Foster Care May Curb Mental Health Problems of Institutionalized Children

October 5, 2018

By Marilynn Larkin

NEW YORK—The risk of psychopathology among severely neglected children raised in an institution may be mitigated at least in part by subsequent placement in foster care, researchers say.

"There really is no replacement for the high level of emotional support, responsiveness, attunement, scaffolding, and one-to-one stimulation that comes from a primary caregiver," Dr. Mark Wade of Boston Children's Hospital told Reuters Health by email.

"These are the types of behaviors that characterized the foster families in our study," he said, "which is probably why, despite their histories of severe neglect, the children (we studied) showed declines in psychopathology over time."

"However," he noted, "it is also important to recognize that, by and large, the children in foster care remain at risk for various psychiatric problems compared to children without histories of adversity."

Dr. Wade and colleagues studied youngsters in Bucharest, Romania, where children living in six institutions were randomly assigned to a care as usual group, meaning they remained institutionalized, or a "high-quality" foster care group. A matched sample of never-institutionalized children served as a control group.

The Bucharest Early Intervention Project began in 2000 with abandoned babies who had spent more than half of their lives in institutions, which was the standard at the time. At age two, researchers randomly selected half of the babies and arranged for them to be moved into high-quality foster homes.

Ever since then, the researchers have been comparing the children who remained in institutions with those who were moved to foster care, and to similar youngsters in biological families who were never institutionalized.

The institutions had high ratios of babies to caregivers, and children were confined to cribs, with little linguistic or sensory stimulation, to age two.

As reported online September 26 in JAMA Psychiatry, a total of 220 children (50% female; 119 ever institutionalized) were included in the analysis. They were tested on several measures of cognition, physical growth and psychiatric symptoms using the MacArthur Health and Behavior questionnaire at mean ages of 8, 12, and 16 years. Feedback from teachers and caregivers were included in the analysis.

At age 8, children in the usual care and foster care groups had higher mean levels of psychopathology than the never-institutionalized group: 0.41, 0.30 and -0.40, respectively.

By age 16, those in foster care had lower mean levels of psychopathology compared with those in usual care (0.07 vs. 0.37). The authors suggest this effect was likely driven by "modest declines" in psychopathology from age 8 to 16 in the foster care group, whereas psychopathology remained "stably high" in the usual care group during that period.

Moreover, the usual care and foster care groups showed increasing divergence over time in externalizing pathology, including defiance, overt and relational aggression, and attention-deficit hyperactivity disorder, such that those in foster care had fewer problems overall (mean, -0.30) than those who remained institutionalized (mean, 0.05).

No between-group differences were seen for internalizing factors such as depression, being overly anxious and social withdrawal/anxiety.

Dr. Wade said, "It is important to note that, in the case of foster homes without the type of social enrichment children in our study received, we should not necessarily expect the same positive outcomes."

"It is not sufficient to simply leave the institutions, although that is a necessary place to start," he said. "The key is that children are receiving the kind of development-enhancing caregiving that protects against later problems."

"In this regard," he added, "resilience is not just some characteristic of children that allows them to thrive in the face of adversity, but the presence of social inputs that buffer against adversity and allow children to reach their full potential."

Johnathan Schaefer of Duke University in Durham, North Carolina, author of a related editorial, commented in an email to Reuters Health, "For researchers and clinicians, these results emphasize the importance of thinking broadly when it comes to assessing the mental health effects of severe deprivation and stress, particularly when they occur early in life."

"We as psychologists are used to thinking of these experiences as increasing risk of later depression or anxiety," he said, "but there's also plenty of evidence to suggest that they can also lead to conduct problems, problems with substance use, or even psychotic symptoms."

"We also know that very few people experience 'pure' forms of mental illness," he added. "It is much more common to have multiple disorders at once, or move from one disorder to another over the years, particularly if you have a trauma history."

"The elegance of (this) study is that (it) capture(s) these effects in the context of what is effectively a randomized-controlled trial, which allows us to be more certain that institutionalized children's higher rates of mental health problems are, in fact, caused by their early experiences," Schaefer concluded.


JAMA Psychiatry 2018.

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