Institutional
Care,
Foster
Home
Care
or Family
Care?
Adefunke Oyemade, M.D., D.P.H., D.T.H.
From the Department of Preventive and Social Medicine, University College Hospital, Ibadan, Nigeria
EDt-mR’s NOTE: We in Europe and the
Amen-cas may be surprised to learn that the simple life and the extended family no longer protect
African children from the complications of
“civil-ization.” Therefore we were particularly interested in Dr. Oyemade’s paper.
Previous studies have shown that young
children who live away from home and are
deprived of the love, attention and continu-ous care of a mother or mother substitute
may suffer such adverse effects which
mani-fest themselves in retarded physical,’3
men-tal and social development.49 In Nigeria no
clinical data on such children are available,
and yet problems which require emphasis
and wider recognition are being
encoun-tered by motherless babies reared in
institu-tions, foster homes and within the extended family. This paper presents three case his-tories which illustrate the physical, social
and mental problems of motherless babies
in the different rearing situations as does an
account of an epidemic in a home.
Case 1
CASE REPORTS
Sakiatu, a 6-month-old female child, was re-ferred to the Oluyoro Day-Care Centre from the University College Hospital when her mother died of cervical cancer. Her father and two older
sib-hogs were at this time receiving treatment for tuberculosis of the lungs.
Because of the family’s medical history, it was decided that the child should be fostered out. Her prospective foster mother was a middle-aged di-vorcee whose main income was derived from fostering. She lived in a two-room aparthent with three other foster children who were all under
5 years of age. On placement into the foster home
at the age of 6 months, Sakiatu weighed 11 lb
and 12 oz. At 9 months of age she had diarrhea but responded quickly to treatment; there was very
little progress in her development. She lay
motion-less on the bed most of the time and was unre-sponsive to the approach of anyone. At 15 months of age she could not crawl or speak. The weight remained constant even after the foster mother was given an extra supply of dried milk, eggs and
cereals which she claimed the child ate very well. Extensive medical investigations revealed no or-ganic pathologic findings for the failure to thrive.
At this point it was decided to have the child trans-ferred to another foster mother who had the repu-tation of being more understanding, honest in her intentions and who cuddled and caressed the chil-dren under her charge more than any other foster mother. Whenever she could, she carried the child on her back. Within a month of the child’s stay with the new “substitute” mother, she became more alert and grew more responsive to people, especially her foster mother. She started to crawl and was standing and holding on to things. In that month she gained 1 lb and continued to m.ke a
steady progress. The weight curve is shown in Figure 1.
Case 2
Funlayo was 1 day old when her mother died and
she apparently had been abandoned in Ibadan
Home by her relatives when a few days old. She was then placed in a foster home. The foster
mother was a pleasant lady, a graduate and mother
of an 11-year-old boy. Being unmarried, her devo-tion to the two children was undivided. Since nothing was heard of the relatives, she had come to regard Funlayo as her own child and became
obsessed with her. The child made steady progress gaining about 1 lb in weight per month. She was
alert, intelligent and cheerful. Friends remarked on the resemblance of the child to the foster
mother! When the child was about 23 years old and progressing satisfactorily, her father turned up at the foster home and expressed his wish to take his daughter home. The foster mother became
emo-tionally upset and very depressed, refusing to give
(Received May 9; revision accepted for publication August 15, 1973.)
This paper is part of an M.D. thesis accepted by the University of Glasgow in January 1973.
ADDRESS FOR REPRINTS : (A.O. ) Department of Preventive and Social Medicine, University
College Hospital, Ibadan, Nigeria.
21
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I-01
the child away. Although she continued to take good care of the child, she did this under emo-tional strain and anxiety.
This case history demonstrates the risk of rearing
a child as one’s own without any legal support as
provided in the British Adoption Laws which are not in force in the Western State of Nigeria where this case was encountered.
Case 3
Basins, a 1-day-old infant, was admitted to Iba-dan Home when his mother died of a postpartum hemorrhage. The father was a poor farmer who had five other dependents, another wife and four children. The child had spent all his life in the
institution and at the time of the study was 3 years
and 10 months old and weighed 33 lb and 7 oz.
