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Irritability reflects a propensity for frustration and anger, and is a transdiagnostic symptom of both externalizing and internalizing psychopathology. While early adverse experiences are associated with higher levels of irritability, experiences of early psychosocial deprivation and whether family-based placements can mitigate the impact on subsequent irritability, remain underexplored. The current study examined irritability in 107 16-year-olds with a history of institutional care from a randomized controlled trial of foster care as an alternative to institutional care and 49 community comparison children. At age 16 years, irritability was assessed using parent- and self-report forms of the Affective Reactivity Index. Compared to community adolescents, those with a history of institutional care exhibited significantly elevated irritability levels. Among those who experienced institutional care, those randomized to foster care had lower levels of irritability compared to participants randomized to the care-as-usual group, and this effect persists after controlling for baseline negative emotionality. These findings suggest a causal link between high-quality foster care and lower irritability following psychosocial deprivation. Additionally, longer duration in institutional care and non-family placement at age 16 years were associated with higher levels of irritability, highlighting the role of caregiving in explaining variation in irritability in adolescence. Policies that support long-term, high-quality family placements for children without regular caregivers should be prioritized., (© 2024. The Author(s).)

This study examined longitudinal data from the Bucharest Early Intervention Project, a randomized controlled trial of foster care as an alternative to institutional care following exposure to severe psychosocial deprivation. We report data from 135 participants assessed in early adulthood (age 18 y). We find that 16 y after randomization occurred, those who had been randomized to high-quality foster care had significantly higher IQ scores (9 points, 0.6 SD) than those randomized to care as usual. Mediation analyses provide evidence that the causal effect of the intervention on cognitive ability in early adulthood could be explained, in part, by higher-quality caregiving and attachment security. These findings indicate that early investment in family care as an alternative to institutional care leads to sustained gains in cognitive ability. Fostering caregiving relationships is a likely mechanism of the intervention. In addition, exploratory analyses indicate that stable placements throughout childhood are associated with the greatest long-term gains in cognitive ability. Whether early interventions for infants and young children lead to lasting change has significant implications for decisions to invest in programs aimed at improving children's developmental outcomes.

This study examined the impact of a school readiness intervention on external response monitoring in children in foster care. Behavioral and event-related potential (ERP) data were collected during a flanker task from children who received the Kids In Transition to School (KITS) Program (n = 26) and children who received services as usual (n = 19) before and after the intervention. While there were no significant group differences on the behavioral data, the ERP data for the two groups of children significantly differed. Specifically, in contrast to the children who received services as usual, the children who received the KITS Program displayed greater amplitude differences between positive and negative performance feedback over time for the N1, which reflects early attention processes, and feedback-related negativity, which reflects evaluation processes. In addition, although the two groups did not differ on amplitude differences between positive and negative performance feedback for these ERP components before the intervention, the children who received the KITS Program displayed greater amplitude differences than the children who received services as usual after the intervention. These results suggest that the KITS Program had an effect on responsivity to external performance feedback, which may be beneficial during the transition into kindergarten.

Background: Children reared in institutions experience profound deprivation that is linked to impairments in social communication (SC). However, little is known about the long-term consequences of institutional rearing on SC through adolescence, and how SC deficits relate to broad-spectrum psychopathology. It is also unclear whether early removal from deprivation and placement into socially enriched environments remediates these difficulties., Methods: Children reared in Romanian institutions from the Bucharest Early Intervention Project were randomly assigned to care as usual or foster care intervention in early childhood. An age- and sex-matched group of never-institutionalized children was also recruited. SC data from 208 children at age 8 and 129 children at 16 were collected using the Social Communication Questionnaire. Psychopathology was assessed as saved factor scores for general (P) and specific internalizing (INT) and externalizing (EXT) problems. We examined (a) whether institutional rearing is associated with continued SC deficits into adolescence; (b) whether early placement into foster care mitigates risk for SC problems; and (c) associations between SC and psychopathology from middle childhood (age 8) to adolescence (age 16)., Results: Findings suggest that: (a) institutionally-reared children have significantly more SC problems than never-institutionalized children at age 16; (b) children placed into foster care early in life have fewer problems with reciprocal social interaction compared to those with prolonged institutional rearing; and (c) deficits in SC at age 8 partially account for the link between institutional rearing and general psychopathology at age 16., Conclusions: Early deprivation is associated with impairments in SC that persist into adolescence, with evidence for the remedial benefit of family-based care in the domain of reciprocal social interaction. Moreover, deficits in SC among ever-institutionalized children in middle childhood may increase the risk of broad-spectrum psychopathology in adolescence, thus providing one putative target for early intervention to safeguard against later psychiatric problems., (© 2020 Association for Child and Adolescent Mental Health.)

