Children randomly assigned to foster care after being institutionalized in infancy have significantly better cognitive and physical outcomes and less severe symptoms of psychopathology than their peers who remain in institutional care, results of a new study suggest.
The study shows that sustained recovery is possible after severe, early-life adversity, study author Kathryn L. Humphreys, PhD, assistant professor, Department of Psychology and Human Development, Vanderbilt University, told Medscape Medical News.
"Given the strong evidence from the present study, I hope physicians will play a role in promoting family placements as an alternative to institutional care for children who have been orphaned."
The findings were presented at the American Psychiatric Association (APA) 2023 Annual Meeting and were published online in The American Journal of Psychiatry.
Millions of children around the world experience psychosocial deprivation while living in institutions, and many more are neglected in their families of origin. In addition, about 6.7 million children lost a parent or caregiver during the COVID-19 pandemic.
In particular, Romania has a history of institutionalizing children. Through decades of repressive policies from the Romanian dictator Nicolae Ceausescu, child abandonment became a national disaster. Families couldn't afford to keep their children and were encouraged to turn them over to the state.
The current study was part of the Bucharest Early Intervention Project (BEIP), initiated in 2001 to examine the impact of high-quality, family-based care on development. It included 136 Romanian children (mean age, about 22 months) who were abandoned at or shortly after birth and were placed in an institution.
Researchers randomly assigned each toddler to one of 56 foster families or to continue living in an institution (care as usual). The researchers had to create a foster care network, because such care was extremely limited at the start of the study.
Providing Stimulating Care
Foster parents in the study received regular support from social workers and US-based psychologists. They were encouraged to "make a commitment to treat the child as if it was their own, providing sensitive, stimulating, and nurturing care, not just in the short term but for their whole life," said Humphreys.
Foster care programs in the US have been criticized for focusing on short-term care, she said. "It's really just a bed to sleep on, clothes to wear, and food to eat rather than the psychological component we think is really important for child development."
For the study, the researchers assessed the children across multiple developmental domains at baseline and at ages 30, 42, and 54 months. They conducted additional assessments when the kids were aged 8, 12, and 16–18 years.
The primary outcomes were cognitive functioning (IQ), physical growth (height, weight, head circumference), brain electrical activity (relative electroencephalography power in the alpha frequency band), and symptoms of five types of psychopathology (disinhibited social engagement disorder, reactive attachment disorder, attention-deficit/hyperactivity disorder [ADHD] symptoms, externalizing symptoms, and internalizing symptoms).
From over 7000 observations analyzed across follow-ups, the investigators found that the intervention had an overall significant effect on cognitive, physical, and neural outcomes when considered collectively across waves (Beta = 0.26, 95% CI, 0.07 – 0.46; P = .012). Compared to children who received care as usual, those in foster homes had significantly higher average IQ scores (P < .001) and physical size (P = .008).
The intervention had an overall beneficial effect in regard to psychopathology. The greatest impact involved a reduction in symptoms of reactive attachment disorder (P < .001).
"There are a few forms of psychopathology that seem to almost entirely occur after severe neglect, including reactive attachment disorder; we think of these as disorders of social relatedness that derive from aberrant or insufficient early care-giving experiences," said Humphreys.
"Being placed in a family reduced the symptoms of reactive attachment disorder to pretty much nonexistent."
To a lesser extent, the intervention reduced symptoms of disinhibited social engagement disorder. The foster care group also had significantly fewer internalizing symptoms than did children in the care-as-usual group.
But there was no significant overall effect of the intervention on symptoms of ADHD or externalizing problems.
Positive Effects Persisted
For the most part, the positive effects of the intervention on children's functioning persisted during nearly two decades of follow-up. The impact of the intervention "can be described as rapidly apparent by age 30 months and sustained through late adolescence," write the authors.
Regarding the impact of age at the time of placement, the study found that, compared to children placed into foster care later, those who entered foster care earlier (younger than 33 months) had significantly higher IQ scores and relative alpha power, but there was no difference in physical growth.
For some outcomes, the benefits of earlier placement were apparent in early childhood but faded by adolescence. But Humphreys noted all placements were early by most definitions.
Researchers also assessed stability of foster care placements. Children were considered "stable" if they remained with their original foster family; they were considered "disrupted" if they no longer resided with the family.
Here, the study found some "striking results," said Humphreys. The effect of placement stability was largest in adolescence, when, overall, those who had remained with their original foster family had better cognitive and physical outcomes and less severe symptoms of psychopathology compared to those who experienced placement disruptions.
As for sex differences, "it's a mixed bag," said Humphreys, although overall, "we didn't see strong evidence of sex differences" in terms of outcomes.
The investigators were unable to examine trajectories of children's functioning, which would have provided important information on aspects such as rate of growth and the shape of growth curves. Specific features of the institutional or foster care environment in Bucharest during the study may limit the generalizability of the findings to other settings.
Absolutely Unique Project
The study examined an "absolutely unique project" and had "very exciting" results that should have "important clinical implications," commented The American Journal of Psychiatry Editor-in-Chief Ned Kalin, MD, Hedberg Professor and Chair, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health.
The findings are "pretty dramatic," added Kalin. "This is probably the study to be thinking about when considering the future of treatment and interventions in children who have suffered from this type of neglect, which is unfortunately extremely common worldwide, including in the US."
In particular, the findings regarding improved psychopathology "bode well for the future," said Kalin. "We know these types of problems are risk factors for the later development of depression and anxiety disorders. It will be really interesting to find out, but my guess is these kids will be protected as they mature further."
The study was supported by the NIH, the John D. and Catherine T. MacArthur Foundation, the Palix Foundation, and the Jacobs Foundation. Humphreys has received research funding from the Brain and Behavior Research Foundation, the Caplan Foundation, the Jacobs Foundation, the National Science Foundation, the NIH, the Vanderbilt Institute for Clinical and Translational Research, the Vanderbilt Kennedy Center, and Vanderbilt University; she has received honoraria from the Journal of Clinical Child and Adolescent Psychology Future Directions Forum, Learning Grove, the University of Iowa, the University of Texas at Austin, and ZERO TO THREE.
American Psychiatric Association (APA) 2023 Annual Meeting: Presented May 22, 2023.
Am J Psychiatry. Published online May 22, 2023. Full text
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Image 1: Department of Psychology and Human Development, Vanderbilt University
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Cite this: Family Placement Better for Deprived Kids Than Institutions - Medscape - May 23, 2023.