other care staff are performed to draw comparisons and continue to evaluate areas of growth and needs for improvements, not only within each child's plan but with attention to how their development reflects on the efficacy of the programme as a whole. We aim to be a well-researched and informed mental health programme, and one that ensures our children can learn to come to an equilibrium with their traumatic pasts and be empowered to shape their own future – something that was previously never allowed for them. As an additional consideration, Udayan Care has developed longitudinal research partnerships to investigate attachment and trauma sequelae in the children, including evaluations by the children of whether their basic needs are being met, versus gaps present, so that interventions and strategies can continue to be refined and informed in the long term.
Case Studies
Names and certain aspects of case material have been disguised to protect the identities of the children discussed.
In order to illustrate for the reader exactly how children in Udayan Care interact and grow within the homes, two case studies will be presented. As discussed, many of the children who come to us are compromised in terms of emotional regulation, their capacity to empathise with others is impaired, and they are often susceptible to unimaginable psychological terror, because of the horrors they have faced. Through our own observations, the resulting behaviours align with the trauma research detailed earlier, and we often see anxiety, instances of aggression, and sometimes extremely violent behaviour and self-harming tactics. Tender love and care models and interventions aimed at the developmental needs of the children at Udayan Ghars work because these approaches are aided by early intensive intervention, and possible treatment models are discussed for addressing the mental health difficulties that inevitably arise in our children. Our team is able to respond to the disaffections and dysregulations observed in our children in a timely and responsive manner, constantly re-moulding our strategies to address the dynamic nature of their development. The hope is that the reader will get a sense of how nuanced this work is through the stories of Jyoti and Rakesh.
Jyoti
Jyoti, a 21-year-old woman, came to Udayan Care, when she was 8 years old, from a broken family and following multiple out-of-home placements. Faulty attachments, pathological parent–child relationships (alcoholic father and remarried mother), neglect, abuse and unpredictable environments, left her easily overwhelmed. As a child, her self-regulatory capacities were impaired and Jyoti was subject to excessively angry and emotional outbursts. For example, at about age 10 or 11, it was time for Jyoti's final exams and she had a final paper due. Jyoti was found by a Mentor Parent yelling at her caregiver and was blaming the caregiver for her inability to complete her paper. When asked what exactly the issue was, she experienced difficulty articulating what was going on and expressed a lot of anger. She said that the caregiver would not provide her with the help that she needed with the paper, without any consideration for the caregiver's lack of ability to help because of the caregiver's lack of an educational background. Additionally, it was well after bedtime at about 22.15, and Jyoti was unable to appreciate the nature of the situation. The Mentor Parent, in spite of knowing Jyoti's story, still experienced difficulty sorting out what Jyoti was experiencing. Later, with the help with our mental health experts, when the entire group sat together to discuss this particular case, it became evident that Jyoti was unable to verbalise the reason for her own anger and transferred the responsibility for her anger to the caregiver. With continued processing, the mental health practitioners suggested that it was possible Jyoti felt ‘unsupported’ during her late-night studies making her feel angry, ‘lonely’ and so anxious about her exam that she felt unable to study. In order to follow-up on the difficulties that arose here, the Mentor Parents explained to Jyoti that the caregivers cannot always be available and do need to sleep as well, but that provisions could be made to request the caregiver's presence for additional support if she was feeling extremely anxious. This would be properly discussed and indicated with enough time before bed, so that if Jyoti felt the urge to wake the caregiver, the caregiver would have proper warning, and a situation where Jyoti felt lonely and unsupported could be prevented. Additionally, caregivers and Mentor Parents were trained in recognising non-verbal cues from children like Jyoti, in order to ascertain additional needs that may arise, such as those that occurred in this situation.
Due to the stabilising influence of Mentor Parents and their constant support in studies and her creative pursuits, especially in art, sports (basketball) and dance, in addition to an ongoing dialogue with the mental health team, Jyoti started organising her feelings and actions in relation to others, and became less overwhelmed by her own sense of being wronged. Developing a sense of responsibility, she started being accountable for her own thoughts and feelings. Since the caregivers are also given training in understanding their own affects and on how to withstand most provocations by the children, her feelings and needs were dealt with empathetically. A culture of positive consequences and rewards at the Udayan Ghar also helped her develop a linkage between emotions, expressions and actions. Today she has better control over her own emotional response systems regarding perceived threats from systems around her. A graduate in fashion technology, Jyoti is presently working in a big fashion house and has been able to maintain a stable emotional life and deal with the demands of her job and the world around her.