Objective: Early psychosocial deprivation is associated with increased risk for psychopathology, yet few studies have examined outcomes in adolescents., Method: At baseline (M age 22 months), 136 children from Bucharest, Romania, living in large institutions, were randomized into foster care (FCG) or to care as usual (CAUG). Caregivers completed psychiatric interviews regarding their children (52 FCG; 51 CAUG) at age 16 years (M = 16.67 years; SD = 0.78) to assess past year diagnoses and symptom counts. In addition, never-institutionalized community comparison children (n = 47) were included., Results: Ever-institutionalized children had higher rates of meeting criteria for any psychiatric disorder and higher symptom counts of internalizing, externalizing, attention-deficit/hyperactivity, and substance use disorders compared to never-institutionalized children (ps < .05). Using intent-to-treat analyses, we found that children in the CAUG had more than twice the rate of psychiatric disorders than children in the FCG (OR = 2.48, 95% CI [1.12, 5.48]). Furthermore, children in foster care who remained in their original placement did not significantly differ in their rates of psychiatric disorders compared to never-institutionalized children., Conclusions: There are many ways children can be separated from parents, including placement into institutional care. The current findings indicate that such placements are associated with significant risks for psychopathology. Moreover, we provide causal evidence for the long-lasting positive effect of foster care in reducing the risk of psychopathology in adolescence, especially among those in stable placements. These results provide strong evidence that early and stable placements into quality foster care may mitigate risk for psychopathology following severe early psychosocial deprivation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Early adversity has been shown to sensitize individuals to the effects of later stress and enhance risk of psychopathology. Using a longitudinal randomized trial of foster care as an alternative to institutional care, we extend the stress sensitization hypothesis to examine whether early institutional rearing sensitizes individuals to stressful events in adolescence engendering chronic low-grade inflammation. At baseline, institutionalized children in Romania (ages 6-31 months) were randomly assigned to foster care or to remain in usual care within institutions. A group of never-institutionalized children was recruited as an in-country comparison sample. At ages 12 and 16, participants reported stressful events. At age 16, Interleukin-6 (IL-6) and C-reactive protein (CRP) were derived from blood spots. Among children assigned to care as usual, more stressful events at age 12, but not age 16, were associated with higher IL-6. In the same group, stressful events at age 16 were associated with higher CRP, though these effects attenuated after adjusting for covariates. These associations were not observed in the foster care or never-institutionalized groups. The findings suggest that heightened inflammation following stress exposure is one pathway through which early neglect could compromise physical health. In contrast, early family care might buffer against these risks.

Background: Children reared in institutions experience profound deprivation that is associated with both heightened levels of psychopathology and deficits in executive functioning (EF). It is unclear whether deficits in EF among institutionally-reared children serve as a vulnerability factor that increases risk for later psychopathology. It is also unclear whether this putative association between EF and psychopathology is transdiagnostic (i.e. cuts across domains of psychopathology), or specific to a given syndrome. Thus, we examined whether global deficits in EF mediate the association between severe childhood neglect and general v. specific psychopathology in adolescence., Methods: The sample consisted of 188 children from the Bucharest Early Intervention Project, a longitudinal study examining the brain and behavioral development of children reared in Romanian institutions and a comparison group of never-institutionalized children. EF was assessed at age 8, 12, and 16 using a well-validated measure of neuropsychological functioning. Psychopathology was measured as general (P) and specific internalizing (INT) and externalizing (EXT) factors at age 12 and 16., Results: Institutionally-reared children had lower global EF and higher general psychopathology (P) at all ages compared to never-institutionalized children. Longitudinal path analysis revealed that the effect of institutionalization on P at age 16 operated indirectly through poorer EF from ages 8 to 12. No indirect effects involving EF were observed for INT or EXT at age 16., Conclusions: We conclude that stable, global deficits in EF serve as a cognitive endophenotype that increases transdiagnostic vulnerability to psychopathology in adolescence among those who have experienced profound early neglect.

Exposure to early psychosocial deprivation as a result of institutional care disrupts typical brain development. The Bucharest Early Intervention Project (BEIP) is the first longitudinal study to investigate the neurodevelopment of institutionalized infants randomized to a foster care (FCG) intervention versus care as usual (CAUG). Here, we present findings from a follow-up assessment of brain electrical activity as indexed by resting EEG at age 16 years. In addition, we examined the effects of disruption of foster care placement (e.g. the number of moves among foster care placements) on brain electrical activity. Resting-state EEG was collected from 48 CAUG, 46 FCG and 48 never institutionalized (NIG) control participants. Absolute (µV 2 ) and relative (proportion) power were computed from eyes closed, resting EEG data for theta, alpha and beta frequency bands. The CAUG displayed higher relative theta and lower relative alpha power compared to the FCG at 16 years of age. The FCG showed brain activity comparable to the NIG. The results further showed that disruptions following the original foster care placement had an adverse effect on brain electrical activity. Within the foster care group, there were no effects of age of placement on EEG power. Placement of children who have experienced early institutional rearing into stable foster care settings ensure long-term improvement in brain functioning., (© 2019 John Wiley & Sons Ltd.)

Childhood adversity may sensitize certain individuals to later stress which triggers or amplifies psychopathology. The current study uses data from a longitudinal randomized controlled trial to examine whether severe early neglect among children reared in institutions increases vulnerability to the effects of later stressful life events on externalizing problems in adolescence, and whether social enrichment in the form of high-quality foster care buffers this risk. Children abandoned to Romanian institutions were randomly assigned to a foster care intervention or care-as-usual during early childhood. A sample of never-institutionalized children served as a comparison group. Here we report that, among those with prolonged institutional rearing, more stressful life events in preadolescence predicted higher externalizing problems in adolescence. This effect was not observed for never-institutionalized children or those in foster care, thus providing experimental evidence that positive caregiving experiences protect against the stress-sensitizing effects of childhood neglect on externalizing problems in adolescence.

Objective: 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., Methods: 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., Results: 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)., Conclusions: 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., Clinical Trial Registration: NCT00747396.

