High-Quality Foster Care Protects Tots From Psychological Harms of Deprivation

SAN FRANCISCO — Placement into foster care after institutional care may help protect young children against the psychological harms of early severe deprivation, according to an analysis of the Bucharest Early Intervention Project (BEIP).

In this randomized controlled trial, young Romanian children who were assigned to foster care had significantly better cognitive, physical, and neural outcomes (β=0.26, 95% CI 0.07-0.46) versus those who remained in institutional care, reported Kathryn L. Humphreys, PhD, EdM, of Vanderbilt University in Nashville, Tennessee, and colleagues.

This was mainly driven by significant differences in greater physical growth and higher IQ scores, she added.

These findings were presented at the American Psychiatric Association (APA) annual meeting and simultaneously published in the American Journal of Psychiatry.

Foster care children also had significantly lower overall psychopathology (β=-0.25, 95% CI -0.42 to -0.08), which was mainly driven by significantly lower incidences of reactive attachment disorder, disinhibited social engagement disorder, and internalizing symptoms.

The other two types of psychopathology, attention deficit-hyperactivity disorder symptoms and externalizing symptoms, tended to be lower among foster kids, but weren’t statistically different.

Timing of foster placement also appeared to play a role, with kids placed earlier — between ages 6 months to 33 months — having significantly better cognitive, physical, and neural outcomes than kids placed later.

“The Bucharest Early Intervention Project tells us about a number of things that may be helpful for long-term care for children who are orphaned and abandoned across the world,” Humphreys said during an APA press conference. “There are millions of orphans living in institutions today.”

“We have insight from the BEIP that early placements into families — making sure those families are child-centered, that they make a psychological commitment to the children, and are willing to be there and provide them care throughout their life — is really important,” she added.

APA session moderator Ned Kalin, MD, of the University of Wisconsin School of Medicine and Public Health in Madison, noted that “it’s great to see research that really has this kind of an impact. [This work] is really important.”

“I think these findings bode well for the future of these children as they continue to mature in age,” he said. “As we know, these types of problems are risk factors for the later development of depression and anxiety disorders, other types of psychopathology, and substance abuse. It’s going to be really interesting to see what happens, but my guess is that these kids — where we see these reductions — are going to be relatively resilient and protected as they mature further.”

Started in 2001, the project enrolled 187 children ages 6 to 31 months who were living at one of six institutions in Bucharest, Romania. Some were then excluded for medical conditions that would severely compromise development.

Half of the remaining 136 children were randomized into foster care or into continued institutional care. The average age at placement was 22.6 months, and siblings were placed together.

“The complaint for a lot of foster care programs in the U.S. is that they’re really focused on short-term instrumental care needs, really just a bed to sleep on, clothes to wear, and food to eat, rather than those psychological components that we think are really important for child development — feeling understood, feeling safe, feeling taken care of, being stimulated in an intellectual way, being responded to in a sensitive way,” said Humphreys.

“The goal for this foster program was to recruit foster care providers who would make that kind of commitment, who would treat the child as it were their own child in providing sensitive, stimulating, nurturing care to that child and making a commitment to care for them, not just in the short term but hopefully for the child’s full life,” she added. “[It’s] a really big difference to foster care in the U.S.”

Throughout the BEIP, social workers visited the foster care families regularly to help them work through any issues that arose.

Children were followed-up with at ages 30 months, 42 months, and 54 months, as well as ages 8, 12, and 16-18 years.

Of the children assigned to foster care, 57% no longer resided with their foster family by the last follow-up assessment. However, there were no differences in regards to psychopathology symptoms or IQ scores between foster children who remained in a “stable” placement (stayed with the same foster family) or were disrupted.

When discussing the ethics of the trial design, Humphreys explained the study had to be randomized because of the possibility for selection bias.

“If a family wanted to go in and adopt a child, they might go in and pick the one with dimples or pick the one who had higher verbal functioning,” she explained. “So we couldn’t rule out the possibility that the better functioning was explained by that selection bias.”