Although his physical appearance was good, a
striking feature was the dull placid look which he
always wore. He played a lot by himself and his choice of toys was dolls, balls and animals. He obeyed simple commands but could not talk. He was the oldest in the home and his playmates were
mostly children learning to crawl or walk. Although
he had been walking for about two years, he sud-denly started to crawl at 3 years and 11 months of age. At this point the Home Committee felt the
child should be sent to a day nursery rather than to his natural home which was regarded as unsuit-able because of the poor home background. He had stayed only three days in the nursery when the head mistress asked for him to be removed as he
was upsetting other children with his incessant crying. He refused to mix with his play group and looked forward to returning to Ibadan Home. In the following months and at about the age of 4
years, he was discharged home. His father who had not visited the institution or seen the child in the past two years was quite unprepared for his arrival, but the stepmother seemed pleased. There
was no further action taken by the Home
Commit-tee since the children were never followed up after discharge. Subsequent visits in the course of the
survey showed that the child was adjusting well. Within three months he had a vocabulary of about six words; he was alert, friendly and always ran
up to strangers and took them by the hand. The stepmother grew very fond of him and took him out many times. He mixed freely with other
chil-dren in the neighborhood and became very popular. His physical development was, however, not so
encouraging. Within a month’s stay at home he
had frequent episodes of diarrhea and lost 2 lb in
weight. Although he maintained a good appetite,
his weight remained constant with very little
change in the following eight months (Fig. 2).
An Account of an Epidemic in a Home
Figure 3 above shows graphically the
morbidity pattern of children in the Ibadan Home during the follow-up period. Diagno-sis was based on history and clinical exam-ination. Cases of diarrhea were reported all
I 2 3 4 5 6 7 8 9 10 II 2 13 415
FOLLOW UP PERIOD IN MONTHS
Fic. 1. Weight curve of patient in case 1 : A,
place-ment with foster parent; B, diarrhea and boils; and C, change of foster parent.
year; malaria, respiratory tract and skin
infections and measles also occurred, but
at a very low incidence. Severity of
ill-nesses was usually assessed by the matron
and the visiting doctor was consulted for
serious ones. At the end of May 1970, the
matron of the Home went on maternity
leave and thus the care of the children was left to the untrained staff. A week after the
matron left, two children had diarrhea
which soon spread to involve 28 out of the
32 children in the home. Specialist medical
opinion was sought and stool specimens
were then collected from the affected
chil-dren and the “nurses.” In the second week
of the epidemic six children died, three of them on the same day. A state-registered
nurse was engaged and immediately
intro-duced measures which brought the
epi-demic under control. The results of stool
examinations proved negative for all the
children, although one of the “nurses” was
found to have salmonella infection.
DISCUSSION
Case 1 illustrates a foster mother who
failed to give the emotional and individual
attention the child needed, and that
re-markable progress was made with a new
and more responsive foster mother. A very good foster home can provide the affection and security of a real family,1#{176}but
unfor-tunately foster parents are hard to find in
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I 2 3 4 5 6 7 8 9 10 II 12
PERIOD OF FOLLOW UP IN MONTHS
FIG. 2. Weight curve of patient in case 3.
I00
90
80
70
60
50
40
30
20
10
cJ
KEY
.--4 I
0 N 0 J F M A M J J A S MONTHS
FIG. 3. Morbidity patterns, as seen in Ibadan Home, of motherless babies between October 1969 and September 1970. Diagnosis was based on history and clinical examination only. The number affected each month has been
expressed as % of the number at risk during the month.
