Early Intervention Can Change the Trajectory of Foster Care Children

JAMA Psychiatry recently published both an original investigation, from Mark Wade and colleagues, as well as an editorial, from Jonathan Schaefer, on the Bucharest Early Intervention Project (BEIP). The BEIP is the only existent randomized clinical trial comparing early foster care to institutional care. The results suggest that children randomly assigned to foster care had lower rates of internalizing problems as compared to children who were assigned to institutional care at 54 months, as well as lower rates of externalizing problems eight years later.

The authors further discovered that children assigned to remain in institutions and those assigned to early foster care had higher general psychopathology at ages 8, 12, and 16 as compared to never-institutionalized children. Children assigned to early foster care, however, showed modest declines in general psychopathology from 8-16 years old, while the institutionalized group remained high in general psychopathology over time.

“Therefore,” the authors write, “it is conceivable that institutional rearing engenders broad deficits in emotion dysregulation, which increase vulnerability to multiple psychiatric problems, but that early placement into socially enriching environments enhances the regulatory competencies that mitigate risk for later psychopathology.”

Children who are raised in institutions are potentially exposed to psychosocial neglect, due to high ratios of children to caregivers, high turnover in caregivers, isolation, and regimentation of children, as well as inadequate social and cognitive stimulation. These effects may be mitigated by placement in early foster care. Little is known about the psychological trajectory of institutionalized children, in part because most studies of such a population are limited to observational design and, accordantly, to investigating observable, measurable factors. The BEIP, meanwhile, examined children who were abandoned in Bucharest, randomizing half the sample to receive high-quality, early foster care, with the other half receiving care as usual in an institutional setting, while the third group of children who had never been institutionalized served as a control. The design provides a unique insight, as Schaefer notes:

“… children who received ‘care as usual’ were also exposed to relatively severe early deprivation and neglect. The BEIP can be thus be viewed not only as a randomized clinical trial that assessed the efficacy of foster care as an intervention for institutionalized young children, but also as a randomized clinical trial that allows investigators to isolate the causal effects of severe early-life deprivation on later outcomes.”

The study investigated a variety of measures of psychopathology, aiming to measure general psychopathology, and also measured internalizing and externalizing symptoms. As already mentioned, both the foster care and institutionalized groups had higher and comparable levels of general psychopathology than did the control group, but the foster care group showed a moderate decline in general psychopathology from ages 8-16, while the institutionalized group remained stable and high. Further, after accounting for general psychopathology, there were no group differences on internalizing symptoms across the three groups, but there was a general decline in externalizing symptoms from 8-16 years old in the foster care group, compared to no such decrease in the institutionalized group, both of which were higher than the control.

“The present results add to this growing literature by providing the first evidence to date that profound psychosocial deprivation as a function of early institutionalization increases transdiagnostic liability to psychopathology from childhood through adolescence,” write Wade and colleagues. “Moreover, these effects appear to be at least partially amenable to foster care intervention, suggesting that, whatever [general psychopathology] is indexing, it is not immutable.”

Despite the novel design, the authors note several limitations to this study: 1) Measures of psychopathology relied on teacher/caregiver ratings, 2) there was missing data over the course of the study, 3) the sample of 136 was rather small, 4) the bifactor models used to analyze internalizing and externalizing symptoms obfuscates their interpretation and 5) there is a potential lack of generalizability given the unique population at hand.

Still, Schaefer concludes:

“The analysis of Wade and colleagues convincingly illustrates how a period of profound early deprivation can have lasting and widespread consequences on later emotional and behavioral functioning. These results affirm the importance of early interventions for institutionalized children and suggest the hypothesis—testable in future research—that interventions for children exposed to less pervasive early adversity may yield similar benefits.”

 

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Wade M, Fox NA, Zeanah CH, Nelson CA. Effect of Foster Care Intervention on Trajectories of General and Specific Psychopathology Among Children With Histories of Institutional rearing Randomized Clinical Trial. JAMA Psychiatry. 2018;75(11):1137–1145. doi:10.1001/jamapsychiatry.2018.2556 (Link)

Schaefer JD. Use of Hierarchical Measures of Psychopathology to Capture the Long (and Wide) Shadow of Early Deprivation in the Bucharest Early Intervention Project Analysis. JAMA Psychiatry. 2018;75(11):1101–1102. doi:10.1001/jamapsychiatry.2018.2215 (Link)