Stereotypies in Children With a History of Early Institutional Care

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 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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