Author: Zach Morrow

Attachment security as a mechanism linking foster care placement to improved mental health outcomes in previously institutionalized children

Written by Zach Morrow on . Posted in Psychological Effects of Orphanhood. Leave a Comment

Study Title: Attachment security as a mechanism linking foster care placement to improved mental health outcomes in previously institutionalized children

Authors: Katie A. McLaughlin, Charles H. Zeanah,Nathan A. Fox, Charles A. Nelson

Abstract: 

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.

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Validity of Evidence-Derived Criteria for Reactive Attachment Disorder: Indiscriminately Social/Disinhibited and Emotionally Withdrawn/Inhibited Types

Written by Zach Morrow on . Posted in Psychological Effects of Orphanhood. Leave a Comment

Study Title: Validity of Evidence-Derived Criteria for Reactive Attachment Disorder: Indiscriminately Social/Disinhibited and Emotionally Withdrawn/Inhibited Types

Authors: Mary Margaret Gleason, M.D., Nathan A. Fox, Ph.D.,Stacy Drury, M.D., Ph.D., Anna Smyke,Ph.D., Helen L. Egger, M.D., Charles A. Nelson III, Ph.D., Matthew C. Gregas, Ph.D., Charles H. Zeanah, M.D.

Abstract: 

Objective

This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD).

Method

As part of a longitudinal intervention trial of previously institutionalized children, caregiver interviews and direct observational measurements provided continuous and categorical data used to examine the internal consistency, criterion validity, construct validity, convergent and discriminant validity, association with functional impairment, and stability of these disorders over time.

Results

As in other studies, the findings showed distinctions between the two types of RAD. Evidence-derived criteria for both types of RAD showed acceptable internal consistency and criterion validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42, and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%), respectively. Signs of indiscriminately social/disinhibited RAD showed little association with caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%), and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally withdrawn/inhibited RAD was moderately associated with caregiving at the first three time points and strongly associated with attachment security. Signs of this type of RAD were associated with depressive symptoms, although two of the five children with this type of RAD at 54 months did not meet criteria for major depressive disorder. Signs of both types of RAD contributed independently to functional impairment and were stable over time.

Conclusions

Evidence-derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited RAD define two statistically and clinically cohesive syndromes that are distinct from each other, shows stability over 2 years, have predictable associations with risk factors and attachment, can be distinguished from other psychiatric disorders, and cause functional impairment. Clinical trial registration information—The Bucharest Early Intervention Project, URL: http://www.clinicaltrials.gov, unique identifier: NCT00747396.

 

 
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The effects of severe psychosocial deprivation and foster care intervention on cognitive development at 8 years of age: findings from the Bucharest Early Intervention Project

Written by Zach Morrow on . Posted in Psychological Effects of Orphanhood. Leave a Comment

Study Title: The effects of severe psychosocial deprivation and foster care intervention on cognitive development at 8 years of age: findings from the Bucharest Early Intervention Project

Authors: Nathan A. Fox, Alisa N. Almas, Kathryn A. Degnan, Charles A. Nelson, Charles H. Zeanah

Abstract: 

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.

 

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Telomere length and early severe social deprivation: linking early adversity and cellular aging

Written by Zach Morrow on . Posted in Longterm Consequences of Orphanhood. Leave a Comment

Study Title: Telomere length and early severe social deprivation: linking early adversity and cellular aging

Authors: S S Drury, K Theall, M M Gleason, A T Smyke, I De Vivo, J Y Y Wong, N A Fox, C H Zeanah and C A Nelson

Abstract: Accelerated telomere length attrition has been associated with psychological stress and early adversity in adults; however, no studies have examined whether telomere length in childhood is associated with early experiences. The Bucharest Early Intervention Project is a unique randomized controlled trial of foster care placement compared with continued care in institutions. As a result of the study design, participants were exposed to a quantified range of time in institutional care, and represented an ideal population in which to examine the association between a specific early adversity, institutional care and telomere length. We examined the association between average relative telomere length, telomere repeat copy number to single gene copy number (T/S) ratio and exposure to institutional care quantified as the percent of time at baseline (mean age 22 months) and at 54 months of age that each child lived in the institution. A significant negative correlation between T/S ratio and percentage of time was observed. Children with greater exposure to institutional care had significantly shorter relative telomere length in middle childhood. Gender modified this main effect. The percentage of time in institutional care at baseline significantly predicted telomere length in females, whereas the percentage of institutional care at 54 months was strongly predictive of telomere length in males. This is the first study to demonstrate an association between telomere length and institutionalization, the first study to find an association between adversity and telomere length in children, and contributes to the growing literature linking telomere length and early adversity.

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Timing of Intervention Affects Brain Electrical Activity in Children Exposed to Severe Psychosocial Neglect

Written by Zach Morrow on . Posted in Longterm Consequences of Orphanhood, Uncategorized. Leave a Comment

Study Title: Timing of Intervention Affects Brain Electrical Activity in Children Exposed to Severe Psychosocial Neglect

Authors: Ross E. Vanderwert, Peter J. Marshall, Charles A. Nelson III, Charles H. Zeanah, Nathan A. Fox

Abstract:

Background

Early psychosocial deprivation has profound effects on brain activity in the young child. Previous reports have shown increased power in slow frequencies of the electroencephalogram (EEG), primarily in the theta band, and decreased power in higher alpha and beta band frequencies in infants and children who have experienced institutional care.

