Long-term cardiometabolic effects of early institutionalization and foster care: Evidence from the Bucharest Early Intervention Project

Young children removed from institutions and placed into foster care or adoptive homes have been shown to experience significant gains in IQ relative to children who remain in institutions. Less is known about the long-term impact of severe early deprivation on development in late childhood. Data are presented from a follow-up of children at 12 years of age in the Bucharest Early Intervention Project, a randomized clinical trial of foster care for institutionally reared children. Of the original 136 children in the study, 107 were tested with the Wechsler Intelligence Scale for Children-IV. Results revealed continued benefit from the intervention through age 12, with 12-year-old children placed in foster care scoring significantly higher on full-scale IQ compared to their peers who received prolonged institutional care. Longitudinal IQ data revealed 2 IQ profiles from early to late childhood. Attachment security emerged as a significant predictor of a profile of stable, typical IQ scores over time. We demonstrate the continued importance of foster care intervention and the negative effects of severe, early psychosocial deprivation on IQ into late childhood. (PsycINFO Database Record

Autonomic nervous system reactivity has been posited to be a mechanism contributing to social and emotional problems among children exposed to early adversity. Leveraging data from the Bucharest Early Intervention Project, a longitudinal randomized controlled trial of foster care versus institutional care of abandoned children in Romania, we assessed whether altered sympathetic reactivity to peer rejection feedback in early adolescence mediated the relation between early institutional rearing and peer problems in later adolescence. We also assessed whether adolescent friendship quality or randomized placement in foster care early in life moderated these associations. Participants include 68 institutionalized children randomized to care as usual, 68 institutionalized children randomized to foster care, and 135 never-institutionalized children. At age 12, participants reported friendship quality with respect to a best friend and completed a social rejection task while electrocardiogram and impedance cardiography were recorded. Sympathetic nervous system reactivity to rejection feedback was assessed using preejection period (PEP). At ages 12 and 16, peer problems were reported by parents. Mediation analysis revealed that less PEP reactivity to social rejection at age 12 partially mediated the association between early institutionalization and greater peer problems at age 16. Further moderated mediation analysis revealed that this indirect effect was evidenced among previously institutionalized youths with low, but not high, quality friendships. We did not observe foster care intervention effects. These findings suggest that altered sympathetic reactivity to social rejection might be a mechanism linking early institutionalization to social difficulties into adolescence, however, positive adolescent friendships may buffer these effects. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The institutional care of young, parentless children (be they orphaned or abandoned) is a practice that dates back centuries. Despite decades of research that document the hazards of institutional care, many countries throughout the world continue to rear children in institutions; indeed, current estimates place the number of parentless children living in institutions at approximately 8 million. The focus of this chapter is the Bucharest Early Intervention Project, which is a randomized controlled trial of foster care as an intervention for early institutionalization. It seeks to examine the developmental sequelae of early institutional rearing and whether placement into a family—in our case, high‐quality foster care—can ameliorate such sequelae. After discussing the context for launching this project and the history of institutional care in Romania, we describe our foster care intervention. We then turn our attention to describing the project itself and its main findings. We conclude by situating the project into a broader framework of developmental psychopathology.

Children raised in institutions experience psychosocial deprivation that can negatively impact attention skills and emotion regulation, which subsequently may influence behavioral regulation and social relationships. The current study examined visual attention biases in 8-year-old children who were part of the Bucharest Early Intervention Project (BEIP). Relations among attention biases and concurrent social outcomes were also investigated. In early childhood, 136 children abandoned at birth or shortly thereafter into institutional care were randomized to receive a high-quality foster care intervention or care-as-usual within the context of the Bucharest Early Intervention Project (BEIP). At 8 years of age, 50 care-as-usual, 55 foster care, and 52 community controls performed a behavioral dot-probe task, and indices of attention biases to threat and positive stimuli were calculated. Concurrent data on social behavior were collected. Children placed into the foster care intervention had a significant attention bias toward positive stimuli, while children who received care-as-usual had a significant bias toward threat. Children in the foster care intervention had a significantly larger positive bias when compared to the care-as-usual group. A positive bias was related to more social engagement, more prosocial behavior, less externalizing disorders, and less emotionally withdrawn behavior. The magnitude of positive bias was predicted by age of placement into foster care among children with a history of institutionalization. An attention bias towards positive stimuli was associated with reduced risk for behavioral problems amongst children who experienced early psychosocial deprivation. Research assessing attention biases in children experiencing early environmental stress may refine our understanding of the mechanisms underlying risk for later psychiatric and social disorders and inform prevention efforts.

