Effects of institutional rearing and foster care on psychopathology at age 12 years in Romania: follow-up of an open, randomised controlled trial

Abstract

Summary Background Early social deprivation can negatively affect domains of functioning. We examined psychopathology at age 12 years in a cohort of Romanian children who had been abandoned at birth and placed into institutional care, then assigned either to be placed in foster care or to care as usual. Methods We used follow-up data from the Bucharest Early Intervention Project (BEIP), a randomised controlled trial of abandoned children in all six institutions for young children in Bucharest, Romania. In the initial trial, 136 children, enrolled between ages 6–31 months, were randomly assigned to either care as usual or placement in foster care. In this study we followed up these children at age 12 years to assess psychiatric symptoms using the Diagnostic Interview Schedule for Children (4th edition; DISC-IV). We also recruited Romanian children who had never been placed in an institution from paediatric clinics and schools in Bucharest as a comparator group who had never been placed in an institution. The primary outcome measure was symptom counts assessed through DISC-IV scores for three domains of psychopathology: internalising symptoms, externalising symptoms, and attention-deficit hyperactivity disorder (ADHD). We compared mean DISC-IV scores between trial participants and comparators who had never been placed in an institution, and those assigned to care as usual or foster care. Analyses were done by modified intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747396. Findings We followed up 110 children from the BEIP trial between Jan 27, 2011, and April 11, 2014, and 49 children as comparators who had never been placed in an institution. The 110 children who had ever been placed in an institution had higher symptom counts for internalising disorders (mean 0.93 [SD 1.68] vs 0.45 [0.84], difference 0.48 [95% CI 0.14–0.82]; p=0.0127), externalising disorders (2.31 [2.86] vs 0.65 [1.33], difference 1.66 [1.06–2.25]; p<0.0001), and ADHD (4.00 [5.01] vs 0.71 [1.85], difference 3.29 [95% CI 2.39–4.18]; p<0.0001) than did children who had never been placed in an institution. Compared with 55 children randomly assigned to receive care as usual, the 55 children in the foster-care group had fewer externalising symptoms (mean 2.89 [SD 3.00] for care as usual vs 1.73 [2.61] for foster care, difference 1.16 [95% CI 0.11 to 2.22]; p=0.0255), but symptom counts for internalising disorders (mean 1.00 [1.59] for care as usual vs 0.85 [1.78] for foster care, difference 0.15 [−0.35 to 0.65]; p=0.5681) and ADHD (mean 3.76 [4.61] for care as usual vs 4.24 [5.41] for foster care, difference −0.47 [−2.15 to 1.20; p=0.5790) did not differ. In further analyses, symptom scores substantially differed by stability of foster-care placement. Interpretation Early foster care slightly reduced the risk of psychopathology in children who had been living in institutions, but long-term stability of foster-care placements is an important predictor of psychopathology in early adolescence. Funding Nation...

Early deprivation, atypical brain development, and internalizing symptoms in late childhood

“…They also align with our recently reported results showing group differences in internalizing symptoms at 12 years of age, assessed with a standardized diagnostic interview (Humphreys et al, 2015). Internalizing symptoms in this study were assessed with teacher report at both time points.…”

Disruptions of working memory and inhibition mediate the association between exposure to institutionalization and symptoms of attention deficit hyperactivity disorder

“…Young children raised in institutions exhibit profound deficits in cognitive, emotional and social functioning (Rutter et al 2010; Nelson et al 2014). Elevations in psychopathology are particularly marked in previously institutionalized children (Rutter et al 2001; Zeanah et al 2009; Humphreys et al 2015). …”

“…By contrast, exposure to institutionalization was associated with an increased risk for externalizing disorders that was not improved by placement into foster care. Twenty-one percent of children raised in institutions met criteria for attention deficit hyperactivity disorder (ADHD) by age 4½ years, even if they later lived in a foster care family (Zeanah et al 2009); at 12 years the rate of ADHD was 19.3% (Humphreys et al 2015). High rates of ADHD have also been observed in other studies of children reared in institutions (Kreppner et al 2001; Stevens et al 2008) and they are markedly higher than in never institutionalized children, where the prevalence of ADHD is estimated to be between 3% and 10% (Kessler et al 2006; Spencer et al 2007).…”

The Effects of Psychosocial Deprivation on Attachment: Lessons from the Bucharest Early Intervention Project

“…Children raised in these socially deprived settings have less gray matter (Sheridan, Fox, Zeanah, McLaughlin, & Nelson, 2012), show a heightened incidence of attention deficit disorder as well as other forms of psychiatric problems (Humphreys, Gleason et al, 2015; Rutter, Sonuga-Barke, & Castle, 2010). There are also data suggesting that being raised early in life in an institution has adverse effects of the development of social relationships, though up until recently these data were correlational in nature.…”

“…These follow-ups demonstrated a robust reduction in signs of reactive attachment disorder and a modest reduction in signs of disinhibited social engagement disorder over time (Smyke, Zeanah, Fox, Nelson, & Guthrie, 2010). At 12 years, there were intervention effects demonstrated both for signs of reactive attachment disorder and signs of disinhibited social engagement disorder (Humphreys, Gleason et al, 2015). …”