Rakesh
Rakesh, a 16-year-old youth, came to Udayan Care at 11 years of age, having been transferred to Udayan Care from another organisation under the orders of the Child Welfare Committee (CWC). Withdrawn in the beginning, Rakesh had suffered neglect and abuse at the hands of his stepmother and abusive father, leading to his running away from home. Placed within an organisation where he was bullied by the older children, he ran away for the second time and was found on a railway platform. Finally, the CWC transferred him to Udayan Care for long-term care and protection. The major concerns that emerged with the passing of several days were defiance, actions performed deliberately to annoy others, revenge/resentment of others, argumentativeness, short-tempered behaviour and a tendency to blame others for his mistakes. Rakesh had become predisposed to reflexive responses such as rage, anxiety and fear, and reacted to environmental provocations impulsively. Rakesh also had a habit of stealing other children's exercise books (workbooks). Consequences were administered, but they did not seem to improve the situation. Eventually, with consultations and group process meetings with our mental health practitioners, we realised that other children were struggling with similar behaviours, so instead of singling out Rakesh, we addressed such behaviours in a group format. Since this intervention was not specifically pinpointed at Rakesh, it avoided the shame and anger associated with being singled out, and facilitated more reflective processes in the children involved in the group. Furthermore, Rakesh was given concrete strategies to manage his anger, such as squeezing a ball, hitting a pillow, or being allowed to go outside and shout at a tree. Rakesh consistently reported feeling a little bit more calm after being allowed these outlets for his anger. His stealing behaviours soon decreased in frequency and intensity.
Rakesh was admitted to school and, with lots of tutoring help, life skills workshops, individual counselling, implementation of consistent regulations and expectations, continuous care, love, consistency and the safety of his Udayan Ghar, Rakesh is now learning to develop a capacity to tolerate frustration. The care staff are being trained constantly to be empathetic to Rakesh's feelings and needs. The mental health guidance and subsequent actions implemented and documented by the social worker, including consistent discussions on strategies to be employed with accompanying care plans, have developed in-sync teamwork, leading to Rakesh settling down, with an ultimate desire to make Udayan Ghar his home. The Udayan Care model has been able successfully to fill in the developmental void and lack of individual attention, and to provide positive reinforcement, of which Rakesh had been deprived from his early years.
Spreading Strength
As demonstrated, Udayan Care is constantly striving to provide the best standard of care and nurture to our children, within the context of limited resources. Volunteers, such as our Mentor Parents, and generous individuals like Dr Gupta and Dr Nayar-Akhtar, who do weekly/monthly training and checks, make further achievements possible. Connecting and integrating the Ghars with the community allows the community a sense of inclusion and responsibility in the lives of our children and, arguably, buffers their eventual transitions out of the orphanage. All of these efforts, which rest upon the generosity of others, has made the LIFE-modelled Udayan Ghars possible, nesting our volunteers within the structure and vision of the orphanage. Having a solid model built on research that helps to inform care for children is extremely important to maintaining our ability to care for our children. Presently, 200 children and young adults are pursuing school and university educations, vocational training and their hobbies. Twenty-eight alumni have left care and are leading independent, productive lives, outside in the larger world; 16 are married and leading a socially integrated life. Although much of this is descriptive and anecdotal, Udayan Care has already established partnerships with other institutions and undergone evaluations to facilitate long-term research that tracks programme development and the well-being of our children. In conclusion, it can be stated that assisting developmental processes is a long-term goal in institutionalised settings, even if this kind of setting is a last resort. Sometimes it is all that a country might have for its children and so we must do the best we can with it, for them. In spite of complexities and massive challenges, Udayan Care acknowledges the importance of promoting overall development and socialisation of children to help them grow as responsible citizens of society. Udayan Care is a constant practice, developing prevention strategies, multi-disciplinary interventions, community-based support mechanisms and social protection systems to attain a more holistic approach to child development. Udayan Care will continue to grow and develop with our children and our hope is that our model can be useful for other institutions aiming to meet the needs of vulnerable children regardless of a poverty of resources.