Children exposed to institutional rearing often exhibit problems across a broad array of developmental domains. We compared the consequences of long-term, high-quality foster care versus standard institution-based care, which began in early childhood on cardiometabolic and immune markers assessed at the time of adolescence. The Bucharest Early Intervention Project is a longitudinal investigation of children institutionalized during early childhood (ages 6 to 30 months at baseline) who were subsequently randomized to either high-quality foster care or continued institutional care. At the age of 16 years, 127 respondents participated in a biomarker collection protocol, including 44 institutionalized children randomly assigned to receive care as usual, 41 institutionalized children randomized to be removed from institutional care and placed in high-quality foster care in infancy, and a control group of 42 demographically matched children raised in biological families. Outcomes included body mass index (BMI), systolic and diastolic blood pressure, C-reactive protein, interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor α, glycosylated hemoglobin A1c, and Epstein-Barr virus antibody titers. Early institutional rearing was not associated with differences in cardiometabolic or immune markers. Randomization to foster care and age of placement into foster care were also unrelated to these markers, with the exception of BMI z-score, where children assigned to care as usual had lower BMI z-scores relative to children assigned to foster care (-0.23 versus 0.08, p = .06), and older age at placement was associated with lower BMI (β = -0.07, p = .03). The impact of institutional rearing on measures of cardiometabolic health and immune system functioning is either absent or not evident until later in development. These findings provide new insights into the biological embedding of adversity and how it varies developmentally and across regulatory systems and adversity type. NCT00747396.

Early psychosocial deprivation can negatively impact the development of executive functions (EFs). Here we explore the impact of early psychosocial deprivation on behavioral and physiological measures (i.e., event-related potentials; ERPs) of two facets of EF, inhibitory control and response monitoring, and their associations with internalizing and externalizing outcomes in the Bucharest Early Intervention Project (BEIP; Zeanah et al., 2003). This project focuses on two groups of children placed in institutions shortly after birth and then randomly assigned in infancy to either a foster care intervention or to remain in their current institutional setting. A group of community controls was recruited for comparison. The current study assesses these children at 8-years of age examining the effects of early adversity, the potential effects of the intervention on EF and the role of EF skills in socio-emotional outcomes. Results reveal exposure to early psychosocial deprivation was associated with impaired inhibitory control on a flanker task. Children in the foster care intervention exhibited better response monitoring compared to children who remained in the institution on the error-related positivity (Pe). Moreover, among children in the foster care intervention those who exhibited larger error-related negativity (ERN) responses had lower levels of socio-emotional behavior problems. Overall, these data identify specific aspects of EF that contribute to adaptive and maladaptive socio-emotional outcomes among children experiencing early psychosocial deprivation.

