Author: Reese Sim

Study Title: Placement in foster care enhances quality of attachment among young institutionalized children

Authors: Smyke, A.T., Zeanah, C.H., Fox, N.A., Nelson, C.A., & Guthrie, D.

Abstract: 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.

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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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Study Title: A new model of foster care for young children: The Bucharest Early Intervention Project

Authors: Smyke, A.T., Zeanah, C.H., Fox, N.A., & Nelson, C.A.

Abstract: 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.

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Study Title: Effects of early psychosocial deprivation on the development of memory and executive function

Authors: Bos, Karen J., Fox, N., Zeanah, C.H., & Nelson, C.N.

Abstract: This study investigated the effects of early institutional care on memory and executive functioning. Subjects were participants in the Bucharest Early Intervention Project (BEIP) and included institutionalized children, children with a history of institutionalization who were assigned to a foster care intervention, and community children in Bucharest, Romania. Memory and executive functioning were assessed at the age of 8years using the Cambridge Neuropsychological Test and Automated Battery (CANTAB). As expected, children with a history of early institutional care performed worse on measures of both visual memory and executive functioning compared to their peers without a history of institutional care. In comparing children randomly assigned to the foster care intervention with their peers who had continued care in the institution, initial comparisons did not show significant differences on any of the memory or executive functioning outcomes. However, for one of the measures of executive functioning, after controlling for birth weight, head circumference, and duration of time spent in early institutional care, the foster care intervention was a significant predictor of scores. These results support and extend previous findings of deficits in memory and executive functioning among school-age children with a history of early deprivation due to institutional care. This study has implications for the millions of children who continue to experience the psychosocial deprivation associated with early institutional care.

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Study Title: Cognitive recovery in socially deprived young children: The Bucharest Early Intervention Project

Authors: Nelson, C.A., Zeanah, C.H., Fox, N.A., Marshall, P. J., Smyke, A.T., & Guthrie, D.

Abstract: 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.

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Study Title: Ethical considerations in international research collaboration: The Bucharest Early Intervention Project

Authors: Zeanah, C.H., Koga, S.F.M., Simion, B., Stanescu, A., Tabacaru, C., Fox, N.A., Nelson, C.A., & the BEIP Core Group

Abstract: The Bucharest Early Intervention Project (BEIP) is the first ever randomized controlled trial of foster care as an alternative to institutional care for young children. It involved a collaboration between American investigators and Romanian health and child protection professionals. We present a brief description of the Romanian context and the project itself before discussing a number of ethical issues raised by the project. Organized around a discussion of exploitation, risk/benefit ratio, and cultural sensitivity, we evaluate a number of ethical issues involved in the BEIP using the Ethical Clinical Research Framework and the Fair Benefits Framework. Based on this review, we conclude that notwithstanding challenging ethical dilemmas, the benefits of the project outweighed its risks. Throughout the planning and implementation of the project, ethical issues were a central focus of discussion among the investigators and in the collaboration between Americans and Romanians. Thoughtful discussions from multiple perspectives are necessary to conduct research that is ethically sound and scientifically meaningful.

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Study Title: Attachment in institutionalized and community children in Romania

Authors: Zeanah, C.H., Smyke, A.T., Koga, S.F.M., Carlson, E., & the BEIP Core Group

Abstract: This study examined attachment in institutionalized and community children 12–31 months of age in Bucharest, Romania. Attachment was assessed using ratings of attachment behaviors and ratings of caregiver descriptions in a structured interview. As predicted, children raised in institutions exhibited serious disturbances of attachment as assessed by all methods. Observed quality of caregiving was related to formation and organization of attachment in children living in institutions. These results held even when other variables, such as cognitive level, perceived competence, and quantitative interaction ratings, were controlled for. Ratings of attachment behavior in the Strange Situation and caregiver reports of signs of Reactive Attachment Disorder converged moderately. The implications of these findings for different perspectives on attachment are discussed.

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Study Title: A comparison of the electroencephalogram between institutionalized and community children in Romania

Authors: Marshall, P.J., Fox, N.A., & the BEIP Core Group

Abstract: Electroencephalographic (EEG) data were collected from a sample of institutionalized infants and young children in Bucharest, Romania, and were compared with EEG data from age-matched children from the local community who had never been institutionalized and who were living with their families in the Bucharest area. Compared with the never-institutionalized group, the institutionalized group showed a pattern of increased low-frequency (theta) power in posterior scalp regions and decreased high-frequency (alpha and beta) power, particularly at frontal and temporal electrode sites. This finding is consistent with EEG studies of children facing environmental adversity and children with learning disorders. The institutionalized group also showed less marked hemispheric EEG asymmetries than the never-institutionalized group, particularly in the temporal region. The results are discussed in the context of two models: that the pattern of EEG in the institutionalized children reflects a maturational lag in nervous system development, or that it reflects tonic cortical hypoactivation.

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