Objectives: To determine the effects of foster care vs institutional care, as well as disruptions in the caregiving environment on physical development through early adolescence., Study Design: This was a randomized controlled trial of 114 institutionalized, though otherwise healthy, children from 6 orphanages and 51 never institutionalized control children living in birth families (family care group) in Bucharest, Romania. Children were followed from baseline (21 months, range 5-31) through age 12 years for caregiving disruptions and growth trajectories and through age 14 years for pubertal development., Results: Children randomized to the foster care group showed greater rates of growth in height, weight, and body mass index (BMI) through age 12 years than institutionalized group. Tanner development was delayed in institutionalized group boys compared with foster care group and family care group boys at 12 but not 14 years. There were no differences in Tanner development and age of menarche among foster care group, institutionalized group, and family care group girls at ages 12 and 14 years. More disruptions in caregiving between 30 months and 12 years moderated decreases in growth rates of height in foster care group and weight in foster care group and institutionalized group across age. institutionalized group boys with ≥2 disruptions showed lower Tanner scores at age 12 vs institutionalized group and foster care group boys with <2 disruptions. foster care group girls with ≥2 disruptions had higher Tanner scores at age 14 vs foster care group girls with <2 disruptions. Age of menarche was not affected by caregiving disruptions., Conclusions: For children who experienced early institutionalization, stable placement within family care is essential to ensuring the best outcomes for physical developmental., Trial Registration: clinicaltrials.gov: NCT00747396., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Importance: It is unclear whether early institutional rearing is associated with more problematic trajectories of psychopathology from childhood to adolescence and whether assignment to foster care mitigates this risk., Objectives: To examine trajectories of latent psychopathology factors-general (P), internalizing (INT), and externalizing (EXT)-among children reared in institutions and to evaluate whether randomization to foster care is associated with reductions in psychopathology from middle childhood through adolescence., Design, Setting, and Participants: This longitudinal, intent-to-treat randomized clinical trial was conducted in Bucharest, Romania, where children residing in 6 institutions underwent baseline testing and were then randomly assigned to a care as usual group (CAUG) or a foster care group (FCG). A matched sample of a never-institutionalized group (NIG) was recruited to serve as a comparison group. The study commenced in April 2001, and the most recent (age 16 years) follow-up started in January 2015 and is ongoing., Intervention: Institutionally reared children randomized to high-quality foster homes., Main Outcomes and Measures: Psychopathology was measured using the MacArthur Health and Behavior Questionnaire. Teachers and/or caregivers reported on symptoms of psychopathology in several domains., Results: A total of 220 children (50.0% female; 119 ever institutionalized) were included in the analysis at the mean ages of 8, 12, and 16 years. A latent bifactor model with general (P) and specific internalizing (INT) and externalizing (EXT) factors offered a good fit to the data. At age 8 years, CAUG (mean, 0.41; 95% CI, 0.17-0.67) and FCG (mean, 0.30; 95% CI, 0.04-0.53) had higher P than NIG (mean, -0.40; 95% CI, -0.56 to -0.18). By age 16 years, FCG (mean, 0.07; 95% CI, -0.18 to 0.29) had lower P than CAUG (mean, 0.37; 95% CI, 0.13-0.60). This effect was likely driven by modest declines in P from age 8 years to age 16 years among FCG (slope, -0.12; 95% CI, -0.26 to 0.04) compared with CAUG, who remained stably high over this period (slope, -0.02; 95% CI, -0.19 to 0.14). Moreover, CAUG and FCG showed increasing divergence in EXT over time, such that FCG (mean, -0.30; 95% CI, -0.58 to -0.02) had fewer problems than CAUG (mean, 0.05; 95% CI, -0.25 to 0.36) by age 16 years. No INT differences were observed., Conclusions and Relevance: Institutionalization increases transdiagnostic vulnerability to psychopathology from childhood to adolescence, a period of significant social and biological change. Early assignment to foster care partially mitigates this risk, thus highlighting the importance of social enrichment in buffering the effects of severe early neglect on trajectories of psychopathology., Trial Registration: ClinicalTrials.gov Identifier: NCT00747396.

Background: Experiences in early life lay the foundation for later development and functioning. Severe psychosocial deprivation, as experienced by children in early institutional care, constitutes an adverse experience with long-term negative consequences. The Bucharest Early Intervention Project sought to examine the effects of foster care as an alternative to institutional care for abandoned infants in Romanian institutions., Methods: At a mean age of 22 months, institutionalized children were randomized to foster care or care as usual. At age 12 years, we followed-up with 98 of these children (50 randomized to foster care), as well as assessed 49 never institutionalized comparison children. Adaptive functioning was assessed across seven domains-mental health, physical health, substance use, risk-taking behavior, family relations, peer relations, and academic performance. Children at or above the threshold for adaptive functioning in at least six of seven domains were classified as having overall adaptive functioning in early adolescence., Results: Among all children who had experienced severe early deprivation, 40% exhibited adaptive functioning. Children randomized to foster care were significantly more likely to exhibit adaptive functioning at age 12 years than children in the care as usual condition (56% vs. 23%). In support of external validity, children who met the threshold for adaptive functioning at age 12 years had higher IQs and were more physiologically responsive to stress. Among children randomized to foster care, children placed prior to age 20 months were more likely to meet the threshold for adaptive functioning than those placed after this age (79% vs. 46%)., Conclusions: This study provides causal evidence that placing children into families following severe deprivation increases the likelihood of adaptive functioning in early adolescence., (© 2018 Association for Child and Adolescent Mental Health.)