Almas AN, Degnan KA, Radulescu A, et al. Effects of early intervention and the moderating effect of brain activity on institutionalized children’s social skills at age 8. PNAS. 2012; 10(Suppl 2): 17228-17231; doi: 10.1073/pnas.1121256109Investigators from multiple institutions sought to understand the effect of early foster care placement on the social skills of previously institutionalized children when they reached middle childhood. This study was part of the Bucharest Early Intervention Project (BEIP) that began in 2001. BEIP is a randomized controlled trial of foster care as an intervention for children abandoned at birth and placed in 1 of 6 institutions for young children in Bucharest, Romania. At the outset of the BEIP, 136 institutionalized children were randomized to either foster care or usual care in the institution in which they currently resided. Children who were randomized to foster care were initially placed at ages 7 to 35 months. A control group of non-institutionalized children from the Bucharest community were also enrolled and were matched on age and gender to children in the intervention groups.For the current study, children had their attachment security to a primary caregiver (foster mother or favorite caregiver in the institution) assessed by the preschool version of the Strange Situation Procedure when they were 42 months old. When participants were 8 years old, brain electrical activity (EEG) was obtained; EEG power in the alpha band (7-12 Hz) was computed, since alpha activity is associated with attention and processing of sensory information and high alpha power reflects cortical maturity.1 The primary outcome was social skills which were measured by administering the Social Skills Rating System (SSRS) to their teachers when the children were 8 years old. Social skills of children in each of the 3 groups were compared, and the effects of age at foster care placement, EEG alpha power, and attachment security on this outcome were assessed.In the present study, there were 44 children in the usual care group, 52 in the foster care group, and 97 in the control group. Only 12 children in the usual care group were still living in an institution at age 8 years. Overall, children in the control group were rated significantly higher on social skills than children in the foster care and usual care groups. However, children placed in foster care before 20 months of age were rated no differently on social skills than control children and were rated significantly higher than usual care children. High EEG power in the alpha band among usual care and foster care children was significantly associated with better attachment security and social skills. There was no significant relationship between attachment security and social skills in usual care and foster care children who had low EEG power in the alpha band.The authors conclude that forming secure foster care relationships positively influences social skills of children who have experienced severe social deprivation from early institutionalization, and that alpha electrical activity appears important in the relationship between attachment and social skills.Middle childhood is a period of increasing interest to both foster and adoptive parents because poor social skills at this critical time in a child’s life can lead to rejection and exclusion by their peers during the transition to adolescence.2 Wiik et al recently reported that postinstitutionalized children have a greater risk of attention-deficit hyperactivity disorder symptoms and emotional or internalizing behavioral disorders than children in foster care/minimal institutionalization and control children (see AAP Grand Rounds, June 2011;25[6]:623). Erol et al found that institutionalized adolescents with few friends and poor relationships have more internalizing and externalizing problem behaviors, which can persist into and complicate their adulthood.4In the current study the BEIP provided researchers a unique opportunity to evaluate how variations in attachment relationships can influence the negative impact of early institutionalization. The investigators have proffered evidence that foster care has the expected positive influence on the social development of children who have experienced deprivation, as long as the intervention occurs early enough in life. However, the results also demonstrate that future research must consider other factors, such as brain development, which can dramatically affect the attachment-social skills relationship.Life is full of limited time offers. For institutionalized children, this study now helps pinpoint the deadline (ie, 20 months of age) after which a critical intervention may no longer change the future bleak outcome and direction of a child’s life. And, like the hidden catches in many of these limited time offers, there is no guarantee that a good intervention will result in the desired outcome.

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This study reports on language outcomes at eight years from the Bucharest Early Intervention Project, a randomized controlled study of foster care. We previously have shown that children placed in foster care by age two have substantially stronger preschool language outcomes than children placed later and children remaining in institutional care. One hundred and five children participated in the current study, fifty-four originally assigned to foster care and fifty-one to continued institutional care. Even though current placements varied, children originally in foster care had longer sentences and stronger sentence repetition and written word identification. Children placed in foster care by age two had significant advantages in word identification and nonword repetition; children placed by age 1 ; 3 performed equivalently to community peers. The results show the continuing adverse effects of early poor institutional care on later language development and the key importance of age of placement in a more optimal environment.

