Article Title: The Effects of Early Social-Emotional and Relationship Experience on the Development of Young Orphanage Children
Authors: The St. Petersburg—USA Orphanage Research Team
Abstract: Undertaken at orphanages in Russia, this study tests the role of early social and emotion experience in the development of children. Children were exposed to either multiple caregivers who performed routine duties in a perfunctory manner with minimal interaction or fewer caregivers who were trained to engage in warm, responsive, and developmentally appropriate interactions during routine care. Engaged and responsive caregivers were associated with substantial improvements in child development and these findings provide a rationale for making similar improvements in other institutions, programs, and organizations.
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Article Title: Review: The consequences of early institutionalization: can institutions be improved? – should they?
Authors: Robert B. McCall
Background and scope
The focus of this review is on institutionalized children, one of the most inequitably and severely treated groups of children. Although institutions vary, many share some common characteristics, including large groups, high children:caregiver ratios, many and changing caregivers and caregiver-child interactions that lack warm, sensitive, contingently-responsive and child-directed behaviours. Resident children develop poorly physically, mentally and social-emotionally, but those adopted from institutions display substantial catch-up growth in many domains of development. If they are adopted at an early age, there have been no long-term consequences of institutionalization yet measured; but if institutionalization is prolonged, they display higher rates of long-term deficiencies and problems in many domains.
This review is based on a database search of the literature, focusing on the development of children while residents, and the development of post-institutionalized children who have been transitioned from institutions to family care. It also draws on the reports and findings of the St. Petersburg–USA Orphanage intervention.
A combination of theories pertaining to attachment (especially caregiver attachment to the infant–toddler), chronic stress and genetics may explain these outcomes. It appears that caregiver–child interactions are a major contributor to children’s outcomes and interventions in institutions that improve such interactions produce substantial increases in children’s physical, mental and social-emotional development, including for children with disabilities.
Deinstitutionalization and the creation of comprehensive professional child welfare systems emphasizing family care alternatives is a preferred goal, but this is likely to take many low-resource countries decades to develop. If substantial numbers of children remain in institutions despite best efforts to find families for them, improving the institutions might help to provide all the children with the best care possible under the circumstances.
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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
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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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.
This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD).
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.
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.
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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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
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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Authors: Karen J. Bos; Charles H. Zeanah Jr, MD; Anna T. Smyke, PhD; Nathan A. Fox, PhD; Charles A. Nelson III, PhD
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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Study Title: Delayed maturation in brain electrical activity partially explains the association between early environmental deprivation and symptoms of attention-deficit/hyperactivity disorder
Authors: McLaughlin, K.A., Fox, N.A., Zeanah, C.H., Sheridan, M. A., Marshall, P.J., & Nelson, C.A.
Abstract: Children raised in institutional settings are exposed to social and environmental circumstances that may deprive them of expected environmental inputs during sensitive periods of brain development that are necessary to foster healthy development. This deprivation is thought to underlie the abnormalities in neurodevelopment that have been found in previously institutionalized children. It is unknown whether deviations in neurodevelopment explain the high rates of developmental problems evident in previously institutionalized children, including psychiatric disorders. We present data from a sample of children raised in institutions in Bucharest, Romania (n = 117) and an age- and sex-matched sample of community control subjects (n = 49). Electroencephalogram data were acquired following entry into the study at age 6 to 30 months, and a structured diagnostic interview of psychiatric disorders was completed at age 54 months. Children reared in institutions evidenced greater symptoms of attention-deficit/hyperactivity disorder, anxiety, depression, and disruptive behavior disorders than community controls. Electroencephalogram revealed significant reductions in alpha relative power and increases in theta relative power among children reared in institutions in frontal, temporal, and occipital regions, suggesting a delay in cortical maturation. This pattern of brain activity predicted symptoms of hyperactivity and impulsivity at age 54 months, and significantly mediated the association between institutionalization and attention-deficit/hyperactivity disorder symptoms. Electroencephalogram power was unrelated to depression, anxiety, or disruptive behaviors. These findings document a potential neurodevelopmental mechanism underlying the association between institutionalization and psychiatric morbidity. Deprivation in social and environmental conditions may perturb early patterns of neurodevelopment and manifest as psychiatric problems later in life.
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Study Title: Stereotypies in children with a history of early institutional care.
Authors: Bos, K., Zeanah, C.Z., Fox, N.A., & Nelson, C.A.
Abstract: 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. 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.
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Study Title: A new model of foster care for young children: The Bucharest Early Intervention Project
Authors: Zeanah, C.H., Egger. H.L., Smyke, A.T., Nelson, C.A., Fox, N.A., Marshall, P.J., & Guthrie, D.
Abstract: 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.
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