Individual differences in the propensity for left versus right frontal electroencephalogram (EEG) asymmetry may underlie differences in approach/withdrawal tendencies and mental health deficits. Growing evidence suggests that early life adversity may shape brain development and contribute to the emergence of mental health problems. The present study examined frontal EEG asymmetry (FEA) following the transition to family care in children adopted internationally from institutional care settings between 15 and 36 months of age (N = 82; 46 female, 36 male). Two comparison groups were included: an international adoption control consisting of children adopted from foster care with little to no institutional deprivation (N = 45; 17 female, 28 male) and a post-adoption condition control consisting of children reared in birth families of the same education and income as the adoptive families (N = 48; 23 female, 25 male). Consistent with evidence of greater approach and impulsivity-related behavior problems in post-institutionalized (PI) children, PI status was associated with greater left FEA than found in the other two groups. In addition, left FEA served as a mediator between institutionalization and age 5 ADHD symptoms for girls. Age at adoption and other preadoption factors were examined with results suggesting that earlier adoption into a supportive family resulted in a more typical pattern of brain functioning. Findings support the idea that the capacity of brain activity to evidence typical functioning following perturbation may differ in relation to the timing of intervention and suggest that the earlier the intervention of adoption, the better.

Two disorders of attachment have been consistently identified in some young children following severe deprivation in early life: reactive attachment disorder and disinhibited social engagement disorder. However, less is known about whether signs of these disorders persist into adolescence. We examined signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years in 111 children who were abandoned at or shortly after birth and subsequently randomized to care as usual or to high-quality foster care, as well as in 50 comparison children who were never institutionalized. Consistent with expectations, those who experienced institutional care in early life had more signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years than children never institutionalized. In addition, using a conservative intent-to-treat approach, those children randomized to foster care had significantly fewer signs of reactive attachment disorder and disinhibited social engagement disorder than those randomized to care as usual. Analyses within the ever institutionalized group revealed no effects of the age of placement into foster care, but number of caregiving disruptions experienced and the percentage of the child's life spent in institutional care were significant predictors of signs of attachment disorders assessed in early adolescence. These findings indicate that adverse caregiving environments in early life have enduring effects on signs of attachment disorders, and provide further evidence that high-quality caregiving interventions are associated with reductions in both reactive attachment disorder and disinhibited social engagement disorder.

Children raised in institutions experience psychosocial deprivation that has detrimental influences on attention and mental health. The current study examined patterns of attention biases in children from institutions who were randomized at approximately 21.6 months to receive either a high-quality foster care intervention or care-as-usual. At age 12, children performed a dot-probe task and indices of attention bias were calculated. Additionally, children completed a social stress paradigm and cortisol reactivity was computed. Children randomized into foster care (N=40) exhibited an attention bias toward positive stimuli but not threat, whereas children who received care-as-usual (N=40) and a never-institutionalized comparison group (N=47) showed no bias. Stability of foster care placement was related to positive bias, while instability of foster care placement was related to threat bias. The magnitude of the positive bias was associated with fewer internalizing problems and better coping mechanisms. Within the foster care group, positive attention bias was related to less blunted cortisol reactivity., (Copyright © 2016 Elsevier B.V. All rights reserved.)

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 (8-13 Hz), but not in higher frequency bands (i.e. in the beta band; 15-30 Hz), 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., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Callous-unemotional (CU) traits in childhood are a developmental precursor to psychopathy, yet the origins and etiology of CU traits are not known. We examined CU traits among 12-year-old children exposed to severe early deprivation and evaluated whether a high-quality foster care intervention mitigated the development of high levels of CU traits., Method: Participants were from the Bucharest Early Intervention Project, a randomized controlled trial of foster care for children in institutions. Children were recruited from institutions in Bucharest, Romania, along with age- and sex-matched children who were never institutionalized. Children raised in institutional settings were randomized (mean age = 22 months) to either a foster care group (n = 68) or a care-as-usual group (n = 68). CU traits were assessed at age 12.75 years in available participants from the randomized trial (n = 95) and children who were never institutionalized (n = 50)., Results: Children who experienced institutional rearing as young children had significantly higher levels of CU traits in early adolescence compared to children who were never institutionalized. Intent-to-treat analysis indicated that, among boys, CU traits were significantly lower among those who received the foster care intervention compared to those randomized to care as usual. Caregiver responsiveness to distress, but not caregiver warmth, mediated the intervention effect on CU traits in boys., Conclusion: These findings provide the first evidence to date that psychosocial intervention can prevent the onset of CU traits. Although severe early deprivation predicted higher levels of CU traits, high-quality foster care that emphasized responsive caregiving reduced the impact of deprivation on CU trait development for boys., Clinical Trial Registration Information: The Bucharest Early Intervention Project; http://clinicaltrials.gov; NCT00747396., (Copyright © 2015 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

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: National Institute of Mental Health and the John D and Catherine T MacArthur Foundation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Disruptions in stress response system functioning are thought to be a central mechanism by which exposure to adverse early-life environments influences human development. Although early-life adversity results in hyperreactivity of the sympathetic nervous system (SNS) and hypothalamic-pituitary-adrenal (HPA) axis in rodents, evidence from human studies is inconsistent. We present results from the Bucharest Early Intervention Project examining whether randomized placement into a family caregiving environment alters development of the autonomic nervous system and HPA axis in children exposed to early-life deprivation associated with institutional rearing. Electrocardiogram, impedance cardiograph, and neuroendocrine data were collected during laboratory-based challenge tasks from children (mean age = 12.9 y) raised in deprived institutional settings in Romania randomized to a high-quality foster care intervention (n = 48) or to remain in care as usual (n = 43) and a sample of typically developing Romanian children (n = 47). Children who remained in institutional care exhibited significantly blunted SNS and HPA axis responses to psychosocial stress compared with children randomized to foster care, whose stress responses approximated those of typically developing children. Intervention effects were evident for cortisol and parasympathetic nervous system reactivity only among children placed in foster care before age 24 and 18 months, respectively, providing experimental evidence of a sensitive period in humans during which the environment is particularly likely to alter stress response system development. We provide evidence for a causal link between the early caregiving environment and stress response system reactivity in humans with effects that differ markedly from those observed in rodent models.