High-Quality Foster Care Mitigates Callous-Unemotional Traits Following Early Deprivation in Boys: A Randomized Controlled Trial

Extreme social and cognitive deprivation as a result of institutional care has profound effects on developmental outcomes across multiple domains for many abandoned or orphaned children. The Bucharest Early Intervention Project (BEIP) examines the outcomes for children originally placed in institutions who were assessed comprehensively and then randomized to foster care (FCG) or care as usual (CAUG) and followed longitudinally. Here we report on the brain electrical activity (electroencephalogram: EEG) of 12-year-old children enrolled in the BEIP. Previous reports suggested improvement in resting EEG activity for the group of children placed in the foster care intervention, particularly those placed before 24 months of age compared to children who were randomized to CAUG or those placed into families after this age. At 12 years, differences between those in the FCG and those in the CAUG persist in the alpha band (8–13Hz), but not in higher frequency bands (i.e. in the beta band; 15–30Hz), except in those children placed into the FCG who remained in high quality care environments over the course of the study. These findings highlight the importance of maintaining a stable high quality caregiving environment, particularly for children exposed to early psychosocial deprivation, for promoting healthy brain development.

Romania’s Abandoned Children: Deprivation, Brain Development, and the Struggle for Recoveryby NelsonCharles A. FoxNathan A. and ZeanahCharles H.. Cambridge, Mass., Harvard University Press, 2014, 416 pp., $29.95.

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

Recovering From Early Deprivation: Attachment Mediates Effects of Caregiving on Psychopathology

Severe neglect in early life is associated with compromises in brain development and associated behavioral functioning. Although early intervention has been shown to support more normative trajectories of brain development, specific improvements in the white matter pathways that underlie emotional and cognitive development are unknown. To examine associations among neglect in early life, early intervention, and the microstructural integrity of white matter pathways in middle childhood. The Bucharest Early Intervention Project is a randomized clinical trial of high-quality foster care as an intervention for institutionally reared children in Bucharest, Romania, from 2000 through the present. During infancy, children were randomly selected to remain in an institution or to be placed in foster care. Those who remained in institutions experienced neglect, including social, emotional, linguistic, and cognitive impoverishment. Developmental trajectories of these children were compared with a group of sociodemographically matched children reared in biological families at baseline and several points throughout development. At approximately 8 years of age, 69 of the original 136 children underwent structural magnetic resonance imaging scans. Four estimates of white matter integrity (fractional anisotropy [FA] and mean [MD], radial [RD], and axial [AD] diffusivity) for 48 white matter tracts throughout the brain were obtained through diffusion tensor imaging. Significant associations emerged between neglect in early life and microstructural integrity of the body of the corpus callosum (FA, β = 0.01 [P = .01]; RD, β = -0.02 [P = .005]; MD, β = -0.01 [P = .02]) and tracts involved in limbic circuitry (fornix crus [AD, β = 0.02 (P = .046)] and cingulum [RD, β = -0.01 (P = .02); MD, β = -0.01 (P = .049)]), frontostriatal circuitry (anterior [AD, β = -0.01 (P = .02)] and superior [AD, β = -0.02 (P = .02); MD, β = -0.01 (P = .03)] corona radiata and external capsule [right FA, β = 0.01 (P = .03); left FA, β = 0.01 (P = .03); RD, β = -0.01 (P = .01); MD, β = -0.01 (P = .03)]), and sensory processing (medial lemniscus [AD, β = -0.02 (P = .045); MD, β = -0.01 (P = .04)] and retrolenticular internal capsule [FA, β = -0.01 (P = .002); RD, β = 0.01 (P = .003); MD, β = 0.01 (P = .04)]). Follow-up analyses revealed that early intervention promoted more normative white matter development among previously neglected children who entered foster care. Results suggest that removal from conditions of neglect in early life and entry into a high-quality family environment can support more normative trajectories of white matter growth. Our findings have implications for public health and policy efforts designed to promote normative brain development among vulnerable children. clinicaltrials.gov Identifier: NCT00747396.