Foster vs Institutional Care Improves Mental Health Trajectory

Megan Brooks

October 05, 2018

Severely neglected orphans reared in institutional settings are at risk for psychopathology, but placing them into high-quality foster care partially mitigates this risk if it's done early, suggest latest findings from the long-running Bucharest Early Intervention Project (BEIP).

"This study expands on what clinicians, researchers, and early childcare workers have known for a long time: that children raised in institutions are at risk for many more mental health problems than those who are raised in family settings," Mark Wade, PhD, from Boston Children's Hospital and Harvard Medical School, told Medscape Medical News.

"However, the most encouraging thing we show is that children who are removed from the institutions early in life and placed into enriched foster homes show declining levels of psychopathology over time," said Wade.

"But we must remember that even the children who left the institutions for foster care still have more difficulties in adolescence than children who never experienced institutional care. This means that, above all else, we should be seeking to prevent institutional or orphanage care whenever we can, avoiding family separation and promoting reunification," said Wade.

The study was published online September 26 in JAMA Psychiatry.

Convincing Illustration

In their article, Wade and colleagues report psychopathology outcomes for 119 orphans who participated in the BEIP study. The children were aged 6 to 31 months at baseline testing (mean age, 22 months) and were as old as 16 years at the latest follow-up. The participants spent at least some time in institutions in Bucharest, Romania, after being abandoned at or around the time of birth. At the time, these institutions were characterized by high child-to-caregiver ratios, high caregiver turnover, frequent isolation, and inadequate stimulation, in effect exposing the children to relatively severe early deprivation and neglect.

Of the 119 orphans, 68 were placed in high-quality foster care at a mean age of 22 months, and 58 remained in institutional care. A total of 101 never-institutionalized children served as control participants. Psychopathology was measured periodically over the years using the MacArthur Health and Behavior Questionnaire.

As expected, never-institutionalized children reported significantly fewer symptoms of psychopathology than both of the previously institutionalized groups, the investigators report.

However, children who entered foster care early experienced declines in general psychopathology and residual externalizing symptoms throughout adolescence, whereas for children who stayed in institutional care, externalizing symptoms remained stably high or increased.

In addition, for the foster-care and institutional-care children, there was an increase in divergence in externalizing behaviors over time, such that those in foster care had fewer problems overall by age 16 than those who remained in institutional care. No between-group differences were seen in internalizing behaviors.

"The unique thing about this study is that it does not just show more psychiatric problems among those raised in institutions; it shows that these children have concerning developmental trajectories, with stable levels of problems from childhood through adolescence," Wade told Medscape Medical News.

"The children who remained in institutional care and those who moved into foster care begin to look different from one another by late childhood, and by adolescence, they look much different in terms of their psychiatric difficulties. So the benefits of being in supportive, family-based care may accumulate over time and help children get back onto healthy developmental trajectories," said Wade.

In a linked editorial, Jonathan Schaefer, MA, Department of Psychology and Neuroscience, Duke University, Durham, North Carolina, said this study "convincingly illustrates how a period of profound early deprivation can have lasting and widespread consequences on later emotional and behavioral functioning.

"These results affirm the importance of early interventions for institutionalized children and suggest the hypothesis — testable in future research — that interventions for children exposed to less pervasive early adversity may yield similar benefits," writes Schaefer.

This study was supported by the John D. and Catherine T. MacArthur Foundation, the Binder Family Foundation, the National Institute of Mental Health, and a Banting Postdoctoral Fellowship. Dr Wade and Jonathan Schaefer have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online September 26, 2018. Abstract, Editorial

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