Importance: 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., Objective: To examine associations among neglect in early life, early intervention, and the microstructural integrity of white matter pathways in middle childhood., Design, Setting, and Participants: 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., Main Outcomes and Measures: 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., Results: 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., Conclusions and Relevance: 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., Trial Registration: clinicaltrials.gov Identifier: NCT00747396.

We examined caregiver report of externalizing behavior from 12 to 54 months of age in 102 children randomized to care as usual in institutions or to newly created high-quality foster care. At baseline no differences by group or genotype in externalizing were found. However, changes in externalizing from baseline to 42 months of age were moderated by the serotonin transporter linked polymorphic region genotype and intervention group, where the slope for short-short (S/S) individuals differed as a function of intervention group. The slope for individuals carrying the long allele did not significantly differ between groups. At 54 months of age, S/S children in the foster care group had the lowest levels of externalizing behavior, while children with the S/S genotype in the care as usual group demonstrated the highest rates of externalizing behavior. No intervention group differences were found in externalizing behavior among children who carried the long allele. These findings, within a randomized controlled trial of foster care compared to continued care as usual, indicate that the serotonin transporter linked polymorphic region genotype moderates the relation between early caregiving environments to predict externalizing behavior in children exposed to early institutional care in a manner most consistent with differential susceptibility.

Institutional rearing of young children has been demonstrated to increase risk for a broad range of psychiatric disorders and other impairments. This has led many countries to consider or to invest in foster care. However, no study to date has explored potential differences in psychiatric symptoms in children placed in different types of foster care. We assessed internalizing disorders, externalizing disorders, and attention deficit hyperactivity disorder (ADHD) in 54-month-old children living with foster families. We compared one group of children living in high-quality foster families who had benefited from specialized training and support to another group of children placed with government-sponsored foster care in Bucharest, Romania. After controlling for duration of time spent in foster care, there was a main group effect in predicting ADHD (p = .021) and a marginal group × gender interaction effect. No effects were noted for signs of externalizing disorders. There was, however, a significant group × gender interaction effect of signs of internalizing disorders (p = .007), with the girls in high-quality foster care having less severe symptomatology than did their counterparts in the government-sponsored group. Governments must invest in quality interventions for their most vulnerable citizens to prevent serious and potentially lasting problems., (© 2014 Michigan Association for Infant Mental Health.)

Objective: This study included 54-month-old children with a history of institutional care. Our goal was to: (1) examine differences in indiscriminate social behaviors in children with a history of institutional care compared with home-reared children; (2) test whether foster care reduces indiscriminate social behaviors in a randomized controlled trial; and (3) examine early predictors of indiscriminate behaviors., Methods: Participants were 58 children with a history of institutional care and 31 never-institutionalized control (NIG) subjects enrolled in a randomized controlled trial of foster care for institutional care, assessed from toddlerhood to 54 months. Indiscriminate social behaviors were measured naturalistically by using the Stranger at the Door procedure., Results: In the Stranger at the Door procedure, children with a history of institutional care left with a stranger at higher rates than NIG subjects (33% vs. 3.5%; P < .001). Children in the care as usual group left more than NIG subjects (41.9% vs. 3.6%; P ≤ .001). The differences between the foster care group (24.1%) and the care as usual group and between foster care group and NIG were not significant. In a logistic regression, early disorganized attachment behaviors, baseline developmental quotient, and caregiving quality after randomization contributed to variance at 54 months. In the same analysis using only children with a history of institutional care, only disorganized attachment contributed significantly to 54-month indiscriminate social behaviors (Exp[B] = 1.6 [95% confidence interval: 1.1-2.5])., Conclusions: Observed socially indiscriminate behaviors at 54 months were associated with prolonged exposure to institutional care. Young children raised in conditions of deprivation who fail to develop organized attachments as toddlers are at increased risk for subsequent indiscriminate behaviors.

Objectives: To determine the effect of psychosocial deprivation early in life on motor development, assess the impact of a foster care intervention on improving motor development, and assess the association between motor and cognitive outcomes in children with a history of institutional care., Study Design: In a randomized controlled trial, children living in Romanian institutions were randomly assigned to care as usual in the institution or placed in family-centered foster care as part of the Bucharest Early Intervention Project. The average age at placement into foster care was 23 months. At age 8 years, the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, Short Form (BOT2-SF) was applied to assess the motor proficiency of children in both groups, as well as a never-institutionalized group from the Romanian community., Results: Children in the never-institutionalized group did significantly better on the BOT2-SF than children who had ever been institutionalized (P < .001). There was no significant difference in performance between children in the care as usual group and the foster care group. This finding also held true for all individual items on the BOT2-SF except sit-ups. Regression analyses revealed that the between-group and within-group differences in BOT2-SF scores were largely mediated by IQ., Conclusion: Early deprivation had a negative effect on motor development that was not resolved by placement in foster care. This effect was predominantly mediated by IQ. This study highlights the importance of monitoring for and addressing motor delays in children with a history of institutionalization, particularly those children with low IQ., (Copyright © 2014 Mosby, Inc. All rights reserved.)

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.