250 TYPES OF CHILD CARE
their recruitment is based on availability rather than by a generally agreed set of
principles and standards. Very little is
known about the motivation and personal
qualities of those who become foster
par-ents, and such characteristics need to be
taken into serious consideration for
suc-cessful foster home care. Motherless babies in particular need to be carefully matched with their prospective foster parents, since
previous findings indicate that foster home
placement of a young child following the
death of the natural mother is significantly associated with failure.’1
Case 2 demonstrates the need for an
adoption law which will give suitable
adop-ters legal rights to provide permanent
homes for the abandoned and homeless
children in our society. It may be mentioned here that adoption has never been socially
accepted by the majority of people in
Ni-geria since the practice is alien to our
cul-ture. In the olden days, the greatness of a
man was partly measured by the number
of wives and children he had. A barren
wife thus became unpopular within the
extended family. Adoption to most people
is, therefore, an open acceptance of failure
to bear children of their own. With
in-creased industrialization and urbanization
and the accompanying social evils, there
will be more children abandoned and
without families.
Serious consideration must be given to
the introduction of the Adoption Law in
order to provide permanent homes where
love and security can be given to the less
priviledged children in the society.
Case S illustrates the importance of a
right environment for both physical and
mental growth, and describes a child who
had spent all his life in an institution and
in whom physical development was normal
and mental development retarded. While in
Ibadan Home, his behavior was seen to
revert to that of an infant and he found it
.- --4 DtARRHOEA
o..-O MALARIA
. S RESPIRATORY INFECTION .O.O-GOBOILS & OTHER SKIN
INFECTION
c:::::ONLY TRAINED STAFF ON
difficult to form any relationship or com-munication with children of his age group.
With a good home environment and a
by-ing stepmother, a marked improvement in
his social and mental development occurred although his physical development suffered a setback.
Any child living away from home is in
an atypical situation, whether he is placed in an institution or in a foster home. He can-not look to mother to see how she reacts, he has no sisters or brothers to play with and if placed in an institution or a foster home where there is insufficient physical, social
and emotional stimulation from a mother
person, he may become mentally and
so-cially retarded. Basiru grew up in the
im-poverished atmosphere of a home where
the only contact with an adult person was
with the nurse who worked in shifts. The
children were hardly caressed, cuddled or
spoken to, due to the fact that the nurses
were too busy with the daily routine work.
The opportunity to make any emotional
attachment or exchange emotional feeling
was lacking. It is, therefore, to be expected that Basiru, having spent all his life in such
an institution, would be mentally and
so-cially retarded. However, a remarkable
progress was made following discharge to
his own home. Before the introduction of
other types of substitute care, motherless
babies had always been cared for in the
extended family. Although the child
iden-tifies himself mainly with the substitute
mother who cuddles, bathes, feeds and
clothes him, the other members of the
fam-ily also feel that they must contribute to
the care of the child. Thus, a motherless baby living with one of such families
invari-ably receives more individual and group
attention. It is not surprising that the
men-tal and social development of Basiru
im-proved on being discharged home. His
physical development, however, suffered a
setback, probably because of inadequate
hygiene and nutrition.
The occurrence of an epidemic in Ibadan Home is a reflection on the quality of staff
in the institution. All the nurses with the
exception of the matron were untrained.
Since they had no basic knowledge of the
cause and mode of transmission of diseases, the infant feeds were likely to be
contam-mated and this invariably resulted in
diar-rhea which soon spread to involve all the
children in the home. The morbidity
ex-perience thus demonstrates the importance
of having trained experienced people in
in-fant institutions and the necessity of peri-odical stool examination of all those work-ing in close contact with the children.
SUMMARY
Three case histories and an account of an
epidemic in a home have highlighted a few of the physical, social and mental problems
encountered by motherless babies in their
different environmental settings. The
insti-tutionalized child may have a normal
phys-ical development, but becomes mentally
re-tarded because of lack of social stimulation and individual attention. On the other hand, a motherless baby reared in an environment
with poor sanitation and inadequate diet
may have poor physical but normal mental
development. The study also showed that a
child can have normal mental, social and
physical development if the right choice of
foster parent is made. It is also revealed
that long-term, successful foster-home
placement does not automatically lead to
adoption, and feelings of frustration can
arise from regarding a foster-home child as
one’s own without the legal support usually
provided in the Adoption Laws.
As demonstrated by the epidemic
de-scribed in this study, the course of a disease can be explosive in an institutional setting. This can be related to the quality of staff
who have no knowledge or training in the
causes of and modes of transmission
of disease.
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