Methodology/Principal Findings

We assessed the consequences of removing infants from institutions and placing them into a foster care intervention on brain electrical activity when children were 8 years of age. We found the intervention was successful for increasing high frequency EEG alpha power, with effects being most pronounced for children placed into foster care before 24 months of age.

Conclusions/Significance

The dependence on age of placement for the effects observed on high frequency EEG alpha power suggests a sensitive period after which brain activity in the face of severe psychosocial deprivation is less amenable to recovery.

 

 
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Stereotypies in Children With a History of Early Institutional Care

Written by Zach Morrow on . Posted in Psychological Effects of Orphanhood, Uncategorized. Leave a Comment

Authors: Karen J. Bos; Charles H. Zeanah Jr, MD; Anna T. Smyke, PhD; Nathan A. Fox, PhD; Charles A. Nelson III, PhD

Abstract:

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.

Trial Registration  clinicaltrials.gov Identifier: NCT00747396

Stereotypies are defined as repetitive, invariant movements with no obvious goal or function.1 Stereotypies may occasionally be seen in typically developing children but are more commonly associated with a number of different medical conditions, including autism and mental retardation. In addition, stereotypies are known to develop in association with atypical and especially restricted sensory environments or deprivation.1 The association of stereotypies with disorders of the central nervous system suggests a neurological basis, but the underlying cause, pathophysiology, and possible approaches for treatment all require further investigation.

In this article, we focus on stereotypies associated with early psychosocial deprivation. Most of our understanding of stereotypies associated with sensory-restricted environments comes from animal models. Stereotypies are the most common form of abnormal behavior found in caged animals, and animal models of deprivation-induced stereotypies have been found across many species. In these animal models, stereotypies have been linked to alterations in the cortical–basal ganglia circuitry.

Human models of severe psychosocial deprivation in early childhood are understandably more limited. However, there are case reports of previously healthy children who developed stereotypies after exposure to prolonged extreme deprivation. In 1 case, a typically developing, healthy, 3-year-old girl in Thailand exhibited a number of motor stereotypies after being isolated in a cage for 6 years. Four years after her reintegration into the community, she showed considerable improvement including the elimination of stereotypies, but she continued to have many developmental difficulties, particularly with speech.

Children raised in institutions provide another unfortunate but important group in which to study the effects of extreme early psychosocial deprivation, including the presence of stereotypies. Institutionalized children are known to exhibit deficits across numerous domains of functioning, including physical, psychiatric, and cognitive outcomes. There are a few reports in the literature suggesting an increased incidence and severity of motor stereotypies in this population, believed to be caused by the restricted sensory environment limiting typical input. Hypotheses for the functional significance of stereotypies in this environment include attempts at self-stimulating, coping mechanisms for self-soothing, or expressions of frustration or anxiety, particularly in children who lack adequate verbal communication skills.

An important issue that has not been addressed to date, to our knowledge, is a systematic study of the reduction or elimination of deprivation-induced stereotypies by restitution of enhanced caregiving environments. One report in the literature suggests a reduction in stereotypies after adoption and calls for additional research in this area. In this study of 46 children adopted from Romanian orphanages by families in British Columbia, Canada, 84% of caregivers reported the presence of stereotypies at the time of placement. The average age of the children at adoption was 18.5 months, and the mean time spent in institutions prior to adoption was 17.5 months. By the time the interview for the study was conducted (a median of 11 months after placement with the adopted family), 98% of stereotyped behavior problems were reported by caregivers to have shown some improvement or to be completely resolved. However, since children in this study were not randomly assigned to foster care placement, the application of these results to all children with a history of early institutional care is limited by selection bias. In addition, the study reports findings from only 1 assessment after placement and therefore does not provide data on stereotypies at later ages.

In the current study, we draw on data from the Bucharest Early Intervention Project (BEIP), a study of current and formerly institutionalized children in Romania. The BEIP is unique in its ability to evaluate directly the effects of early family placement rather than institutional care for young children because the participants were institutionalized children randomly assigned either to continued care as usual in the institution or to a foster care intervention. The BEIP is the first such randomized clinical trial to evaluate foster care as an alternative to institutional care for abandoned children. Because the children enrolled in this study were closely followed up longitudinally, this study also provides the unusual opportunity within the population of institutionalized children to investigate the course of stereotypies in children exposed to extreme deprivation and the presence of sensitive periods for the development or remediation of stereotypies.

This study addressed the following questions: (1) How many young children being raised in institutions exhibit stereotypies? (2) For children with a history of early institutionalization, does placement in a foster care intervention reduce or eliminate stereotypies? If so, is there an effect of timing of placement? (3) To characterize those children who continue to exhibit stereotypies compared with those whose stereotypies resolve, are there any correlates of stereotypies that we can identify in this population, particularly focusing on outcomes in language, cognition, and anxiety?

 

 

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