Objective: The authors examined signs of emotionally withdrawn (inhibited type) and indiscriminately social (disinhibited type) reactive attachment disorder in Romanian children enrolled in a randomized trial of foster care compared with institutional care and in a comparison group of never-institutionalized children., Method: At baseline and when children were ages 30, 42, and 54 months and 8 years, caregivers were interviewed with the Disturbances of Attachment Interview to assess changes in signs of reactive attachment disorder in three groups of children: those receiving care as usual (including continued institutional care) (N=68); those placed in foster care after institutional care (N=68); and those who were never institutionalized (N=72). The impact of gender, ethnicity, and baseline cognitive ability was also examined., Results: On the Disturbances of Attachment Interview, signs of the inhibited type of reactive attachment disorder decreased after placement in foster care, and scores were indistinguishable from those of never-institutionalized children after 30 months. Signs of the disinhibited type were highest in the usual care group, lower in the foster care group, and lowest in the never-institutionalized group. Early placement in foster care (before age 24 months) was associated with fewer signs of the disinhibited type. Lower baseline cognitive ability was associated with more signs of the inhibited type in the usual care group and more signs of the disinhibited type in both groups., Conclusions: Signs of the inhibited type of reactive attachment disorder responded quickly to placement in foster care; signs of the disinhibited type showed less robust resolution with foster placement. Lower baseline cognitive ability was linked to signs of reactive attachment disorder.

Early adversity can negatively impact the development of cognitive functions, although little is known about whether such effects can be remediated later in life. The current study examined one facet of executive functioning - inhibitory control - among children who experienced institutional care and explored the impact of a foster care intervention within the context of the Bucharest Early Intervention Project (BEIP). Specifically, a go/nogo task was administered when children were eight years old and behavioral and event-related potential (ERP) measures were collected. Results revealed that children assigned to care as usual (i.e. institutional care) were less accurate and exhibited slower neural responses compared to children assigned to the foster care intervention and children who had never been institutionalized. However, children in both the care as usual and foster care groups exhibited diminished attention processing of nogo cues as assessed via P300 amplitude. Foster care children also showed differential reactivity between correct and error responses via the error-related negativity (ERN) as compared to children in the care as usual group. Combined, the results highlight perturbations in neural sources of behavioral and attention problems among children experiencing early adversity. Potential implications for academic adjustment in at risk children are discussed., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Children reared in institutions experience elevated rates of psychiatric disorders. Inability to form a secure attachment relationship to a primary caregiver is posited to be a central mechanism in this association. We determined whether the ameliorative effect of a foster care (FC) intervention on internalizing disorders in previously institutionalized children was explained by the development of secure attachment among children placed in FC. Second we evaluated the role of lack of attachment in an institutionalized sample on the etiology of internalizing disorders within the context of a randomized trial., Methods: A sample of 136 children (aged 6-30 months) residing in institutions was recruited in Bucharest, Romania. Children were randomized to FC (n = 68) or to care as usual (CAU; n = 68). Foster parents were recruited, trained, and overseen by the investigative team. Attachment security at 42 months was assessed using the Strange Situation Procedure, and internalizing disorders at 54 months were assessed using the Preschool Age Psychiatric Assessment., Results: Girls in FC had fewer internalizing disorders than girls in CAU (OR = 0.17, p = .006). The intervention had no effect on internalizing disorders in boys (OR = 0.47, p = .150). At 42 months, girls in FC were more likely to have secure attachment than girls in CAU (OR = 12.5, p < .001), but no difference was observed in boys (OR = 2.0, p = .205). Greater attachment security predicted lower rates of internalizing disorders in both sexes. Development of attachment security fully mediated intervention effects on internalizing disorders in girls., Conclusion: Placement into FC facilitated the development of secure attachment and prevented the onset of internalizing disorders in institutionalized girls. The differential effects of FC on attachment security in boys and girls explained gender differences in the intervention effects on psychopathology. Findings provide evidence for the critical role of disrupted attachment in the etiology of internalizing disorders in children exposed to institutionalization., (© 2011 The Authors. Journal of Child Psychology and Psychiatry © 2011 Association for Child and Adolescent Mental Health.)

Background: Previous reports from the Bucharest Early Intervention Project suggested that children removed from institutions and placed into intervention displayed gains in IQ relative to children randomized to remain in institutional care., Method: The current report presents data from the 8-year follow-up of these children. One hundred and three of the original 136 children in the study were tested with the WISC IV., Results: Results reveal continued benefit from the intervention even though many of the children in both the intervention and control groups were no longer residing in their initial placements. Gains in IQ were particularly evident for those children who remained with their intervention family. There were also modest timing effects such that children placed earlier displayed higher scores on the WISC processing speed subscale. Early placement was also a significant predictor of a profile of stable, typical IQ scores over time., Conclusion: These data suggest the continued importance of early intervention and the negative effects of severe psychosocial deprivation on the development of IQ scores across early childhood., (© 2011 The Authors. Journal of Child Psychology and Psychiatry © 2011 Association for Child and Adolescent Mental Health.)

This report examines 174 young children's language outcomes in the Bucharest Early Intervention Project, the first randomized trial of foster placement after institutional care. Age of foster placement was highly correlated with language outcomes. Placement by 15 months led to similar expressive and receptive language test scores as typical age peers at 30 and 42 months. Placement from 15 to 24 months also led to dramatic language improvement. In contrast, children placed after 24 months had the same severe language delays as children in institutional care. Language samples at 42 months confirmed that placement after 24 months led to lower expressive skill., (© 2011 The Authors. Child Development © 2011 Society for Research in Child Development, Inc.)

Children raised in institutions, considered an extreme example of social deprivation, are one group through which we can better understand the impact of neglect on child health and development. The Bucharest Early Intervention Project (BEIP) is the first randomized, controlled trial of foster care as an intervention for institutionalized children. In this review we describe the mental health outcomes from the BEIP. Specifically, we report findings on attachment styles, attachment disorders, emotional reactivity, and psychiatric symptomatology for children in the BEIP. We describe the impact of the foster care intervention on these outcomes and also describe how outcomes differ by gender and by length of time spent in the institution. In addition, we explore the influence of genetic variation on individual outcomes and recovery from early severe social deprivation, as well as the role of differences in brain development in mediating later psychiatric morbidity. The results from the BEIP confirm and extend the previous findings on the negative sequelae of early institutional care on mental health. The results also underscore the benefit of early family placement for children living in institutions.

