For very young children abandoned by their parents and placed in institutional care settings, what is the potentially beneficial impact of being placed with a foster family? Does it matter if children are placed with foster families early or later in their development? If a child moves from one foster family to another, how much will that affect the child’s ability to adjust and physically and emotionally develop?  Can such things be measured?

An attempt to do just this is reported in a study appearing in the American Journal of Psychiatry. Led by senior author Kathryn L. Humphreys, Ph.D., of Vanderbilt University, a 2020 and 2015 BBRF Young Investigator, researchers analyzed data from a singular cohort of young people: a group of 136 children in Romania, who, after being orphaned or abandoned by their parents, were placed into institutional care during infancy, a little over 20 years ago. Half were soon placed into high-quality foster care. Now, the team has found “strong and conclusive evidence” that the family-based care these children received did benefit them in a variety of ways.

The research team also included: Nathan A. Fox, Ph.D., 2007 BBRF Distinguished Investigator; and Charles A. Nelson, Ph.D., and Charles H. Zeanah, M.D., all of whom received the 2017 BBRF Ruane Prize for Outstanding Achievement in Child and Adolescent Psychiatric Research in connection with this project.

It is well known not only to scientists but to the vast majority of parents that beyond satisfying basic needs including food, shelter and safety, infants require psychosocial care. Sadly, as the team notes, “millions of children being raised without parents experience severe deprivation” in institutional settings, “where high child-to-caregiver ratios and lack of nurturing care lead to psychosocial neglect, even when survival needs are met.” Psychosocial deprivation also occurs, of course, in some families, and in both institutions and disturbed family settings it has been repeatedly linked with delays in cognitive, physical, and socioemotional development.

The original study in which the Romanian children were enrolled, The Bucharest Early Intervention Project, was the first randomized controlled trial of foster care as an alternative to institutional care. It began in 2001 following an invitation from the Secretary of State for Child Protection in Romania to inform policies regarding the placement of the tens of thousands of children residing in institutions there. The current study synthesizes data from years of assessments of the trial participants that followed.

The original study ended when each child reached an age of 54 months (4 and a half years). The group of 136 children had been randomly assigned to two equally sized groups: 68 receiving “care as usual,” meaning that their placements were not determined by the study team, and often meant greater duration of exposure to institutional care in Bucharest; and 68 placed with families recruited to take part in a newly-created program to provide child-centered foster care—all at or before they reached an age of 33 months (2 years 9 months).

One of the most valuable perspectives afforded by the study was its ability to specifically assess how children placed with foster families very early (by 33 months) fared in various ways relative to those who were randomized to “care as usual,” which usually meant living in an institution, at least at the outset.

The participants in the original trial were assessed at 30, 42, and 54 months. Follow-ups took place at ages 8, 12, and 16-18 years. At each of these assessments, measurements were made for IQ, physical growth, brain electrical activity (as measured by EEG), and symptoms of five types of psychopathology. The team’s total data set consisted of some 7,088 observations of the 136 youths made across the 20 years.

The initial trial’s randomized design allowed the researchers to determine a causal relationship between being placed in a caring family environment early, after initial neglect, and outcomes including IQ, physical growth, and symptoms of disorders, particularly those involving social relatedness (reactive attachment disorder and disinhibited social engagement disorder), as well as “internalizing symptoms,” i.e., inner-directed psychiatric symptoms such as anxiety, depression and withdrawal.

After analysis of the total datsaset, Dr. Humphreys and colleagues reported they “found that children who were randomized to foster care had better cognitive and physical outcomes and less severe symptoms of psychopathology than did their peers who remained in institutions and experienced more prolonged exposure to psychosocially depriving conditions.” The benefits of family-based care, they added, “were remarkably consistent across development.”

Importantly, the model of foster care used in the Romania trial encouraged foster parents to make a psychological commitment to the child, “and thus differs from the model currently used in the U.S., which emphasizes only instrumental care needs,” the researchers said. The Romanian trial also provided foster parents with support from trained social workers and psychologists.

While it is possible that early gains in a child can lead to greater gains over time as they age, the team stressed that their results specifically indicate that “the impact of [foster care] intervention is rapidly apparent by 30 months of age,” at which point it is “sustained through late adolescence, with minimal evidence of fade-out over time.”

Another of the study’s findings is that children placed earlier with a foster family fared better, in certain respects, including IQ, but they did not differ in physical growth from children placed later. The impact of the age of placement from infancy to adolescence tended to vary with respect to psychiatric symptoms and cognitive outcomes. Instability in placement—moving among foster families—tended to have the most noticeable effects in adolescence, and children who remained with their original foster families had better cognitive and physical outcomes and less severe psychiatric symptoms compared with children who experienced placement disruptions.

Noting that 6.7 million children have lost a parent or caregiver as a result of the pandemic, the team stressed the relevance of their finding that children who experience early deprivation do “benefit from high-quality family-based care, and more broadly, that the nature of the early caregiving environment has an extensive and lasting impact on development.”