Objectives: To determine effects of improved nurturing compared with institutional care on physical growth and to investigate the association between growth and cognitive development., Design: A randomized controlled trial beginning in infants (mean age, 21.0 months; range, 5-32 months), with follow-up at 30, 42, and 54 months of age., Setting: Institutionalized and community children in Bucharest, Romania., Participants: One hundred thirty-six healthy institutionalized children from 6 orphanages and 72 typically developing, never-institutionalized children., Intervention: Institutionalized children were randomly assigned to receive foster care or institutional care as usual., Outcome Measures: Auxology and measures of intelligence over time., Results: Growth in institutionalized children was compromised, particularly in infants weighing less than 2500 g at birth. Mean height and weight, though not head size, increased to near normal within 12 months in foster care. Significant independent predictors for greater catch-up in height and weight included age younger than 12 months at randomization, lower baseline z scores, and higher caregiving quality, particularly caregiver sensitivity and positive regard. Baseline developmental quotient, birth weight, and height catch-up were significant independent predictors of cognitive abilities at follow-up. Each incremental increase of 1 in standardized height scores between baseline and 42 months was associated with a mean increase of 12.6 points (SD, 4.7 points) in verbal IQ (P < .05)., Conclusions: Foster care had a significant effect on growth, particularly with early placement and high-quality care. Growth and IQ in low-birth-weight children are particularly vulnerable to social deprivation. Catch-up growth in height under more nurturing conditions is a useful indicator of caregiving quality and cognitive improvement.

Objectives: To investigate the prevalence of stereotypies in children with a history of early institutional care, evaluate the efficacy of a foster care intervention compared with institutional care on the course of stereotypies, and describe correlates in language, cognition, and anxiety for children who exhibit stereotypies., Design: Randomized controlled trial., Setting: Institutions in Bucharest, Romania., Participants: One hundred thirty-six children with a history of early institutional care. Intervention Comparison of a foster care intervention with continued care as usual in an institution., Main Outcome Measures: The presence of stereotypies as well as outcomes in language, cognition, and anxiety., Results: At the baseline assessment prior to placement in foster care (average age of 22 months), more than 60% of children in institutional care exhibited stereotypies. Follow-up assessments at 30 months, 42 months, and 54 months indicated that being placed in families significantly reduced stereotypies, and with earlier and longer placements, reductions became larger. For children in the foster care group, but not in the care as usual group, stereotypies were significantly associated with lower outcomes on measures of language and cognition., Conclusions: Stereotypies are prevalent in children with a history of institutional care. A foster care intervention appears to have a beneficial/moderating role on reducing stereotypies, underscoring the need for early placement in home-based care for abandoned children. Children who continue to exhibit stereotypies after foster care placement are significantly more impaired on outcomes of language and cognition than children without stereotypies and thus may be a target for further assessments or interventions.

This study examined classifications of attachment in 42-month-old Romanian children (N = 169). Institutionalized since birth, children were assessed comprehensively, randomly assigned to care as usual (CAU) or to foster care, and compared to family-reared children. Attachment classifications for children in foster care were markedly different from those in the CAU. Importantly, children placed in foster care before 24 months were more likely to have secure attachments and if placed earlier were less likely to have disorganized or insecure-other attachments. Cognitive status predicted greater likelihood of organized attachment in the CAU and greater likelihood of secure attachment in the foster care and never-institutionalized groups. Foster care is an important intervention to reduce the adverse effects following early deprivation.

Objective: There is increasing interest in the relations between adverse early experiences and subsequent psychiatric disorders. Institutional rearing is considered an adverse caregiving environment, but few studies have systematically examined its effects. This study aimed to determine whether removing young children from institutional care and placing them with foster families would reduce psychiatric morbidity at 54 months of age., Method: Young children living in institutions in Bucharest were enrolled when they were between 6 and 30 months of age. Following baseline assessment, 136 children were randomly assigned to care as usual (continued institutional care) or to removal and placement in foster care that was created as part of the study. Psychiatric disorders, symptoms, and comorbidity were examined by structured psychiatric interviews of caregivers of 52 children receiving care as usual and 59 children in foster care when the children were 54 months of age. Both groups were compared to 59 typically developing, never-institutionalized Romanian children recruited from pediatric clinics in Bucharest. Foster care was created and supported by social workers in Bucharest who received regular consultation from U.S. clinicians., Results: Children with any history of institutional rearing had more psychiatric disorders than children without such a history (53.2% versus 22.0%). Children removed from institutions and placed in foster families were less likely to have internalizing disorders than children who continued with care as usual (22.0% versus 44.2%). Boys were more symptomatic than girls regardless of their caregiving environment and, unlike girls, had no reduction in total psychiatric symptoms following foster placement., Conclusions: Institutional rearing was associated with substantial psychiatric morbidity. Removing young children from institutions and placing them in families significantly reduced internalizing disorders, although girls were significantly more responsive to this intervention than boys.

The Bucharest Early Intervention Project is a randomized controlled trial of foster care as an intervention for young children who have spent most of their lives in institutions in Bucharest, Romania. The authors implemented an attachment-based model of child-centered foster care there, and a team of three Romanian social workers trained and supported foster parents in managing the complex challenges of caring for postinstitutionalized infants and toddlers. They received regular weekly consultation from US-based clinicians designed to guide their work with foster parents and children. From language development to toilet training to encouraging the development of the young child's ability to trust, foster parents received ongoing support to help these young children transition to family life. Developmental outcomes so far indicate significantly better outcomes for young children in this foster care program than children who remained in institutions. For some domains of development, earlier placement was associated with better outcomes but for others, timing of placement did not appear to matter.

The current study was designed to explore the use of behavioral (i.e., accuracy and reaction times) and electrophysiological measures (i.e., event-related potentials) to assess the impact of a family-based preventive intervention for preschool-aged, maltreated children in foster care. These measures were recorded during a computerized flanker task designed to assess cognitive control and response monitoring. The sample was recruited from a larger randomized efficacy trial of Multidimensional Treatment Foster Care for Preschoolers (MTFC-P) and included foster children assigned to the intervention condition (n = 10), foster children assigned to a services-as-usual comparison condition (n = 13), and low-income, nonmaltreated community children (n = 11). The children's behavioral and electrophysiological performance on the task was generally consistent with previous research with adults and older children. There were no group differences on the behavioral measures of cognitive control or response monitoring. Notably, however, group differences were observed on the electrophysiological measures of response monitoring. Specifically, the foster children who received services as usual were significantly less responsive to performance feedback about errors than the foster children who received the intervention and the nonmaltreated children. Applications of this methodology and implications of the results for future prevention research are discussed.

Background: We examined the effects of a foster care intervention on attention and emotion expression in socially deprived children in Romanian institutions., Methods: Institutionalized children were randomized to enter foster care or to remain under institutional care. Subsequently, the institutionalized and foster care groups, along with a community-based comparison group, were evaluated on emotion tasks at 30 and 42 months of age. Behaviors reflecting positive and negative affect and attention were coded from videotapes., Results: Data indicated that at both age points, children who received the foster care intervention showed higher levels of attention and positive affect compared to children who remained institutionalized. Compared to the community sample, children in the foster care intervention showed higher levels of attention to the emotion-eliciting tasks at 42 months of age., Conclusions: The results of this randomized trial demonstrate the impact of a family-based intervention on the development of attention and positive affect.

Two groups of Romanian children were compared on spectral power and coherence in the electroencephalogram (EEG) in early childhood. One group consisted of previously institutionalized children who had been randomly assigned to a foster care intervention at a mean age of 23 months. The second group had been randomized to remain in institutional care. Because of a policy of noninterference, a number of these children also experienced placement into alternative family care environments. There were minimal group differences between the foster care and institutionalized groups in EEG power and coherence across all measured frequency bands at 42 months of age. However, age at foster care placement within the foster care group was correlated with certain measures of EEG power and coherence. Earlier age at foster care placement was associated with increased alpha power and decreased short-distance EEG coherence. Further analyses separating age at placement from duration of intervention suggest that this effect may be more robust for EEG coherence than EEG band power. Supplementary analyses examined whether the EEG measures mediated changes in intellectual abilities within the foster care children, but no clear evidence of mediation was observed.

In a randomized controlled trial, we compared abandoned children reared in institutions to abandoned children placed in institutions but then moved to foster care. Young children living in institutions were randomly assigned to continued institutional care or to placement in foster care, and their cognitive development was tracked through 54 months of age. The cognitive outcome of children who remained in the institution was markedly below that of never-institutionalized children and children taken out of the institution and placed into foster care. The improved cognitive outcomes we observed at 42 and 54 months were most marked for the youngest children placed in foster care. These results point to the negative sequelae of early institutionalization, suggest a possible sensitive period in cognitive development, and underscore the advantages of family placements for young abandoned children.

Understanding the impact that early psychosocial neglect has on the course of human development has implications for the millions of children around the world who are living in contexts of adversity. In the United States, approximately 76% of cases reported to child protective services involve neglect; worldwide, there are more than 150 million orphaned or abandoned children, including 10.5 million orphaned because of COVID-19. In much of the world, children without primary caregivers are reared in institutional settings. We review two decades of research based on the only randomized controlled trial of foster care as an alternative to institutional care. We report that children randomly assigned to continued care as usual (institutional care) suffer from persistent deficits in social, cognitive, and emotional development and show evidence of disruptions in brain development. By contrast, children randomly assigned to foster care show improvements in most domains of functioning, although the degree of recovery is in part a function of how old they were when placed into foster care and the stability of that placement. These findings have important implications for understanding critical periods in human development as well as elucidate the power of the psychosocial environment in shaping multiple domains of human development. [ABSTRACT FROM AUTHOR]

The Bucharest Early Intervention Project is the first randomized controlled trial of foster care as an alternative to institutional care. The authors synthesized data from nearly 20 years of assessments of the trial to determine the overall intervention effect size across time points and developmental domains. The goal was to quantify the overall effect of the foster care intervention on children's outcomes and examine sources of variation in this effect, including domain, age, and sex assigned at birth. An intent-to-treat approach was used to examine the causal effects of the randomized controlled trial for 136 children residing in institutions in Bucharest, Romania (baseline age, 6–31 months) who were randomly assigned to either foster care (N=68) or care as usual (N=68). At ages 30, 42, and 54 months and 8, 12, and 16–18 years, children were assessed for IQ, physical growth, brain electrical activity (EEG), and symptoms of five types of psychopathology. Participants provided 7,088 observations across follow-up waves. Children assigned to foster care had better cognitive and physical outcomes and less severe psychopathology than did those who received care as usual. The magnitude of these effect sizes remained stable across development. The foster care intervention most influenced IQ and disorders of attachment/social relatedness. Young children benefit from placement in families after institutional care. The benefits of foster care for previously institutionalized children were remarkably stable across development. [ABSTRACT FROM AUTHOR]